Migraine ICYMI

Key clinical point: Plasma glucose level increases during spontaneous migraine attacks, and the increase is independent of the presence of aura symptoms and pain intensity.

Main finding: Plasma glucose levels were higher in the ictal phase than in the interictal phase of migraine (mean, 98.83 vs. 88.63 mg/dL; P = .0014) after adjusting for diurnal variation. The attack-related elevation in plasma glucose level was not influenced by pain intensity or the presence of aura symptoms.

Study details: In this study, plasma glucose levels were measured during and outside of spontaneous attacks of migraine in 31 patients (13 with aura and 18 without aura).

Disclosures: The study was funded by the Lundbeck Foundation, the Novo Nordisk Foundation, the University of Copenhagen, the Research Foundation of the Capital Region of Denmark, and the Danish Council for Independent Research-Medical Sciences. Faisal Mohammad Amin and Anders Hougaard reported receiving personal fees and/or honoraria from multiple pharmaceutical companies. Messoud Ashina reported consultancy/advisory for multiple pharmaceutical companies. Other authors declared no disclosures. 

Citation: Zhang DG et al. Headache. 2020 Feb 7. doi: 10.1111/head.13760.

Key clinical point: Plasma glucose level increases during spontaneous migraine attacks, and the increase is independent of the presence of aura symptoms and pain intensity.

Main finding: Plasma glucose levels were higher in the ictal phase than in the interictal phase of migraine (mean, 98.83 vs. 88.63 mg/dL; P = .0014) after adjusting for diurnal variation. The attack-related elevation in plasma glucose level was not influenced by pain intensity or the presence of aura symptoms.

Study details: In this study, plasma glucose levels were measured during and outside of spontaneous attacks of migraine in 31 patients (13 with aura and 18 without aura).

Disclosures: The study was funded by the Lundbeck Foundation, the Novo Nordisk Foundation, the University of Copenhagen, the Research Foundation of the Capital Region of Denmark, and the Danish Council for Independent Research-Medical Sciences. Faisal Mohammad Amin and Anders Hougaard reported receiving personal fees and/or honoraria from multiple pharmaceutical companies. Messoud Ashina reported consultancy/advisory for multiple pharmaceutical companies. Other authors declared no disclosures. 

Citation: Zhang DG et al. Headache. 2020 Feb 7. doi: 10.1111/head.13760.

Key clinical point: Plasma glucose level increases during spontaneous migraine attacks, and the increase is independent of the presence of aura symptoms and pain intensity.

Main finding: Plasma glucose levels were higher in the ictal phase than in the interictal phase of migraine (mean, 98.83 vs. 88.63 mg/dL; P = .0014) after adjusting for diurnal variation. The attack-related elevation in plasma glucose level was not influenced by pain intensity or the presence of aura symptoms.

Study details: In this study, plasma glucose levels were measured during and outside of spontaneous attacks of migraine in 31 patients (13 with aura and 18 without aura).

Disclosures: The study was funded by the Lundbeck Foundation, the Novo Nordisk Foundation, the University of Copenhagen, the Research Foundation of the Capital Region of Denmark, and the Danish Council for Independent Research-Medical Sciences. Faisal Mohammad Amin and Anders Hougaard reported receiving personal fees and/or honoraria from multiple pharmaceutical companies. Messoud Ashina reported consultancy/advisory for multiple pharmaceutical companies. Other authors declared no disclosures. 

Citation: Zhang DG et al. Headache. 2020 Feb 7. doi: 10.1111/head.13760.

Key clinical point: Quarterly treatment with OnabotulinumtoxinA (BoNT-A) up to 4 years can provide long-lasting prevention of chronic migraine in real-life settings.

Main finding: From baseline to 48 months, there was a significant reduction in the mean number of monthly headache days and hours, consumption of analgesics, and latency time (P less than .001 for all). With repeated BoNT-A treatment, a progressive shift toward lower degrees of disability was seen at each subsequent timepoint (P less than .001 for trend). Six patients experienced transitory neck pain. 

Study details: The data come from a retrospective real-life study of patients with chronic migraine who received quarterly treatment with BoNT-A up to 16 cycles (n = 109).

Disclosures: The authors declared no conflict of interest.

Citation: Santoro A et al. Neurol Sci. 2020 Feb 12. doi: 10.1007/s10072-020-04283-y.

Key clinical point: Quarterly treatment with OnabotulinumtoxinA (BoNT-A) up to 4 years can provide long-lasting prevention of chronic migraine in real-life settings.

