Associations between the burdens of comorbid sleep problems, central sensitization, and headache-related disability in patients with migraine.

Objective: Sleep disturbances are common in migraine patients and affect quality of life. Central sensitization (CS) is likely to play a role in the increased severity and chronicity of migraine. We hypothesized that the number of comorbid sleep problems would affect headache-related disability through the effects of central sensitization (CS). Methods: We performed a cross-sectional study including 215 consecutive patients with migraine. Insomnia was defined as a Pittsburgh Sleep Quality Index (PSQI) global score greater than 5. Probable REM sleep behavior disorder (pRBD) was defined as an RBD screening score of 5 or greater. Excessive daytime sleepiness (EDS) was defined as an Epworth Sleepiness Scale score of 10 or higher. Suspected sleep apnea (SA) was defined as patients with snoring or sleep apnea witnessed 3 or more nights a week. CS was assessed by the Central Sensitization Inventory (CSI). Results: Restless legs syndrome, insomnia, EDS, SA and pRBD were observed in 25.6%, 71.6%, 34.4%, 10.2%, and 21.4%, respectively, of the patients. At least one sleep problem was present in 87.0% of the patients. According to the results of the multinomial logistic regression analysis with no sleep problems as a reference, after we corrected for adjustment factors, the Migraine Disability Assessment (MIDAS) score significantly increased when three or more comorbid sleep problems were present. According to our mediation analysis, an increased number of sleep problems had a direct effect on the MIDAS score after we adjusted for other variables, and the CSI score was indirectly involved in this association. Conclusion: The present study showed an association between migraine-related disability and the burden of multiple sleep problems, which was partially mediated by CS.

Status migrainosus.

Status migrainosus is one of the recognized complications of migraine with or without aura, defined as a persistent debilitating migraine attack lasting for more than 72h with little reprieve, leading to functional disability. The individual impact of status migrainosus and the substantial healthcare burden are highlighted. Current case series which inform our understanding of this condition are examined with two groups emergent, those with classic status migrainosus and those with episodic status migrainosus. The question as to whether status migrainosus is a distinct biological state beyond the established migraine pathophysiology is examined. With the underlying pathophysiology not fully understood, attention is turned to therapeutic considerations and the available evidence informing practice. A practical approach to treatment of status migrainosus is presented. Given the severity and need for emergency care, options detailed are in line with recommendations for acute migraine care: with a staged approach initially combining subcutaneous sumatriptan with parenteral options including dopamine receptor antagonists, nonsteroidal anti-inflammatories and acetaminophen. The place of combination treatment with parenteral magnesium sulfate, dihydroergotamine, antiepileptics, corticosteroids, and anesthetic agents is outlined. With a paucity of high-quality evidence to consolidate current clinical approaches, consideration of future therapies and research questions is raised.

Validation of the Utah Photophobia Symptom Impact Scale (version 2) as a headache-specific photophobia assessment tool.

OBJECTIVE: To present an updated version of the Utah Photophobia Symptom Impact Scale version 2 (UPSIS2), providing robust clinical and psychometric validation, to improve headache-specific evaluation of light sensitivity and headache-related photophobia. BACKGROUND: The original UPSIS filled a gap in available tools for assessment of headache-associated light sensitivity by providing patient-reported evaluation of the impact of light sensitivity on activities of daily living (ADLs). We have since revised the original questionnaire to provide a more robust item construct and refined validation approach. METHODS: We conducted a psychometric validation of the UPSIS2 through a primary analysis of an online survey of volunteers with recurrent headaches recruited from the University of Utah clinics and surrounding community. Volunteers completed the original UPSIS and UPSIS2 questionnaire versions in addition to measures of headache impact, disability, and frequency. The UPSIS2 now includes a pre-defined recall period and a 1-4 Likert scale with standardized response anchors to improve clarity. Internal construct validity, external construct validity, and test-retest reliability, were evaluated. RESULTS: Responses were obtained from 163 volunteers, with UPSIS2 scores ranging from 15 to 57 (out of a possible 15-60) with a mean (standard deviation) of 32.4 (8.80). Construct validity was satisfactory, as evidenced by sufficient unidimensionality, monotonicity, and local independence. Reliability was excellent, with Rasch test reliability = 0.90 and Cronbach's alpha = 0.92, and an intraclass correlation of 0.79 (95% confidence interval 0.65-0.88) for participants who took the test twice. UPSIS2 correlates well with other headache measures (Spearman's correlations >0.50), as well as the original UPSIS (Spearman's correlation = 0.87), indicating good convergent validity. UPSIS2 scores differ significantly across International Classification of Headache Disorders (third edition) groups, indicating good known group validity. CONCLUSION: The UPSIS2 provides a well-validated headache-specific outcome measure for the assessment of photophobia impact on ADLs.

