Unveiling the comparative efficacy and tolerability of comprehensive treatments for migraine: A protocol of systematic review and Bayesian network meta-analysis.

BACKGROUND: Migraine is a chronic paroxysmal incapacitating neurological disorder, which endangers the health of human worldwide ranking as the third most prevalent medical condition. There are no comprehensive estimates of treatments for migraine. We will conduct this systematic review and Bayesian network meta-analysis (NMA) to synthesis quantitative and comparative evidence on the efficacy and tolerability of all the known pharmacological and non-pharmacological interventions for migraine. METHOD: We will perform the systematic electronic search of the literature utilizing MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), Cumulative Index to Nursing & Allied Health (CINAHL), and PsycINFO. We will only include randomized controlled trials (RCTs) of high quality which appraise the efficacy or safety of any potential pharmacological or non-pharmacological interventions in the treatment of patients with migraine. The traditional pairwise meta-analyses will be performed to anticipate the heterogeneities and publication bias and the NMA will be conducted within a Bayesian hierarchical model framework to obtain estimates for all valuable treatments for migraine. The entire heterogeneity will be quantified by Q statistic and I2 index. Other analyses included sensitivity analyses, meta-regression, and subgroup analyses will also be conducted. The whole process will be conducted using in R-3.6.0 software. RESULTS: This study will obtain the efficacy and tolerability of all potential treatments for migraine, aiming at providing consolidated evidence to help make the best choice of interventions. The results will be published in a peer-reviewed journal. DISCUSSION: This Bayesian network meta-analysis may be the first attempt to quantitatively synthesize the efficacy and tolerability of all potential treatments for migraine. And this method can ensure us to fully utilize both the direct and indirect evidence as well as gain the comparative estimates displayed in the derived hierarchies. Besides, we have registered this protocol on the international prospective register of systematic review (PROSPERO) (CRD42020157278).

Neurorehabilitation of Persistent Sport-Related Post-Concussion Syndrome.

BACKGROUND: Persistent Sport-Related Post-Concussion Syndrome is often diagnosed with any type of prolonged PCS symptoms. However, there are not specific diagnostic criteria for PPCS such that misdiagnosis often occurs. Further, the signs and symptoms of PCS overlap with other common illnesses such as depression, anxiety, migraines, ADHD and others. Misdiagnosis may lead to less than efficacious treatment, resulting in prolonged symptoms. OBJECTIVE: This article will review relevant evidence-based literature on PCS, pointing out the lack of a systemic diagnostic framework. It will also provide evidence that highlights the multiple conflicting findings in the literature. This article will posit the BioPsychoSocial framework as the best diagnostic framework for understanding the impact of concussions on the person and to generate individualized and personal interventions. METHODS: A narrative review of sport concussion-related articles was conducted, after extensive searches of relevant and non-relevant literature by each author, as well as articles recommended by colleagues. Articles varied from American Academy of Neurology Class I to IV for evaluation and critique. Class IV articles were reviewed, as there is much public misconception regarding sport and other concussion treatment that needed identification and discussion. RESULTS: Articles reviewed varied by quality of research design and methodology. Multiple symptoms, recovery patterns and rehabilitation treatment approaches are purported in the sport-related concussion literature. Current consensus data as well as the mixed and contradictory findings were explored. CONCLUSIONS: Persistent Sport-Related Post-Concussion Syndrome is a topic of great interest to both professionals and the general public. There is much misunderstanding about the etiology, causation, diagnostic formulations, symptom presentation, prolonging factors and treatment involved in this syndrome. This article posits an individualized multi-system diagnostic formulation, examining all relevant factors, as generating the best interventions for neurorehabilitation of Persistent Sport-Related Post-Concussion Syndrome.

The effect of aerobic exercise on the number of migraine days, duration and pain intensity in migraine: a systematic literature review and meta-analysis.