Main finding: From baseline to 48 months, there was a significant reduction in the mean number of monthly headache days and hours, consumption of analgesics, and latency time (P less than .001 for all). With repeated BoNT-A treatment, a progressive shift toward lower degrees of disability was seen at each subsequent timepoint (P less than .001 for trend). Six patients experienced transitory neck pain. 

Study details: The data come from a retrospective real-life study of patients with chronic migraine who received quarterly treatment with BoNT-A up to 16 cycles (n = 109).

Disclosures: The authors declared no conflict of interest.

Citation: Santoro A et al. Neurol Sci. 2020 Feb 12. doi: 10.1007/s10072-020-04283-y.

Key clinical point: Quarterly treatment with OnabotulinumtoxinA (BoNT-A) up to 4 years can provide long-lasting prevention of chronic migraine in real-life settings.

Main finding: From baseline to 48 months, there was a significant reduction in the mean number of monthly headache days and hours, consumption of analgesics, and latency time (P less than .001 for all). With repeated BoNT-A treatment, a progressive shift toward lower degrees of disability was seen at each subsequent timepoint (P less than .001 for trend). Six patients experienced transitory neck pain. 

Study details: The data come from a retrospective real-life study of patients with chronic migraine who received quarterly treatment with BoNT-A up to 16 cycles (n = 109).

Disclosures: The authors declared no conflict of interest.

Citation: Santoro A et al. Neurol Sci. 2020 Feb 12. doi: 10.1007/s10072-020-04283-y.

Key clinical point: Rimegepant 75 mg demonstrates favorable efficacy and safety for the treatment of acute migraine compared with the placebo.

Main finding: Rimegepant 75 mg resulted in a significant freedom from pain (20.6% vs. 12.5%; relative risk [RR], 1.70; P less than .001), pain relief (58.6% vs. 44.6%; RR, 1.34; P less than .001), and freedom from the most bothersome symptoms (36.0% vs. 25.1%; RR, 1.44; P less than .001) at 2 hours after dosing compared with the placebo. There was no significant increase in adverse events compared with the placebo.

Study details: A meta-analysis of 4 randomized controlled trials including 3,827 patients with acute migraine.

Disclosures: This study was supported by the Suzhou Health Talents Training Project. The authors declared no conflict of interest.

Citation: Gao B et al. Front Pharmacol. 2020 Jan 24. doi: 10.3389/fphar.2019.01577.

Key clinical point: Rimegepant 75 mg demonstrates favorable efficacy and safety for the treatment of acute migraine compared with the placebo.

Main finding: Rimegepant 75 mg resulted in a significant freedom from pain (20.6% vs. 12.5%; relative risk [RR], 1.70; P less than .001), pain relief (58.6% vs. 44.6%; RR, 1.34; P less than .001), and freedom from the most bothersome symptoms (36.0% vs. 25.1%; RR, 1.44; P less than .001) at 2 hours after dosing compared with the placebo. There was no significant increase in adverse events compared with the placebo.

Study details: A meta-analysis of 4 randomized controlled trials including 3,827 patients with acute migraine.

Disclosures: This study was supported by the Suzhou Health Talents Training Project. The authors declared no conflict of interest.

Citation: Gao B et al. Front Pharmacol. 2020 Jan 24. doi: 10.3389/fphar.2019.01577.

Key clinical point: Rimegepant 75 mg demonstrates favorable efficacy and safety for the treatment of acute migraine compared with the placebo.

Main finding: Rimegepant 75 mg resulted in a significant freedom from pain (20.6% vs. 12.5%; relative risk [RR], 1.70; P less than .001), pain relief (58.6% vs. 44.6%; RR, 1.34; P less than .001), and freedom from the most bothersome symptoms (36.0% vs. 25.1%; RR, 1.44; P less than .001) at 2 hours after dosing compared with the placebo. There was no significant increase in adverse events compared with the placebo.

Study details: A meta-analysis of 4 randomized controlled trials including 3,827 patients with acute migraine.

Disclosures: This study was supported by the Suzhou Health Talents Training Project. The authors declared no conflict of interest.

Citation: Gao B et al. Front Pharmacol. 2020 Jan 24. doi: 10.3389/fphar.2019.01577.

Urgent care centers may not use optimal medications for the management of acute migraine attacks, according to a study published in the March issue of Headache. Pain and nausea or vomiting associated with migraine may go undertreated, and treatment may not be consistent with American Headache Society (AHS) guidelines for EDs, said Mia T. Minen, MD, of the department of neurology and population health at NYU Langone Health in New York and colleagues.