The effect of the COVID-19 pandemic on headache-related disability among young adults with migraine.

OBJECTIVE: The present study aimed to explore the relationship between the COVID-19 pandemic and headache-related disability among a sample of young adults with migraine. BACKGROUND: Comorbid psychological symptoms compound migraine-related disability. Due to COVID-19 pandemic procedures, many students experienced institutional closures and corresponding increases in depression, stress, and anxiety. The present study sought to examine changes in headache-related disability before (Spring and Fall of 2019) and during (Fall of 2020 and Spring 2021) the COVID-19 pandemic and whether psychological symptoms mediated such changes. METHODS: A cross-sectional study at a southern U.S. university assessed 365 individuals with migraine on headache and psychological variables, comparing those surveyed before COVID-19 with another group surveyed during the pandemic. The direct and indirect effects of COVID-19 status (pre- versus during COVID-19) on headache-related disability through depression, anxiety, and stress symptoms were assessed. RESULTS: Statistically higher levels of depression, (M = 13.9 [SD = 12.2] vs. M = 8.7 [SD = 8.7], p < 0.001), anxiety (12.3 [10.0] vs. 9.7 [8.2], p = 0.01), and stress symptoms (17.6 [10.2] vs. 13.2 [7.9], p < 0.001) were endorsed during the COVID-19 pandemic. The direct path from COVID-19 status to headache-related disability was significant and negative, c' = -1.6 (95% CI: -3.1, -0.1). Anxiety (b = 0.3 [95% CI: 0.01, 0.9]) and depression (b = 0.7 [95% CI: 0.07, 1.4]) symptoms acted as mediators of this relationship, rendering the total effect nonsignificant and negating the lowered disability observed during the pandemic. Only depression symptoms remained a significant mediator after controlling for headache frequency (b = 0.7 [95% CI: 0.09, 1.4]). CONCLUSIONS: Increased depression and anxiety symptoms attenuated the improvements in disability associated with the pandemic. As such, interventions that address comorbid psychological symptoms may hold value in reducing headache-related disability and improving outcomes for young adults whose headache developed or worsened during the COVID-19 pandemic.

Effects on pain and cognition of transcranial direct current stimulation over the dorsolateral prefrontal cortex in women with chronic migraine.

We compared the effects of one versus two daily sessions of anodal transcranial direct current stimulation (a-tDCS) delivered to the left dorsolateral prefrontal cortex (DLPFC) for 10 days in a cohort of 30 women (mean age 28.0±6.92) with chronic migraine (CM, disease duration: 37.8±48.41 month). Participants were randomly allocated to three groups: a-tDCS 1-s Group received one daily a-tDCS session; a-tDCS 2-s Group received two daily a-tDCS sessions; Group SHAM received one daily session with a simulated (placebo) current. All participants were assessed before, after and one month after treatment, using the Migraine Disability Assessment, Montreal Cognitive Assessment, d2 Test of Attention, Trail Making Test (part B), Sequence of Letters and Numbers of the Wechsler Adult Intelligence Scale - III, and Nine Hole Peg Test. We found no difference between groups in the cognitive measures and motor dexterity. However, after treatment, a significant decrease in migraine-related disability was found for the a-tDCS 1-s Group. For all variables, no cumulative effects were observed in a-tDCS 2-s compared to the a-tDCS 1-s Group. The study findings provide preliminary results for future clinical trials designed to compare different intervals between tDCS sessions in CM.

Exploring the contributing factors to multiple chemical sensitivity in patients with migraine.

OBJECTIVE: Multiple chemical sensitivity (MCS) is a form of chemical intolerance in which various systemic symptoms are triggered by exposure to a variety of chemical substances. Although migraine has been associated with central sensitivity syndrome, the relationship between MCS and migraine has not been studied. We assessed the frequency of MCS and its related factors in patients with migraine. METHODS: We performed a cross-sectional study that included 95 patients (14 M/81 F; age, 45.4 ± 12.4 years) out of 100 consecutive patients with migraine from our outpatient headache clinic. MCS was defined as having a combination of Q1 ≥ 30, Q3 ≥ 13, and Q5 ≥ 17 on the quick environment exposure sensitivity inventory (QEESI; Japanese version). Central sensitization inventory-A scores >40 were considered an indication of central sensitization. Headache-related disability and psychological distress were evaluated with the Migraine Disability Assessment score (MIDAS) and Kessler Psychological Distress Scale (K6), respectively. RESULTS: MCS was identified in 20% of patients with migraine; however, none had previously been diagnosed with MCS. The MCS-positive group had higher rates of photophobia, osmophobia, visual aura, sensory aura, and central sensitization and higher MIDAS and K6 scores than the MCS-negative group. A logistic regression analysis showed that osmophobia, sensory aura, and central sensitization were significant contributors to MCS. CONCLUSION: We showed that MCS was observed in 20% of patients with migraine, and our study results may indicate a possible association of MCS with central sensitization and hypersensitivity-related symptoms in patients with migraine.