BACKGROUND: In patients with frequent migraine, prophylactic treatments are used. Patients often request non-pharmacological alternatives. One treatment option can be aerobic exercise. The value of aerobic exercise as prophylactic treatment however needs to be determined. METHODS: A systematic review and meta-analysis was performed to investigate the result of aerobic exercise on the number of migraine days, duration and pain intensity in patients with migraine. After screening three online databases, PubMed, Cochrane library and Web of Science, using predefined in- and exclusion criteria, six studies were retained. Pooling of data was performed when possible. RESULTS: Significant reductions in the number of migraine days after aerobic exercise treatment were found with a mean reduction of 0.6 ± 0.3 migraine days/month. Other outcomes were too variable to pool due to heterogeneity of outcome measurements. Unpooled data revealed small to moderate reductions in attack duration (20-27%) and pain intensity (20-54%) after aerobic exercise intervention. Various exercise intensities are applied. CONCLUSION: There is moderate quality evidence that in patients with migraine aerobic exercise therapy can decrease the number of migraine days. No conclusion for pain intensity or duration of attacks can be drawn. Effect sizes are small due to a lack of uniformity. For future studies, we recommend standardized outcome measures and sufficiently intense training programs. TRIAL REGISTRATION: CRD42018091178 .

Longitudinal Analysis of Patient-Reported Outcomes From an Interdisciplinary Pediatric Pain Rehabilitation Program for Children With Chronic Migraine and Headache.

BACKGROUND: Many children suffering from chronic headache and migraine present with comorbid functional disability, including physical, social, emotional, and academic activities. For children severely impaired by headache, intensive interdisciplinary pain rehabilitation treatment (IIPT) can improve functioning. However, there are limited data evaluating children's response to rehabilitation across several time points. OBJECTIVE: This study aims to evaluate the trajectory of recovery for children undergoing IIPT for chronic headache, as well as to examine the proposed assumption that physical and psychosocial functioning improves prior to a reported reduction in pain. METHODS: A retrospective analysis of patient-reported outcomes in a clinical database of 135 children admitted to an IIPT program between the years 2008 and 2014 was analyzed. Available data across 5 separate time points (up to 1-year post-discharge) were reviewed. RESULTS: One hundred and thirty-five children of mean age 15.2 (SD = 2.2) and 74% female provided data for review. Linear mixed model demonstrated a statistically significant improvement in pain-specific measures of functioning, including daily functioning (change estimate = -14.53) emotional functioning (change estimate = -14.63), family functioning (change estimate = -5.78), and school absences (change estimate = -11.47) over a 12-month period (all P's ≤ .01). A more general measure of quality of life improved during the program, based upon child (change estimate = +10.07) and parent report (change estimate = +15.31); although these gains did not continue to improve post-discharge. As expected, although children did not report a reduction in pain during rehabilitation (change estimate = +0.07), they did report a significant drop in perceived pain in the 12 months following discharge from the program (change estimate = -2.12, P ≤ .01). CONCLUSIONS: Children with chronic headache and migraine who are severely functionally impaired demonstrated linear improvement in pain-specific patient-reported outcomes over time; however, there remains a need for improved methodology in analyzing response to IIPT programs.

Effects of a Physical Therapy Protocol in Patients with Chronic Migraine and Temporomandibular Disorders: A Randomized, Single-Blinded, Clinical Trial.