“Our study findings raise the question as to whether the patients with migraine in the urgent care setting should be managed similarly to the ED, and whether the AHS guidelines for the ED should be revisited and applied to urgent care,” the researchers noted.

Relative to the ED, urgent care centers may provide cost savings and emerge “as a preferred place for treatment for people with migraine, perhaps as they are potentially more quiet medical settings where people with migraine might expeditiously receive care,” the authors said.

Dr. Minen and colleagues conducted a retrospective chart review to assess migraine management at two urgent care centers in New York. They examined the number of urgent care visits for migraine, treatments used, and how closely clinicians followed the AHS recommendations for administration of antiemetic medication and triptans, among other outcomes.

The study population included adults diagnosed with migraine at the NYU Langone Medhattan Urgent Care center between Dec. 1, 2015, and Dec. 1, 2018, or at the NYU Langone Ambulatory Care Urgent Care West Side center between May 1, 2017, and Dec. 1, 2018. Of more than 32,000 urgent care visits during the study period, 78 patients received a migraine diagnosis. Patients with migraine had an average age of 32.5 years, and 79.5% were female. More than half had a documented history of migraine. Two of the patients (2.6%) had been to an emergency department for headache or migraine.

Less than half of the patients who presented with pain (46.6%) were given medication, most commonly ketorolac injection. Most patients (78.2%) received prescriptions, and 25.6% received a triptan prescription. About 60% of patients were told to follow up with a neurologist. In addition, 11.5% revisited urgent care with a migraine or headache or to request a prescription refill.

“Patients in this study appeared to be using the urgent care centers specifically for acute care,” the researchers said. “The patients generally had infrequent headaches and the majority would not have qualified for migraine preventive treatment.”

Although AHS guidelines include three “should offer” medications for acute management of migraine in the ED – intravenous metoclopramide, intravenous prochlorperazine, and subcutaneous sumatriptan – two of the medications, subcutaneous sumatriptan and intravenous prochlorperazine, were not available in the urgent care pharmacy. “Of the level B migraine medications, only metoclopramide IV was in the pharmacy, and only 12.3% was given this at their urgent care visit,” the researchers said. “There was also likely undertreatment of nausea/vomiting; despite 39 patients with recorded nausea or vomiting with their migraine, less than half (46.2%) received an antiemetic at the visit,” including metoclopramide or ondansetron through oral or intravenous administration.

Future studies should look at headache and migraine visits at urgent care centers across the United States, the investigators suggested.

One of the authors of the study (Leslie Miller, MD) is the head of the NYU Langone Health Urgent Care Centers. Dr. Minen has received grant support, honoraria, or travel funds from the National Institutes of Health, the American Academy of Neurology, the American Brain Foundation, the National Multiple Sclerosis Society, the National Headache Foundation, the American Headache Society, Barnard College, and NYU. Dr. Minen is associate editor of Headache.

jremaly@mdedge.com

SOURCE: Minen MT et al. Headache. 2020;60(3):542-52.

Urgent care centers may not use optimal medications for the management of acute migraine attacks, according to a study published in the March issue of Headache. Pain and nausea or vomiting associated with migraine may go undertreated, and treatment may not be consistent with American Headache Society (AHS) guidelines for EDs, said Mia T. Minen, MD, of the department of neurology and population health at NYU Langone Health in New York and colleagues.

“Our study findings raise the question as to whether the patients with migraine in the urgent care setting should be managed similarly to the ED, and whether the AHS guidelines for the ED should be revisited and applied to urgent care,” the researchers noted.

Relative to the ED, urgent care centers may provide cost savings and emerge “as a preferred place for treatment for people with migraine, perhaps as they are potentially more quiet medical settings where people with migraine might expeditiously receive care,” the authors said.

Dr. Minen and colleagues conducted a retrospective chart review to assess migraine management at two urgent care centers in New York. They examined the number of urgent care visits for migraine, treatments used, and how closely clinicians followed the AHS recommendations for administration of antiemetic medication and triptans, among other outcomes.

The study population included adults diagnosed with migraine at the NYU Langone Medhattan Urgent Care center between Dec. 1, 2015, and Dec. 1, 2018, or at the NYU Langone Ambulatory Care Urgent Care West Side center between May 1, 2017, and Dec. 1, 2018. Of more than 32,000 urgent care visits during the study period, 78 patients received a migraine diagnosis. Patients with migraine had an average age of 32.5 years, and 79.5% were female. More than half had a documented history of migraine. Two of the patients (2.6%) had been to an emergency department for headache or migraine.