[Effects of Inhaling Essential Oil on Headache-Related Quality of Life Among Nurses Working in Emergency and Critical Care Units].

BACKGROUND: Headache attacks are prevalent symptoms in emergency and critical care nurses. Prior evidence supports the analgesic effects of essential oils on headache symptoms. However, few empirical studies have examined how essential oil may further improve the relief of related symptoms. If essential oils are effective in headache relief, nurses' quality of life and care quality may also be improved. PURPOSE: This study was designed to examine the effects of inhaling essential oil on (1) headache-related disability, (2) headache-related quality of life, and (3) perceived care quality in emergency and critical care nurses. METHODS: A cluster randomized control trial and crossover experimental design were adopted. The participants, all nurses with headaches working in emergency and critical care units (N = 49) in a medical center in northern Taiwan, were cluster randomized to Group A and B. Group A wore a necklace with essential oil (100% Lavandula angustifolia 0.1 ml + 100% citrus bergamia 0.1 ml) for 28 days (intervention period), stopped wearing the necklace for 7 days (wash-out), and then wore the necklace without essential oil for 28 days (control period). Group B underwent the control period (28 days) first, followed by the wash-out (7 days) and then the intervention period (28 days). Data were collected using a self-administered questionnaires that was administered three times (at day 0, day 28, day 63). The questionnaire included a demographic and headache-related datasheet, headache diary, Headache Disability Index, Migraine-Specific Questionnaire version 2.1 (role restrictive, role preventive, and emotion function), SERVQUAL (Service Quality), DASS-21, and Copenhagen Burnout Inventory. Repeated measures ANOVA (RM-ANOVA) and generalized estimating equations (GEEs) were used to analyze data. RESULTS: Headache-related quality of life showed significant improvement in the role restrictive (ß = 9.77, p = .008) and role preventive (ß = 10.03, p = .018) domains. However, headache-related disability and care quality showed no significant differences (p > .05), indicating that inhaling essential oil had a positive effect on quality of life. CONCLUSIONS: The findings of this study support that using a necklace with essential oil (Lavandula angustifolia and citrus bergamia 1:1) for 28 days effectively improves quality of life, especially in the domain of role function, in nurses working in emergency and critical care units. Additional empirical studies may be developed in the future to promote the benefits of using essential oils to ease pain.

Investigating the relationships between the burden of multiple sensory hypersensitivity symptoms and headache-related disability in patents with migraine.

OBJECTIVE: Sensory hypersensitivities such as photophobia, phonophobia, and osmophobia are common in patients with migraine. We investigated the burden of these multiple sensory hypersensitivities in migraine. METHODS: In this cross-sectional study, 187 consecutive patients with migraine (26 men/161 women; age, 45.9 ± 13.2 years) were included. Sensory hypersensitivity symptoms such as photo-/phono-/osmophobia and accompanying symptoms were determined by neurologists in interviews. The Migraine Disability Assessment (MIDAS) was used to assess headache-related disability. The Kessler Psychological Distress Scale (K6) was also administered. RESULTS: Photophobia, phonophobia and osmophobia were observed in 75.4%, 76.5% and 55.1% of the patients with migraine, respectively. A significant overlap in sensory hypersensitivities (photo-/phono-/osmophobia) was found; the proportions of patients with 2 and 3 coexisting sensory hypersensitivities were 33.2% and 41.7%, respectively. The MIDAS score was higher in those with 3 sensory hypersensitivity symptoms than in those with 0 to 2 sensory hypersensitivity symptoms. A generalized linear model with ordinal logistic regression analysis revealed that multiple sensory hypersensitivities, younger age, more migraine days per month, and a higher K6 score were significantly related to the higher MIDAS score. CONCLUSION: Our study showed that sensory hypersensitivities commonly occur and overlap in patients with migraine and that multiple sensory hypersensitivity symptoms have a significant impact on headache-related disability.

Impact of the COVID-19 pandemic on migraine in Japan: a multicentre cross-sectional study.