AIMS: To investigate the effects of adding orofacial treatment to cervical physical therapy in patients with chronic migraine and temporomandibular disorders (TMD). METHODS: A total of 45 participants with chronic migraine and TMD aged 18 to 65 years were randomized into two groups: a cervical group (CG) and a cervical and orofacial group (COG). Both groups continued their medication regimens for migraine treatment and received physical therapy. The CG received physical therapy only in the cervical region, and the COG received physical therapy in both the cervical and orofacial regions. Both groups received six sessions of treatment that consisted of manual therapy and therapeutic exercise in the cervical region or the cervical and orofacial regions. Scores on the Craniofacial Pain and Disability Inventory (CF-PDI) and the Headache Impact Test (HIT-6) were primary outcome variables, and the secondary outcome variables were scores on the Tampa Scale for Kinesiophobia (TSK-11), pain intensity measured on a visual analog scale (VAS), pressure pain thresholds (PPTs) in the temporal, masseter (2 points, M1 and M2) and extratrigeminal (wrist) regions, and maximal mouth opening (MMO). Data were recorded at baseline, posttreatment, and after 12 weeks of follow-up. The α level was set at .05 for all tests and two-way repeated-measures analysis of variance (ANOVA) for within- and between-group interactions. RESULTS: There were 22 CG participants (13.6% men and 86.4% women) and 23 COG participants (13% men and 87% women). The ANOVA analysis revealed statistically significant differences for group × time interaction in CF-PDI, HIT-6 in the last follow-up, pain intensity, PPTs in the trigeminal region, and MMO (P < .05), with a medium-large magnitude of effect. No statistically significant differences were found in the PPTs of the extratrigeminal region or in the TSK-11 (P > .05). CONCLUSION: Both groups reported a significant improvement in CF-PDI, HIT-6, and pain intensity. Cervical and orofacial treatment was more effective than cervical treatment alone for increasing PPTs in the trigeminal region and producing pain-free MMO. Physical therapy alone was not effective for increasing the PPTs in the extratrigeminal region (wrist) or decreasing the level of TSK-11.

The effects of aerobic exercise for persons with migraine and co-existing tension-type headache and neck pain. A randomized, controlled, clinical trial.

Aim To evaluate aerobic exercise in migraine and co-existing tension-type headache and neck pain. Methods Consecutively recruited persons with migraine and co-existing tension-type headache and neck pain were randomized into an exercise group or control group. Aerobic exercise consisted of bike/cross-trainer/brisk walking for 45 minutes, three times/week. Controls continued usual daily activities. Pain frequency, intensity, and duration; physical fitness, level of physical activity, well-being and ability to engage in daily activities were assessed at baseline, after treatment and at follow-up. Results Fifty-two persons completed the study. Significant between-group improvements for the exercise group were found for physical fitness, level of physical activity, migraine burden and the ability to engage in physical activity because of reduced impact of tension-type headache and neck pain. Within the exercise group, significant reduction was found for migraine frequency, pain intensity and duration, neck pain intensity, and burden of migraine; an increase in physical fitness and well-being. Conclusions Exercise significantly reduced the burden of migraine and the ability to engage in physical activity because of reduced impact of tension-type headache and neck pain. Exercise also reduced migraine frequency, pain intensity and duration, although this was not significant compared to controls. These results emphasize the importance of regular aerobic exercise for reduction of migraine burden.

Aplicación de la digitopuntura en pacientes con cefalea migrañosa. Policlínico Contreras, Matanzas, 2014 / Digitopuncture application in patients with migrainous cephalalgia. Contreras Policlinic, Matanzas, 2014

Introducción: la cefalea es toda sensación dolorosa que tiene lugar en la parte superior de la cabeza, desde el reborde orbitario hasta la nuca. Constituye la primera causa de acudir al neurólogo y uno de los motivos más frecuentes en consultas de Medicina Interna. La cefalea tipo tensión es frecuente en la práctica diaria y la más invalidante desde los puntos de vistas físico, social, económico y psicológico. Objetivo: mostrar la actuación de Enfermería en el alivio de la migraña y describir la efectividad de la digitopuntura en pacientes con cefalea migrañosa, del Policlínico Contreras, primer trimestre de 2014. Materiales y métodos: estudio observacional, descriptivo y transversal. El grupo de estudio, 120 pacientes que acudieron a la consulta de Medicina Natural y Tradicional. Resultados: la edad de mayor incidencia 25-34 años, con 47.4 %. Prevaleció el sexo femenino, en un 70 %; la duración del dolor mostró un 43.3 % de afectación. Transcurrió entre las 4 y 8 horas, y siempre tuvo relación con el estrés, en 44.2 %; en un 69.2 % existió relación del dolor con la ingestión de alimentos. Se alivió con el sueño el 61.7 %, y el 52,5 % alcanzaron estado evolutivo excelente. Conclusiones: la aplicación de la digitopuntura a pacientes con cefalea migrañosa contribuyó a que los casos estudiados evolucionaran satisfactoriamente, expresando alivio del dolor. El tratamiento demostró efectividad y contribuyó a la disminución de drogas utilizadas en esta entidad, disminución de gastos económicos que implica el consumo de las mismas; lograr reincorporar a la vida laboral y social en un menor tiempo al paciente (AU).