Less than half of the patients who presented with pain (46.6%) were given medication, most commonly ketorolac injection. Most patients (78.2%) received prescriptions, and 25.6% received a triptan prescription. About 60% of patients were told to follow up with a neurologist. In addition, 11.5% revisited urgent care with a migraine or headache or to request a prescription refill.

“Patients in this study appeared to be using the urgent care centers specifically for acute care,” the researchers said. “The patients generally had infrequent headaches and the majority would not have qualified for migraine preventive treatment.”

Although AHS guidelines include three “should offer” medications for acute management of migraine in the ED – intravenous metoclopramide, intravenous prochlorperazine, and subcutaneous sumatriptan – two of the medications, subcutaneous sumatriptan and intravenous prochlorperazine, were not available in the urgent care pharmacy. “Of the level B migraine medications, only metoclopramide IV was in the pharmacy, and only 12.3% was given this at their urgent care visit,” the researchers said. “There was also likely undertreatment of nausea/vomiting; despite 39 patients with recorded nausea or vomiting with their migraine, less than half (46.2%) received an antiemetic at the visit,” including metoclopramide or ondansetron through oral or intravenous administration.

Future studies should look at headache and migraine visits at urgent care centers across the United States, the investigators suggested.

One of the authors of the study (Leslie Miller, MD) is the head of the NYU Langone Health Urgent Care Centers. Dr. Minen has received grant support, honoraria, or travel funds from the National Institutes of Health, the American Academy of Neurology, the American Brain Foundation, the National Multiple Sclerosis Society, the National Headache Foundation, the American Headache Society, Barnard College, and NYU. Dr. Minen is associate editor of Headache.

jremaly@mdedge.com

SOURCE: Minen MT et al. Headache. 2020;60(3):542-52.

Urgent care centers may not use optimal medications for the management of acute migraine attacks, according to a study published in the March issue of Headache. Pain and nausea or vomiting associated with migraine may go undertreated, and treatment may not be consistent with American Headache Society (AHS) guidelines for EDs, said Mia T. Minen, MD, of the department of neurology and population health at NYU Langone Health in New York and colleagues.

“Our study findings raise the question as to whether the patients with migraine in the urgent care setting should be managed similarly to the ED, and whether the AHS guidelines for the ED should be revisited and applied to urgent care,” the researchers noted.

Relative to the ED, urgent care centers may provide cost savings and emerge “as a preferred place for treatment for people with migraine, perhaps as they are potentially more quiet medical settings where people with migraine might expeditiously receive care,” the authors said.

Dr. Minen and colleagues conducted a retrospective chart review to assess migraine management at two urgent care centers in New York. They examined the number of urgent care visits for migraine, treatments used, and how closely clinicians followed the AHS recommendations for administration of antiemetic medication and triptans, among other outcomes.

The study population included adults diagnosed with migraine at the NYU Langone Medhattan Urgent Care center between Dec. 1, 2015, and Dec. 1, 2018, or at the NYU Langone Ambulatory Care Urgent Care West Side center between May 1, 2017, and Dec. 1, 2018. Of more than 32,000 urgent care visits during the study period, 78 patients received a migraine diagnosis. Patients with migraine had an average age of 32.5 years, and 79.5% were female. More than half had a documented history of migraine. Two of the patients (2.6%) had been to an emergency department for headache or migraine.

Less than half of the patients who presented with pain (46.6%) were given medication, most commonly ketorolac injection. Most patients (78.2%) received prescriptions, and 25.6% received a triptan prescription. About 60% of patients were told to follow up with a neurologist. In addition, 11.5% revisited urgent care with a migraine or headache or to request a prescription refill.

“Patients in this study appeared to be using the urgent care centers specifically for acute care,” the researchers said. “The patients generally had infrequent headaches and the majority would not have qualified for migraine preventive treatment.”

Although AHS guidelines include three “should offer” medications for acute management of migraine in the ED – intravenous metoclopramide, intravenous prochlorperazine, and subcutaneous sumatriptan – two of the medications, subcutaneous sumatriptan and intravenous prochlorperazine, were not available in the urgent care pharmacy. “Of the level B migraine medications, only metoclopramide IV was in the pharmacy, and only 12.3% was given this at their urgent care visit,” the researchers said. “There was also likely undertreatment of nausea/vomiting; despite 39 patients with recorded nausea or vomiting with their migraine, less than half (46.2%) received an antiemetic at the visit,” including metoclopramide or ondansetron through oral or intravenous administration.

Future studies should look at headache and migraine visits at urgent care centers across the United States, the investigators suggested.