OBJECTIVES: To assess the impacts of social situation changes due to the coronavirus disease 2019 (COVID-19) pandemic on headache-related disability and other symptoms in patients with migraine in Japan. METHODS: We conducted a multicentre, cross-sectional study including 659 outpatients with migraine diagnosed by headache specialists. The participants were asked about the impacts of the first wave of the COVID-19 pandemic on headache-related disability, headache days, headache intensity, stress, physical activity, hospital access and their work and home lives. For headache-related disability, the total Migraine Disability Assessment (MIDAS) score and part A and B scores were analysed. Multivariate stepwise linear regression analysis was performed to identify the clinical predictors of changes in the total MIDAS score before and during the COVID-19 pandemic. Logistic regression analysis was performed to determine the factors related to new-onset headache during the COVID-19 pandemic. RESULTS: Finally, 606 migraine patients (73 M/533 F; age, 45.2 ± 12.0 years) were included in the study, excluding those with incomplete data. Increased stress, substantial concern about COVID-19 and negative impacts of the first wave of the COVID-19 pandemic on daily life were reported in 56.8 %, 55.1 and 45.0 % of the participants, respectively. The total MIDAS and A and B scores did not significantly change after the first wave of the COVID-19 pandemic. New-onset headache, which was observed in 95 patients (15.7 %), was associated with younger age and worsened mood and sleep in the logistic regression analysis. The multivariate stepwise linear regression analysis of changes in the total MIDAS score before and during the first wave of COVID-19 pandemic identified worsened sleep, increased acute medication use, increased stress, medication shortages, comorbidities, the absence of an aura and new-onset headache were determinants of an increased total MIDAS score during the first wave of the COVID-19 pandemic. CONCLUSIONS: In this multicentre study, clinical factors relevant to headache-related disability, such as new-onset headache, stress and sleep disturbances, were identified, highlighting the importance of symptom management in migraine patients during the first wave of the COVID-19 pandemic.

Exploring Emotional Distress, Psychological Traits and Attitudes in Patients with Chronic Migraine Undergoing OnabotulinumtoxinA Prophylaxis versus Withdrawal Treatment.

This explorative cross-sectional study aims at exploring emotional distress, psychological profiles, and the attitude towards receiving psychological support in eighty-seven patients with chronic migraine (CM) undergoing OnabotulinumtoxinA prophylactic treatment (OBT-A, n = 40) or withdrawal treatment (WT, n = 47). The outcomes were explored through a specific battery of questionnaires. 25% of patients undergoing OBT-A and almost half of the patients undergoing WT reported psychological distress of at least moderate-severe level, respectively. Coping strategies, self-efficacy, and perceived social support were similar in the two groups. Patients undergoing OBT-A presented lower psychological inflexibility than patients undergoing WT. Predictors of higher psychological distress were low perceived social support by friends, low self-efficacy, and higher avoidance strategies. In both groups, most of the patients evaluated receiving psychological support to be useful (79%). The potential beneficial effects of OBT-A on the severity of symptoms and psychological distress might further support its role in the multidisciplinary management of patients with CM. Identifying patients with psychological vulnerabilities who may benefit from psychological support is relevant in patients with CM.

The current state of acute treatment for migraine in adults in the United States.

Migraine is a common and disabling disorder with substantial personal, social, and economic burden that affects 37 million people in the United States. Risk factors for migraine include age, sex, and genetics. The goal of acute treatment of migraine attacks is to stop the pain and associated symptoms of the migraine attack and return the patient to normal function. The acute treatment landscape for migraine has recently expanded beyond the standard nonsteroidal anti-inflammatory drugs, analgesics, triptans, ergotamines, and combination therapies, to include neuromodulation devices, and recently approved calcitonin gene-related peptide receptor antagonists and a serotonin (5-HT1F) receptor agonist. Unmet acute treatment needs still exist due to lack of efficacy, unwanted side effects, or contraindication to treatment. Effective treatment of migraine requires the clinician to assess the patient, make an accurate diagnosis, and then offer appropriate therapy based on the patient's medical history, comorbidities, and preferences, as well as published clinical evidence. The objective of this narrative review is to familiarize primary care clinicians with the variety of acute treatment options available in the United States today based on clinical trial findings, meta-analyses, evidence-based guidelines, and professional society consensus statements.

The Effect of Psychiatric Comorbidities on Headache-Related Disability in Migraine: Results From the Chronic Migraine Epidemiology and Outcomes (CaMEO) Study.