Introduction: cephalalgia is any painful sensation occurring in the superior part of the head, from the orbital ridge to the nape. It is the first cause of visiting a neurologist and one of the most frequent causes of Internal Medicine consultations. The tension-kind cephalalgia is frequent in daily practice and the most invaliding one from the physical, social, economic and psychological point of view. Aim: to show Nursery behavior in migraine alleviation and to describe the digitopuncture effectiveness in patients with migrainous cephalalgia from Contreras Policlinic in the first trimester of 2014. Materials and methods: observational, descriptive, cross-sectional study. The studied group was 120 patients assisting the consultation of Natural and Traditional Medicine. Outcomes: the 25-34 age group was the one that showed higher incidence, with 47.4 %. The female sex prevailed with 70 %; pain lasting had 44.3 % of affectation. It lasted between 4 and 8 hours, always related to stress in 44.2 %. There it was a relation between pain and food intake in 69.2 %. 61.7 % of the cases were lessened with sleep, and 52.5 % achieved an excellent evolving status. Conclusions: Acupuncture application to patients with migrainous cephalalgia contributed to the satisfactory evolution of the studied cases: The patients expressed pain relieve. The treatment showed effectiveness and facilitated the decrease of drug usage in this entity, also diminishing the economic expenses its use implies; the patients reincorporated to social and working life in a shorter time period (AU).

Aplicación de la digitopuntura en pacientes con cefalea migrañosa. Policlínico Contreras, Matanzas, 2014 / Digitopuncture application in patients with migrainous cephalalgia. Contreras Policlinic, Matanzas, 2014

Introducción: la cefalea es toda sensación dolorosa que tiene lugar en la parte superior de la cabeza, desde el reborde orbitario hasta la nuca. Constituye la primera causa de acudir al neurólogo y uno de los motivos más frecuentes en consultas de Medicina Interna. La cefalea tipo tensión es frecuente en la práctica diaria y la más invalidante desde los puntos de vistas físico, social, económico y psicológico. Objetivo: mostrar la actuación de Enfermería en el alivio de la migraña y describir la efectividad de la digitopuntura en pacientes con cefalea migrañosa, del Policlínico Contreras, primer trimestre de 2014. Materiales y métodos: estudio observacional, descriptivo y transversal. El grupo de estudio, 120 pacientes que acudieron a la consulta de Medicina Natural y Tradicional. Resultados: la edad de mayor incidencia 25-34 años, con 47.4 %. Prevaleció el sexo femenino, en un 70 %; la duración del dolor mostró un 43.3 % de afectación. Transcurrió entre las 4 y 8 horas, y siempre tuvo relación con el estrés, en 44.2 %; en un 69.2 % existió relación del dolor con la ingestión de alimentos. Se alivió con el sueño el 61.7 %, y el 52,5 % alcanzaron estado evolutivo excelente. Conclusiones: la aplicación de la digitopuntura a pacientes con cefalea migrañosa contribuyó a que los casos estudiados evolucionaran satisfactoriamente, expresando alivio del dolor. El tratamiento demostró efectividad y contribuyó a la disminución de drogas utilizadas en esta entidad, disminución de gastos económicos que implica el consumo de las mismas; lograr reincorporar a la vida laboral y social en un menor tiempo al paciente (AU).