One of the authors of the study (Leslie Miller, MD) is the head of the NYU Langone Health Urgent Care Centers. Dr. Minen has received grant support, honoraria, or travel funds from the National Institutes of Health, the American Academy of Neurology, the American Brain Foundation, the National Multiple Sclerosis Society, the National Headache Foundation, the American Headache Society, Barnard College, and NYU. Dr. Minen is associate editor of Headache.

jremaly@mdedge.com

SOURCE: Minen MT et al. Headache. 2020;60(3):542-52.

LOS ANGELES – Investigators have developed a risk score to predict the likelihood of stroke among patients with migraine with aura. The study on which the risk score is based was presented at the International Stroke Conference sponsored by the American Heart Association. Migraine with aura, for which younger women are at higher risk, increases the risk of ischemic stroke. “With our new risk-prediction tool, we could start identifying those at higher risk, treat their risk factors, and lower their risk of stroke,” said Souvik Sen, MD, MPH, professor and chair of neurology at the University of South Carolina in Columbia, in a press release.

Risk groups significantly discriminated stroke risk

To create the score, Dr. Sen and colleagues examined data from the ARIC (Atherosclerosis Risk in Communities) cohort, which includes community-dwelling people in Forsyth County, N.C.; Jackson, Miss.; Washington County, Md.; and the suburbs of Minneapolis. Researchers have been following the participants since 1987. From this population, Dr. Sen and colleagues identified 429 participants with a history of migraine with aura. Most of these participants were women aged 50-59 years at their first visit. The researchers analyzed the association between potential risk factors and ischemic stroke using Cox proportional hazards analysis.

Of the 429 participants, 31 had an ischemic stroke during a follow-up period of 20 years. Dr. Sen’s group created a risk score by identifying five risk factors for stroke and assigning them points in proportion to their influence (i.e., their regression coefficients). They assigned diabetes mellitus – 7 points; age older than 65 years – 5 points; heart rate variability (i.e., the standard deviation of all normal-to-normal RR intervals) – 3 points; hypertension – 3 points – and sex – 1 point. Then the researchers calculated risk scores for each patient and defined a low-risk group (from 0-4 points), a moderate-risk group (5-10 points), and a high-risk group (11-21 points).

After 18 years of follow-up, the incidence of stroke was 3% in the low-risk group, 8% in the moderate-risk group, and 34% in the high-risk group. The hazard ratio for ischemic stroke in the high-risk group, compared with the low-risk group, was 7.35. Kaplan Meier curves indicated that the risk-stratification groups significantly discriminated stroke risk among the sample. The risk score should be validated in an independent population cohort, said the investigators.

Dr. Sen and colleagues did not report any funding for this study. Investigators reported receiving grants from the National Institutes of Health, the American Heart Association, and the American Academy of Neurology.

Score may leave important variables unexamined

One mechanism through which migraine increases the risk of stroke is the constriction of blood vessels, said Louis R. Caplan, MD, professor of neurology at Harvard Medical School in Boston and member of the editorial advisory board of Neurology Reviews. Triptans, which many patients use to treat migraine, also cause vasoconstriction. In addition, migraine increases blood coagulation.

Although the risk score developed by Dr. Sen and colleagues accounts for various comorbidities, it may not apply equally to all patients. “As I understand it, they’re just using migraine with aura as a single factor,” said Dr. Caplan. Variables such as prolonged aura, frequent episodes, and aura-related deficit are associated with increased risk of stroke, but the risk score does not examine these factors.

Patients with severe, long-lasting attacks or attacks that involve weakness or aphasia should receive prophylactic treatment to prevent vasoconstriction, such as verapamil (Verelan), said Dr. Caplan. Antithrombotic agents such as aspirin also may be appropriate prophylaxis. Whether effective treatment of migraine with aura decreases the risk of stroke remains unknown.

egreb@mdedge.com

SOURCE: Trivedi T et al. ISC 2020. Abstract WMP117.

LOS ANGELES – Investigators have developed a risk score to predict the likelihood of stroke among patients with migraine with aura. The study on which the risk score is based was presented at the International Stroke Conference sponsored by the American Heart Association. Migraine with aura, for which younger women are at higher risk, increases the risk of ischemic stroke. “With our new risk-prediction tool, we could start identifying those at higher risk, treat their risk factors, and lower their risk of stroke,” said Souvik Sen, MD, MPH, professor and chair of neurology at the University of South Carolina in Columbia, in a press release.