OBJECTIVE: To examine the influences of depression and anxiety on headache-related disability in people with episodic migraine or chronic migraine. BACKGROUND: Depression and anxiety are common comorbidities in people with migraine, especially among those with chronic migraine. METHODS: This cross-sectional analysis of data from the longitudinal, internet-based Chronic Migraine Epidemiology and Outcomes Study assessed sociodemographic and headache features, and headache-related disability (Migraine Disability Assessment Scale). Four groups were defined based on scores from validated screeners for depression (9-item Patient Health Questionnaire) and anxiety (7-item Generalized Anxiety Disorder Scale): depression alone, anxiety alone, both, or neither. RESULTS: Respondents (N = 16,788) were predominantly women (74.4% [12,494/16,788]) and white (84.0% [14,044/16,788]); mean age was 41 years. Depression was more likely in persons with chronic migraine vs episodic migraine (56.6% [836/1476] vs 30.0% [4589/15,312]; P < .001), as were anxiety (48.4% [715/1476] vs 28.1% 4307/15,312]; P < .001) and coexisting depression and anxiety (42.0% [620/1476] vs 20.8% [3192/15,312]; P < .001). After controlling for headache frequency and other covariates, depression alone, and anxiety alone were associated with 56.0% (rate ratio [RR], 1.56; 95% confidence interval [CI], 1.46-1.66) and 39.0% (RR, 1.39; 95% CI, 1.30-1.50) increased risks of moderate/severe migraine-related disability (both P < .001), respectively; the combination had an even greater effect on risk of moderate/severe disability (79.0% increase; RR, 1.79; 95% CI, 1.71-1.87; P < .001). CONCLUSIONS: Depression alone and anxiety alone are associated with greater headache-related disability after controlling for sociodemographic and headache features. Coexisting depression and anxiety are more strongly associated with disability than either comorbidity in isolation. Interventions targeting depression and anxiety as well as migraine itself may improve headache-related disability in people with migraine.

Migraine: Epidemiology, Burden, and Comorbidity.

Migraine affects an estimated 12% of the population. Global estimates are higher. Chronic migraine (CM) affects 1% to 2% of the global population. Approximately 2.5% of persons with episodic migraine progress to CM. Several risk factors are associated with the progression to CM. There is significant short-term variability in migraine frequency independent of treatment. Migraine is associated with cardiovascular disease, psychiatric disease, and sleep disorders. It is the second most disabling condition worldwide. CM is associated with higher headache-related disability/impact, medical and psychiatric comorbidities, health care resource use, direct and indirect costs, lower socioeconomic status, and health-related quality of life.

Optimism, Pessimism, and Migraine: A Cross-Sectional, Population-Based Study.

BACKGROUND: Optimism and pessimism are related to several mental health and brain disorders, are significant predictors of physical and psychological health outcomes, and implicated as psychosocial determinants of the pain experience. Despite this promising evidence, limited information is available on optimism and pessimism in headache disorders. OBJECTIVE: To evaluate the influence of optimism and pessimism in meeting criteria for migraine and related disability in a population-based sample. METHODS: This is an observational, cross-sectional study. The sample population was selected through a stratified, multi-stage area probability sample of households, as used by the last Brazilian Census. A validated questionnaire eliciting data on demographics, headache features, migraine-related disability, depression (PHQ-9), anxiety (GAD-7), optimism, and pessimism (life orientation test - revised) was administered to people with migraine and headache-free control participants from the general population in São Paulo, Brazil via trained interviewers. Six hundred individuals were contacted. The odds for having migraine/no headache diagnosis were calculated by binary logistic regression, and ordinal regression was performed to check associations between migraine-related disability and optimism. RESULTS: A total of 302 individuals (mean ± SD age: 39.7 ± 12.7; BMI: 26.5 ± 5.9) met inclusion criteria and were included, 140 controls (with no history of headache disorders) and 162 people meeting criteria for migraine (29 with chronic migraine, that is, 15 or more headache days/month). People with migraine were less optimistic and more pessimistic than controls, and endorsed higher levels of anxious and depressive symptoms. Pessimism (OR 95% CI = 1.16 [1.05-1.28], P = .005) and anxiety (OR 95% CI = 1.19 [1.10-1.29], P < .001) were predictors of meeting criteria for migraine, while optimism (ß 95% CI = -0.915 [-1.643, -0.188], P = .01) was inversely associated with migraine-related disability. CONCLUSIONS: Optimism and pessimism are associated with migraine and migraine-related disability. These concepts should be further explored in people with migraine with regard to their potential influences on clinical research outcomes and treatments.

Restless legs syndrome is associated with headache-related disabilities in patients with migraine: a prospective 7-year follow-up study.