Introduction: cephalalgia is any painful sensation occurring in the superior part of the head, from the orbital ridge to the nape. It is the first cause of visiting a neurologist and one of the most frequent causes of Internal Medicine consultations. The tension-kind cephalalgia is frequent in daily practice and the most invaliding one from the physical, social, economic and psychological point of view. Aim: to show Nursery behavior in migraine alleviation and to describe the digitopuncture effectiveness in patients with migrainous cephalalgia from Contreras Policlinic in the first trimester of 2014. Materials and methods: observational, descriptive, cross-sectional study. The studied group was 120 patients assisting the consultation of Natural and Traditional Medicine. Outcomes: the 25-34 age group was the one that showed higher incidence, with 47.4 %. The female sex prevailed with 70 %; pain lasting had 44.3 % of affectation. It lasted between 4 and 8 hours, always related to stress in 44.2 %. There it was a relation between pain and food intake in 69.2 %. 61.7 % of the cases were lessened with sleep, and 52.5 % achieved an excellent evolving status. Conclusions: Acupuncture application to patients with migrainous cephalalgia contributed to the satisfactory evolution of the studied cases: The patients expressed pain relieve. The treatment showed effectiveness and facilitated the decrease of drug usage in this entity, also diminishing the economic expenses its use implies; the patients reincorporated to social and working life in a shorter time period (AU).

A Systematic Review and Meta-Analysis of the Efficacy of Cognitive Behavioral Therapy for the Management of Pediatric Migraine.

INTRODUCTION: Migraine headaches are common in children and adolescents. Current pharmacologic treatment options are limited despite the prevalence and debilitating effects of pediatric migraine. Cognitive behavioral therapy (CBT) is an evidence-based practice that focuses on the development of coping strategies and cognitive restructuring to alter the pain experience. Till date, no meta-analysis has been done to examine the use of CBT in pediatric migraine. METHODS: Using the keywords (cognitive behavioral therapy OR cognitive behavior therapy OR cognitive behavioral therapy OR cognitive behavior therapy OR CBT) AND (headache OR migraine), a preliminary search on the PubMed and Ovid database yielded 3841 articles published in English between 1 Jan 1980 and 1 May 2016. Full articles were also reviewed for references of interest. After data extraction, 14 studies were included in the meta-analysis. RESULTS: The results of the meta-analysis well-support the clinical role of CBT in the management of pediatric migraine. The pooled odds ratios of clinically significant improvement, that is, 50% or greater headache activity reduction post-treatment and at follow-up (3 months or later) were OR 9.11 (95% CI: 5.01 to 16.58, P < .001) and OR 9.18 (95% CI: 5.69 to 14.81, P < .001) respectively, demonstrating significant clinical improvement with CBT as compared with wait-list control, placebo, or standard medication. Furthermore, the clinical improvement was stable, even at a 1-year follow-up as evident in some of the studies. CONCLUSION: There is good evidence that CBT is beneficial to children suffering from migraine, and may also augment the efficacy of standard medications such as amitriptyline.

Psychological interventions for migraine: a systematic review.

Migraine causes major health impairment and disability. Psychological interventions offer an addition to pharmacotherapy but they are not currently recommended by the National Institute of Clinical Excellence (NICE) or available in the National Health Service. We aimed to systematically review evidence on the efficacy of psychological interventions for migraine in adults. A search was done of MEDLINE, psychINFO, http://www.opengrey.eu , the meta-register of controlled trials and bibliographies. Twenty-four papers were included and rated independently by two people using the Yates scale, which has 35 points. Cochrane recommendations are that high quality reports score above the mid-point (18 points). Methods used in 17/24 papers were rated 'high quality'. However, frequently descriptions of key areas such as randomisation methods were omitted. Eighteen studies measured effects of psychological interventions on headache-related outcomes, fifteen reporting significant improvements, ranging 20-67 %. Interventions also produced improvements in psychological outcomes. Few trials measured or reported improvement in disability or quality of life. We conclude that evidence supports the efficacy of psychological interventions in migraine. Over half of the studies were from the USA, which did not provide universal health care at the time of the study, so it is difficult to generalise results to typical populations in receipt of publically funded health services. We agree with the NICE recommendation that high quality pragmatic randomised controlled trials are needed in the UK.