Risk groups significantly discriminated stroke risk

To create the score, Dr. Sen and colleagues examined data from the ARIC (Atherosclerosis Risk in Communities) cohort, which includes community-dwelling people in Forsyth County, N.C.; Jackson, Miss.; Washington County, Md.; and the suburbs of Minneapolis. Researchers have been following the participants since 1987. From this population, Dr. Sen and colleagues identified 429 participants with a history of migraine with aura. Most of these participants were women aged 50-59 years at their first visit. The researchers analyzed the association between potential risk factors and ischemic stroke using Cox proportional hazards analysis.

Of the 429 participants, 31 had an ischemic stroke during a follow-up period of 20 years. Dr. Sen’s group created a risk score by identifying five risk factors for stroke and assigning them points in proportion to their influence (i.e., their regression coefficients). They assigned diabetes mellitus – 7 points; age older than 65 years – 5 points; heart rate variability (i.e., the standard deviation of all normal-to-normal RR intervals) – 3 points; hypertension – 3 points – and sex – 1 point. Then the researchers calculated risk scores for each patient and defined a low-risk group (from 0-4 points), a moderate-risk group (5-10 points), and a high-risk group (11-21 points).

After 18 years of follow-up, the incidence of stroke was 3% in the low-risk group, 8% in the moderate-risk group, and 34% in the high-risk group. The hazard ratio for ischemic stroke in the high-risk group, compared with the low-risk group, was 7.35. Kaplan Meier curves indicated that the risk-stratification groups significantly discriminated stroke risk among the sample. The risk score should be validated in an independent population cohort, said the investigators.

Dr. Sen and colleagues did not report any funding for this study. Investigators reported receiving grants from the National Institutes of Health, the American Heart Association, and the American Academy of Neurology.

Score may leave important variables unexamined

One mechanism through which migraine increases the risk of stroke is the constriction of blood vessels, said Louis R. Caplan, MD, professor of neurology at Harvard Medical School in Boston and member of the editorial advisory board of Neurology Reviews. Triptans, which many patients use to treat migraine, also cause vasoconstriction. In addition, migraine increases blood coagulation.

Although the risk score developed by Dr. Sen and colleagues accounts for various comorbidities, it may not apply equally to all patients. “As I understand it, they’re just using migraine with aura as a single factor,” said Dr. Caplan. Variables such as prolonged aura, frequent episodes, and aura-related deficit are associated with increased risk of stroke, but the risk score does not examine these factors.

Patients with severe, long-lasting attacks or attacks that involve weakness or aphasia should receive prophylactic treatment to prevent vasoconstriction, such as verapamil (Verelan), said Dr. Caplan. Antithrombotic agents such as aspirin also may be appropriate prophylaxis. Whether effective treatment of migraine with aura decreases the risk of stroke remains unknown.

egreb@mdedge.com

SOURCE: Trivedi T et al. ISC 2020. Abstract WMP117.

LOS ANGELES – Investigators have developed a risk score to predict the likelihood of stroke among patients with migraine with aura. The study on which the risk score is based was presented at the International Stroke Conference sponsored by the American Heart Association. Migraine with aura, for which younger women are at higher risk, increases the risk of ischemic stroke. “With our new risk-prediction tool, we could start identifying those at higher risk, treat their risk factors, and lower their risk of stroke,” said Souvik Sen, MD, MPH, professor and chair of neurology at the University of South Carolina in Columbia, in a press release.

Risk groups significantly discriminated stroke risk

To create the score, Dr. Sen and colleagues examined data from the ARIC (Atherosclerosis Risk in Communities) cohort, which includes community-dwelling people in Forsyth County, N.C.; Jackson, Miss.; Washington County, Md.; and the suburbs of Minneapolis. Researchers have been following the participants since 1987. From this population, Dr. Sen and colleagues identified 429 participants with a history of migraine with aura. Most of these participants were women aged 50-59 years at their first visit. The researchers analyzed the association between potential risk factors and ischemic stroke using Cox proportional hazards analysis.

Of the 429 participants, 31 had an ischemic stroke during a follow-up period of 20 years. Dr. Sen’s group created a risk score by identifying five risk factors for stroke and assigning them points in proportion to their influence (i.e., their regression coefficients). They assigned diabetes mellitus – 7 points; age older than 65 years – 5 points; heart rate variability (i.e., the standard deviation of all normal-to-normal RR intervals) – 3 points; hypertension – 3 points – and sex – 1 point. Then the researchers calculated risk scores for each patient and defined a low-risk group (from 0-4 points), a moderate-risk group (5-10 points), and a high-risk group (11-21 points).