BACKGROUND AND PURPOSE: No prospective study has evaluated the impact of restless legs syndrome (RLS) on clinical factors in patients with migraine. We planned a prospective study to assess the impact of RLS comorbid status on clinical factors in patients with migraine. METHODS: A total of 101 patients with migraine who were evaluated for RLS twice at 7-year intervals in a university hospital setting were included in this study. The RLS group was defined as positive for RLS at either baseline or follow-up and the non-RLS group was defined as negative for RLS at both baseline and follow-up. The Migraine Disability Assessment (MIDAS) questionnaire, Beck Depression Inventory-II (BDI-II), Pittsburgh Sleep Quality Index (PSQI) and Epworth Sleepiness Scale were administered to all patients. RESULTS: The RLS prevalence was 16.8% at baseline and 20.8% at follow-up. Compared with the non-RLS group (n = 27), the RLS group (n = 74) showed a significantly higher rate of smoking and higher MIDAS and BDI-II scores at 7-year follow-up. A significant reduction in MIDAS and BDI-II scores at 7-year follow-up compared with those at baseline was observed in the non-RLS group, but not in the RLS group. The non-RLS group showed a significantly lower MIDAS score at 7-year follow-up than the RLS group after adjusting for confounding variables such as age, gender, smoking status, Epworth Sleepiness Scale and PSQI scores using analysis of covariance. The persistent RLS group (n = 11) (positive for RLS at both baseline and follow-up) showed a significantly higher rate of smoking and increased MIDAS, BDI-II and PSQI scores compared with the non-RLS group (n = 74) at 7-year follow-up. CONCLUSION: Our prospective study showed that RLS had a significant impact on headache-related disability in patients with migraine.

The Role of Negative Affect on Headache-Related Disability Following Traumatic Physical Injury.

OBJECTIVE: Acute postinjury negative affect (NA) may contribute to headache pain following physical injury. Early psychiatric-headache comorbidity conveys increased vulnerability to chronic headache-related disability and impairment. Yet, it is unknown whether NA is involved in the transition to chronic headache related-disability after injury. This prospective observational study examined the role of acute postinjury NA on subacute and chronic headache-related disability above and beyond nonpsychiatric factors. METHODS: Eighty adult survivors of single-incident traumatic physical injury were assessed for negative affect (NA): a composite of depression and anxiety symptoms, and symptoms of posttraumatic stress disorder (PTSS) during the acute 2-week postinjury phase. NA was examined as the primary predictor of subacute (6-week) and chronic (3-month) headache-related disability; secondary analyses examined whether the individual NA components differentially impacted the outcomes. RESULTS: Hierarchical linear regression confirmed NA as a unique predictor of subacute (Cohen's f 2 = 0.130; P = .005) and chronic headache related-disability (Cohen's f 2 = 0.160; P = .004) beyond demographic and injury-related factors (sex, prior headaches, and closed head injury). Upon further analysis, PTSS uniquely predicted greater subacute (Cohen's f 2 = 0.105; P = .012) and chronic headache-related disability (Cohen's f 2 = 0.103; P = .022) above and beyond demographic and injury-related factors, depression, and anxiety. Avoidance was a robust predictor of subacute headache impairment (explaining 15% of the variance) and hyperarousal was a robust predictor of chronic headache impairment (10% of the variance). CONCLUSION: Although NA consistently predicted headache-related disability, PTSS alone was a unique predictor above and beyond nonpsychiatric factors, depression, and anxiety. These results are suggestive that early treatment of acute postinjury PTSS may correlate with reductions in disability and negative physical health sequelae associated with PTSS and chronic headache.

Faster Improvement in Migraine Pain Intensity and Migraine-Related Disability at Early Time Points with AVP-825 (Sumatriptan Nasal Powder Delivery System) versus Oral Sumatriptan: A Comparative Randomized Clinical Trial Across Multiple Attacks from the COMPASS Study.