Randomized Controlled Pilot Trial of Behavioral Insomnia Treatment for Chronic Migraine With Comorbid Insomnia.

BACKGROUND: Migraine frequently co-occurs with and is triggered by sleep disturbance, particularly insomnia, and the large majority of patients with chronic migraine (CM) have comorbid insomnia. Limited evidence suggests that behavioral regulation of sleep may reduce migraine frequency, but studies to date have not assessed the viability of stimulus control and sleep restriction interventions or included objective measurement of sleep parameters. The aim of this study, thus, was to pilot-test the efficacy of a brief behavioral insomnia intervention for adults with CM and comorbid insomnia; headache diaries and actigraphy were included to assess outcomes throughout the trial. METHODS: This randomized parallel-arm pilot trial recruited adults with both CM and comorbid insomnia. Participants were randomly assigned to three 30-minute biweekly sessions of cognitive-behavioral therapy for insomnia (CBTi) or control treatment. Participants were blinded to treatment and control conditions to control for outcome expectations. Each treatment condition involved training in and daily practice in 5 instructions/skills. The CBTi group learned and practiced skills pertaining to stimulus control and sleep restriction. The control intervention was the same as used by Calhoun and Ford (2007) and involved training in and daily practice of skills pertaining to keeping a consistent food/liquid intake, range of motion exercises, and acupressure. Participants provided outcome data via daily headache diaries, actigraphy, and self-report measures. The primary outcome was reduction in headache frequency at 2 weeks post-treatment and 6-week follow-up; secondary outcomes included other headache parameters, objective actigraphic and subjective changes in sleep, and treatment effect sizes and perceived credibility. Generalized estimating equations with a binomial logit link and inverse probability weights were used to assess the primary outcome among the intent-to-treat sample, and repeated measures generalized linear models were used to assess changes in secondary outcomes after controlling for baseline values. RESULTS: The intent-to-treat analyses included 31 adults (M age = 30.8 [12.9] years; 90.3% female; 80.6% white) with CM and comorbid insomnia. Both interventions yielded reductions in headache frequency at post-treatment (26.9% reduction for CBTi vs. 36.2% for control) and follow-up (48.9% for CBTi vs. 25.0% for control). At follow-up the odds of experiencing headache were 60% lower for CBTi than for control treatment, indicative of a large effect size that did not reach statistical significance after Bonferroni correction for assessing two primary endpoints (odds ratio: 0.40; 95% CI: 0.17, 0.91; P = .028). CBTi produced significantly larger increases than control treatment in total sleep time and sleep efficiency as quantified by actigraphy, as well as in self-reported insomnia severity. Adherence was high and treatments were perceived as credible without differences between groups, but the control group experienced a higher rate of dropouts. No adverse events were reported. CONCLUSIONS: Behavioral treatment of comorbid insomnia in individuals with CM produced large reductions in headache frequency, though some improvement in headache occurred with a behavioral intervention not focused on modifying sleep. Among the CBTi group only, both headache frequency and sleep parameters continued to improve after treatment, suggesting the presence of enduring effects over time. Directly treating insomnia using components of stimulus control and sleep restriction holds promise for reducing comorbid migraine. Development of and comparison to a truly inert pseudotherapy control presents unique challenges that future studies should address.

Aerobic Exercise for Reducing Migraine Burden: Mechanisms, Markers, and Models of Change Processes.