After 18 years of follow-up, the incidence of stroke was 3% in the low-risk group, 8% in the moderate-risk group, and 34% in the high-risk group. The hazard ratio for ischemic stroke in the high-risk group, compared with the low-risk group, was 7.35. Kaplan Meier curves indicated that the risk-stratification groups significantly discriminated stroke risk among the sample. The risk score should be validated in an independent population cohort, said the investigators.

Dr. Sen and colleagues did not report any funding for this study. Investigators reported receiving grants from the National Institutes of Health, the American Heart Association, and the American Academy of Neurology.

Score may leave important variables unexamined

One mechanism through which migraine increases the risk of stroke is the constriction of blood vessels, said Louis R. Caplan, MD, professor of neurology at Harvard Medical School in Boston and member of the editorial advisory board of Neurology Reviews. Triptans, which many patients use to treat migraine, also cause vasoconstriction. In addition, migraine increases blood coagulation.

Although the risk score developed by Dr. Sen and colleagues accounts for various comorbidities, it may not apply equally to all patients. “As I understand it, they’re just using migraine with aura as a single factor,” said Dr. Caplan. Variables such as prolonged aura, frequent episodes, and aura-related deficit are associated with increased risk of stroke, but the risk score does not examine these factors.

Patients with severe, long-lasting attacks or attacks that involve weakness or aphasia should receive prophylactic treatment to prevent vasoconstriction, such as verapamil (Verelan), said Dr. Caplan. Antithrombotic agents such as aspirin also may be appropriate prophylaxis. Whether effective treatment of migraine with aura decreases the risk of stroke remains unknown.

egreb@mdedge.com

SOURCE: Trivedi T et al. ISC 2020. Abstract WMP117.

Patients with suspected migraine and a normal neurological examination without any atypical features or red flags do not need an MRI or CT, according to recent updated recommendations in a guideline released by the American Headache Society.

Migraine with atypical features may require neuroimaging, according to the guideline. These include an unusual aura; change in clinical features; a first or worst migraine; a migraine that presents with brainstem aura, confusion, or motor manifestation; migraine accompaniments in later life; headaches that are side-locked or posttraumatic; and aura that presents without headache.
 

Assessing the evidence

The recommendation to avoid MRI or CT in otherwise neurologically normal patients with migraine carried a grade A recommendation from the American Headache Society, while the specific considerations for neuroimaging was based on consensus and carried a grade C recommendation, according to lead author Randolph W. Evans, MD, of the department of neurology at Baylor College of Medicine in Houston, and colleagues.

The recommendations, published in the journal Headache (2020 Feb;60(2):318-36), came from a systematic review of 23 studies of adults at least 18 years old who underwent MRI or CT during outpatient treatment for migraine between 1973 and 2018. Ten studies looked at CT neuroimaging in patients with migraine, nine studies examined MRI neuroimaging alone in patients with migraine, and four studies contained adults with headache or migraine who underwent either MRI or CT. The majority of studies analyzed were retrospective or cross-sectional in nature, while four studies were prospective observational studies.

Dr. Evans and colleagues noted that neuroimaging for patients with suspected migraine is ordered for a variety of reasons, such as excluding conditions that aren’t migraine, diagnostic certainty, cognitive bias, practice workflow, medicolegal concerns, addressing patient and family anxiety, and addressing clinician anxiety. Neuroimaging also can be costly, they said, adding up to an estimated $1 billion annually according to one study, and can lead to additional testing from findings that may not be clinically significant.
 

Good advice, with caveats

In an interview, Alan M. Rapoport, MD, editor-in-chief of Neurology Reviews, said that while he generally does not like broad guideline recommendations, the recommendation made by the American Headache Society to avoid neuroimaging in patients with a normal neurological examination without any atypical features and red flags “takes most of the important factors into consideration and will work almost all the time.” The recommendation made by consensus for specific considerations of neuroimaging was issued by top headache specialists in the United States who reviewed the data, and it is unlikely a patient with a migraine as diagnosed by the International Classification of Headache Disorders with a normal neurological examination would have a significant abnormality that would appear with imaging, Dr. Rapoport said.

“If everyone caring for migraine patients knew these recommendations, and used them unless the patients fit the exclusions mentioned, we would have more efficient clinical practice and save lots of money on unnecessary scanning,” he said.

However, Dr. Rapoport, clinical professor of neurology at the University of California, Los Angeles, founder of the New England Center for Headache, and past president of The International Headache Society, said that not all clinicians will be convinced by the American Headache Society’s recommendations.