BACKGROUND: Fast relief of migraine pain, associated symptoms, and migraine-related disability are priorities in the acute treatment of migraine. Efforts to improve the pharmacokinetic profiles of acute migraine treatments with the aim of providing faster relief include the development of non-oral routes of administration. AVP-825 (ONZETRA® Xsail® ) is a delivery system containing 22 mg sumatriptan powder that uses a patient's own breath to deliver medication intranasally, targeting the upper posterior nasal cavity beyond the narrow nasal valve, an area lined with vascular mucosa conducive to rapid drug absorption into the systemic circulation. While most studies comparing treatments measure differences in proportions of patients achieving a dichotomous endpoint at fixed time intervals, in this study we compare trajectories of migraine pain and disability over time for AVP-825 versus 100 mg oral sumatriptan tablets. METHODS: We used data from the COMPASS study (NCT01667679, clinicaltrials.gov), a double-blind, double-dummy, active-comparator, cross-over study of people with a diagnosis of migraine. Participants treated up to five qualifying migraine attacks within 1 hour of onset with either AVP-825 plus placebo tablets or 100 mg oral sumatriptan tablets plus placebo delivery system during the first of two 12-week treatment periods, and then switched treatment sequences to treat up to five more attacks in the second treatment period. Patients recorded ordinal migraine pain intensity and migraine-related disability before dosing (predose), and at 10, 15, 30, 45, 60, 90 and 120 minutes. Three-level ordinal multilevel models accounted for unique data structure (repeated measures nested within attacks for each patient) and tested for treatment differences in migraine pain and migraine-related disability through the first 2 hours of attacks post dose. RESULTS: Among 259 study participants (mean age 40.0 years, 84.6% female, 78.4% white), there was significant between and within person variability in migraine pain intensity and migraine-related disability. A typical individual showed significantly faster reductions in migraine pain over the first 30 minutes and migraine-related disability over the first 45 minutes when treating with AVP-825 compared with oral sumatriptan. Overall levels of pain and disability also favored AVP-825 over 2 h following treatment. Model-based odds ratios (OR) comparing AVP-825 to oral sumatriptan ranged from 0.38 to 0.76 for pain and 0.37 to 0.65 for disability, with OR <1 indicating reduced pain/disability in the AVP-825 condition. CONCLUSIONS: Compared with 100 mg oral sumatriptan, treatment with AVP-825 was associated with faster reductions in migraine pain intensity and migraine-related disability starting at 10 minutes postdose and continuing through the first 30 minutes for migraine pain intensity and the first 45 minutes for migraine-related disability, resulting in lower overall pain intensity and disability that lasted through the first 2 h following treatment. Both migraine pain intensity and disability varied substantially both across subjects and within subjects across attacks.

A Comparison of the Chronic Migraine Epidemiology and Outcomes (CaMEO) Study and American Migraine Prevalence and Prevention (AMPP) Study: Demographics and Headache-Related Disability.

OBJECTIVE: To compare the methods and baseline characteristics of the American Migraine Prevalence and Prevention (AMPP) and Chronic Migraine Epidemiology and Outcomes (CaMEO) studies. BACKGROUND: The AMPP and CaMEO studies are the largest longitudinal efforts designed to improve our understanding of episodic and chronic migraine in the United States. The studies have complementary strengths and weaknesses. METHODS: This analysis compares and contrasts the study methods and participation rates of the AMPP and CaMEO studies. We then compare and contrast baseline results in terms of demographic characteristics, headache features, and disability as measured by the Migraine Disability Assessment Scale (MIDAS) among people with episodic and chronic migraine. RESULTS: AMPP and CaMEO sampled from panels constructed to be representative of the US population. The AMPP Study collected data using a mailed questionnaire while CaMEO relied on a web survey methodology. Response rates were higher in AMPP (64.8%) than in CaMEO (16.5%). Both studies assessed headache features using the American Migraine Study/AMPP diagnostic module. Both identified persons with episodic (<15 headache days/month) and chronic migraine (≥15 headache days/month) based on the International Classification of Headache Disorders. AMPP collected data annually over 5 years, while CaMEO collected data quarterly over 15 months. Baseline demographic distribution was generally similar, indicating that each study was broadly representative of the US population. The proportion of persons with migraine who had chronic migraine was similar (AMPP, 6.6%; CaMEO, 8.8%). Respondents had similar median headache frequency (days/month) by sex for chronic migraine (AMPP: men = 21.7, women = 20.0; CaMEO: men = 20.0, women = 20.0) and episodic migraine (AMPP: men = 1.7, women = 2.0; CaMEO: men = 2.0, women = 3.0). Median MIDAS scores were substantially higher in both studies for chronic migraine (severe disability [Grade IV]; AMPP: men = 33.0, women = 45.0; CaMEO: men = 32.0, women = 38.0) than episodic migraine (little/mild disability [Grade I/II]; AMPP: men = 3.0, women = 6.0; CaMEO: men = 4.0, women = 7.0). Rates of moderate/severe disability (Grade III/IV) were substantially higher in both studies for chronic migraine (AMPP: men = 66.9%, women = 78.9%; CaMEO: men = 71.0%, women = 82.6%) than episodic migraine (AMPP: men = 23.0%, women = 31.8%; CaMEO: men = 26.7%, women = 37.9%). More women than men respondents in both studies experienced moderate/severe disability. CONCLUSIONS: AMPP and CaMEO are longitudinal cohort studies that used different methods, but yielded similar results for demographic features, headache frequency, and headache-related disability. Both studies found more severe headache-related disability in those with chronic versus episodic migraine.