BACKGROUND: Engagement in regular exercise routinely is recommended as an intervention for managing and preventing migraine, and yet empirical support is far from definitive. We possess at best a weak understanding of how aerobic exercise and resulting change in aerobic capacity influence migraine, let alone the optimal parameters for exercise regimens as migraine therapy (eg, who will benefit, when to prescribe, optimal types, and doses/intensities of exercise, level of anticipated benefit). These fundamental knowledge gaps critically limit our capacity to deploy exercise as an intervention for migraine. OVERVIEW: Clear articulation of the markers and mechanisms through which aerobic exercise confers benefits for migraine would prove invaluable and could yield insights on migraine pathophysiology. Neurovascular and neuroinflammatory pathways, including an effect on obesity or adiposity, are obvious candidates for study given their role both in migraine as well as the changes known to accrue with regular exercise. In addition to these biological pathways, improvements in aerobic fitness and migraine alike also are mediated by changes in psychological and sociocognitive factors. Indeed a number of specific mechanisms and pathways likely are operational in the relationship between exercise and migraine improvement, and it remains to be established whether these pathways operate in parallel or synergistically. As heuristics that might conceptually benefit our research programs here forward, we: (1) provide an extensive listing of potential mechanisms and markers that could account for the effects of aerobic exercise on migraine and are worthy of empirical exploration and (2) present two exemplar conceptual models depicting pathways through which exercise may serve to reduce the burden of migraine. CONCLUSION: Should the promise of aerobic exercise as a feasible and effective migraine therapy be realized, this line of endeavor stands to benefit migraineurs (including the many who presently remain suboptimally treated) by providing a new therapeutic avenue as an alternative or augmentative compliment to established interventions for migraine.

Efficacy of interventions used by physiotherapists for patients with headache and migraine-systematic review and meta-analysis.

AIM: We aimed to conduct a systematic review evaluating the effectiveness of interventions used by physiotherapists on the intensity, frequency and duration of migraine, tension-type (TTH) and cervicogenic headache (CGH). METHODS: We performed a systematic search of electronic databases and a hand search for controlled trials. A risk of bias analysis was conducted using the Cochrane risk of bias tool (RoB). Meta-analyses present the combined mean effects; sensitivity analyses evaluate the influence of methodological quality. RESULTS: Of 77 eligible trials, 26 were included in the RoB assessment. Twenty trials were included in meta-analyses. Nineteen out of 26 trials had a high RoB in >1 domain. Meta-analyses of all trials indicated a reduction of TTH ( ITALIC! p < 0.0001; mean reduction -1.11 on a 0-10 visual analog scale (VAS); 95% CI -1.64 to -0.57) and CGH ( ITALIC! p = 0.0002; mean reduction -2.52 on a 0-10 VAS; 95% CI -3.86 to -1.19) pain intensity, CGH frequency ( ITALIC! p < 0.00001; mean reduction -1.34 days per month; 95% CI -1.40 to -1.28), and migraine ( ITALIC! p = 0.0001; mean reduction -22.39 hours without relief; 95% CI -33.90 to -10.88) and CGH ( ITALIC! p < 0.00001; mean reduction -1.68 hours per day; 95% CI -2.09 to -1.26) duration. Excluding high RoB trials increased the effect sizes and reached additional statistical significance for migraine pain intensity ( ITALIC! p < 0.00001; mean reduction -1.94 on a 0-10 VAS; 95% CI -2.61 to -1.27) and frequency ( ITALIC! p < 0.00001; mean reduction -9.07 days per month; 95% CI -9.52 to -8.62). DISCUSSION: Results suggest a statistically significant reduction in the intensity, frequency and duration of migraine, TTH and CGH. Pain reduction and reduction in CGH frequency do not reach clinically relevant effect sizes. Small sample sizes, inadequate use of headache classification, and other methodological shortcomings reduce the confidence in these results. Methodologically sound, randomized controlled trials with adequate sample sizes are required to provide information on whether and which physiotherapy approach is effective. According to Grading of Recommendations Assessment, Development and Evaluation (GRADE), the current level of evidence is low.

Behavioral treatments for migraine management: useful at each step of migraine care.