Assessing Barriers to Chronic Migraine Consultation, Diagnosis, and Treatment: Results From the Chronic Migraine Epidemiology and Outcomes (CaMEO) Study.

OBJECTIVE: To assess the rates and predictors of traversing steps essential to good medical care for chronic migraine, including: (1) medical consultation, (2) accurate diagnosis, and (3) minimal pharmacologic treatment. Candidate predictors included socioeconomic, demographic, and headache-specific variables. BACKGROUND: Previous research has established that barriers to effective management for episodic migraine include the absence of health insurance, lack of appropriate medical consultation, failure to receive an accurate diagnosis, and not being offered a regimen with acute and preventive treatments. METHODS/DESIGN: The Chronic Migraine Epidemiology and Outcomes (CaMEO) Study, a longitudinal web-based panel study of migraine, included a cross-sectional module focused on patterns of and barriers to medical care. Participants eligible for this analysis met the study criteria for chronic migraine, had evidence of headache-related disability, and provided data on health insurance status. The main outcomes in the current analysis included the proportion of respondents who sought consultation for headache with a designated healthcare professional, self-reported receiving a diagnosis of chronic or transformed migraine, and received minimal pharmacologic treatment for headache with a focus on prescribed acute and preventive treatments. RESULTS: In the CaMEO Study, 80,783 respondents provided study data, 16,789 (20.8% of respondents) met criteria for migraine, and 1476 (8.8% of those with migraine) met chronic migraine criteria. In total, 1254 participants (85.0% of those with chronic migraine) met inclusion criteria for this analysis. Of those, 512 respondents (40.8%) reported currently consulting with a healthcare professional for headache. Odds of consulting increased with increasing age (OR 1.02; 95% CI 1.01-1.03), body mass index (BMI) (OR 1.01; 95% CI 1.00-1.03), migraine-related disability (OR 1.02; 95% CI 1.00-1.04), and migraine severity (OR 1.16; 95% CI 1.11-1.22) and presence of health insurance (OR 4.61; 95% CI 3.05-6.96). Among those consulting a healthcare professional, 126 (24.6%) received an accurate diagnosis and 56 of those with a correct diagnosis (44.4%) received both acute and preventive pharmacologic treatments; odds of a CM diagnosis were higher for women (OR 1.93; 95% CI 1.03-3.61), those with greater migraine severity (OR 1.25; 95% CI 1.14-1.37), and those currently consulting a specialist (OR 2.38; 95% CI 1.54-3.69). No predictors of receiving appropriate treatment were identified among those currently consulting. Among our sample of people with chronic migraine, only 56 (4.5%) individuals successfully traversed the series of 3 barriers to successful chronic migraine care (ie, consulted a healthcare professional for migraine, received an accurate diagnosis, and were prescribed minimal acute and preventive pharmacologic treatments). CONCLUSION: Our findings suggest that <5% of persons with chronic migraine traversed 3 barriers to receiving care for headache (consultation, diagnosis, and treatment), representing a large unmet need for improving care in this population. Predictors of consulting a healthcare professional included age, having health insurance, greater migraine-related disability, and greater migraine symptom severity. Among those consulting, predictors of an appropriate diagnosis included consulting a specialist, female sex, and greater migraine severity. Public health efforts are needed to improve outcomes for patients with chronic migraine by a range of interventions and educational efforts aimed at improving consultation rates, diagnostic accuracy, and adherence to minimal pharmacologic treatment.

The relation of PTSD symptoms to migraine and headache-related disability among substance dependent inpatients.

Despite emerging evidence for the comorbidity of posttraumatic stress disorder (PTSD) and migraine, few studies have examined the relation of PTSD and migraine, particularly among clinical populations at-risk for both conditions (e.g., substance-dependent patients). This study examined the role of PTSD symptoms in migraine and headache-related disability within a sample of 153 substance-dependent inpatients (37.25% female, Mean age 36.46). PTSD symptoms predicted both migraine and headache-related disability above and beyond gender, depression and anxiety symptoms, the experience of a Criterion A traumatic event, and current alcohol use disorder. Findings highlight the strong association between migraine and PTSD symptoms in a unique population at risk for both conditions.