Migraine is a disabling and prevalent disorder. Migraine is most effectively treated with a stepped care approach, where patients initially receive a broad level of care (primary care) and proceed to receive increasingly specialized care throughout the course of treatment. Behavioral treatments for migraine modify behaviors of people with migraine with the intention to prevent migraine episodes and secondary consequence of migraine. Behavioral treatments can be incorporated into each level of the stepped care approach for migraine treatment. In this article, we provide a rationale for including behavioral treatment strategies in the treatment of migraine. We then describe and review the evidence for behavioral treatment strategies for migraine, including patient education, relaxation strategies, biofeedback, and cognitive behavioral treatment strategies. Finally, we describe how behavioral treatments can be integrated into a stepped care approach for migraine care.

Nurses' knowledge of pain management for patients with combat-related traumatic brain injuries on rehabilitation units.

PURPOSE: The purpose of this project was to survey nurses' knowledge of pain management for patients with combat-related traumatic brain injuries (TBI). DESIGN/METHODS: A survey was used to collect data regarding nurses' knowledge of pain assessment and management for patients with combat-related TBI. Nurses were invited to participate in the study via email and provided with a link to the electronic survey. FINDINGS: Twenty-five surveys were returned (52% response rate). A total of 76% of nurse respondents perceived that TBI patients over report pain intensity. Only 40% of nurses were able to correctly identify the appropriate medication to treat migraine-type headache pain in TBI patients. CONCLUSION: This study identified gaps in knowledge regarding pain management for patients with combat related TBIs. CLINICAL RELEVANCE: Nurses need additional education regarding common pain syndromes, available treatments, and a better understanding of addiction in order to provide optimal care to these patients.

Comparison between neck pain disability and cervical range of motion in patients with episodic and chronic migraine: a cross-sectional study.

OBJECTIVE: The purpose of this study was to evaluate neck pain-related disability and cervical range of motion (CROM) in patients with episodic migraine (EM) and chronic migraine (CM) and to examine the correlation of both outcomes. METHODS: This cross-sectional study consisted of 91 patients with EM and 34 with CM. Cervical range of motion was measured with the CROM device, and pain during the cervical movement was recorded. Self-reported disability related to neck pain was assessed with the Neck Disability Index. RESULTS: Patients with CM showed higher Neck Disability Index scores and more moderate and severe disability (P = .01). Severe disability as a result of neck pain was associated with 7.6-fold risk of developing CM (P = .003). No significant differences in CROM were identified between groups. Moderate negative correlations between CROM and disability were found for 4 motions within the CM group (-0.60

One-day behavioral intervention in depressed migraine patients: effects on headache.

OBJECTIVE: To determine whether a 1-day behavioral intervention, aimed at enhancing psychological flexibility, improves headache outcomes of migraine patients with comorbid depression. BACKGROUND: Migraine is often comorbid with depression, with each disorder increasing the risk for onset and exacerbation of the other. Managing psychological triggers, such as stress and depression, may result in greater success of headache management. METHOD: Sixty patients with comorbid migraine and depression were assigned to a 1-day Acceptance and Commitment Training plus Migraine Education workshop (ACT-ED; N = 38) or to treatment as usual (TAU; N = 22). Patients completed a daily headache diary prior to, and for 3 months following, the intervention. Clinical variables examined included headache frequency/severity, medication use, disability, and visit to a health care professional. Comparisons were made between baseline findings and findings at the 3-month follow up. RESULTS: Participants assigned to the ACT-ED condition exhibited significant improvements in headache frequency, headache severity, medication use, and headache-related disability. In contrast, the TAU group did not exhibit improvements. The difference in headache outcomes between ACT-ED and TAU was not statistically significant over time (ie, the treatment by time interaction was nonsignificant). These results complement those of a previous report showing effects of ACT-ED vs TAU on depression and disability. CONCLUSION: A 1-day ACT-ED workshop targeting psychological flexibility may convey benefit for patients with comorbid migraine and depression.These pilot study findings merit further investigation using a more rigorously designed large-scale trial.