“Various third parties often jump on society recommendations or guidelines and prevent smart clinicians from doing what they need to do when they want to disregard the recommendation or guideline,” he explained. “More importantly, if a physician feels the need to think out of the box and image a patient without a clear reason, and the patient cannot pay for the scan when a medical insurance company refuses to authorize it, there can be a bad result if the patient does not get the study.”

Dr. Rapoport noted that the guideline does not address situations where neuroimaging may not pick up conditions that lead to migraine, such as a subarachnoid or subdural hemorrhage, reversible cerebral vasoconstriction syndrome, or early aspects of low cerebrospinal fluid pressure syndrome. Anxiety on the part of the patient or the clinician is another area that can be addressed by future research, he said.

“If the clinician does a good job of explaining the odds of anything significant being found with a typical migraine history and normal examination, and the patient says [they] need an MRI with contrast to be sure, it will be difficult to dissuade them,” said Dr. Rapoport. “If you don’t order one, they will find a way to get one. If it is abnormal, you could be in trouble. Also, if the clinician has no good reason to do a scan but has anxiety about what is being missed, it will probably get done.”

There was no funding source for the guidelines. The authors reported personal and institutional relationships in the form of advisory board memberships, investigator appointments, speakers bureau positions, research support, and consultancies for a variety of pharmaceutical companies, agencies, institutions, publishers, and other organizations.

Patients with suspected migraine and a normal neurological examination without any atypical features or red flags do not need an MRI or CT, according to recent updated recommendations in a guideline released by the American Headache Society.

Migraine with atypical features may require neuroimaging, according to the guideline. These include an unusual aura; change in clinical features; a first or worst migraine; a migraine that presents with brainstem aura, confusion, or motor manifestation; migraine accompaniments in later life; headaches that are side-locked or posttraumatic; and aura that presents without headache.
 

Assessing the evidence

The recommendation to avoid MRI or CT in otherwise neurologically normal patients with migraine carried a grade A recommendation from the American Headache Society, while the specific considerations for neuroimaging was based on consensus and carried a grade C recommendation, according to lead author Randolph W. Evans, MD, of the department of neurology at Baylor College of Medicine in Houston, and colleagues.

The recommendations, published in the journal Headache (2020 Feb;60(2):318-36), came from a systematic review of 23 studies of adults at least 18 years old who underwent MRI or CT during outpatient treatment for migraine between 1973 and 2018. Ten studies looked at CT neuroimaging in patients with migraine, nine studies examined MRI neuroimaging alone in patients with migraine, and four studies contained adults with headache or migraine who underwent either MRI or CT. The majority of studies analyzed were retrospective or cross-sectional in nature, while four studies were prospective observational studies.

Dr. Evans and colleagues noted that neuroimaging for patients with suspected migraine is ordered for a variety of reasons, such as excluding conditions that aren’t migraine, diagnostic certainty, cognitive bias, practice workflow, medicolegal concerns, addressing patient and family anxiety, and addressing clinician anxiety. Neuroimaging also can be costly, they said, adding up to an estimated $1 billion annually according to one study, and can lead to additional testing from findings that may not be clinically significant.
 

Good advice, with caveats

In an interview, Alan M. Rapoport, MD, editor-in-chief of Neurology Reviews, said that while he generally does not like broad guideline recommendations, the recommendation made by the American Headache Society to avoid neuroimaging in patients with a normal neurological examination without any atypical features and red flags “takes most of the important factors into consideration and will work almost all the time.” The recommendation made by consensus for specific considerations of neuroimaging was issued by top headache specialists in the United States who reviewed the data, and it is unlikely a patient with a migraine as diagnosed by the International Classification of Headache Disorders with a normal neurological examination would have a significant abnormality that would appear with imaging, Dr. Rapoport said.

“If everyone caring for migraine patients knew these recommendations, and used them unless the patients fit the exclusions mentioned, we would have more efficient clinical practice and save lots of money on unnecessary scanning,” he said.

However, Dr. Rapoport, clinical professor of neurology at the University of California, Los Angeles, founder of the New England Center for Headache, and past president of The International Headache Society, said that not all clinicians will be convinced by the American Headache Society’s recommendations.

“Various third parties often jump on society recommendations or guidelines and prevent smart clinicians from doing what they need to do when they want to disregard the recommendation or guideline,” he explained. “More importantly, if a physician feels the need to think out of the box and image a patient without a clear reason, and the patient cannot pay for the scan when a medical insurance company refuses to authorize it, there can be a bad result if the patient does not get the study.”

Dr. Rapoport noted that the guideline does not address situations where neuroimaging may not pick up conditions that lead to migraine, such as a subarachnoid or subdural hemorrhage, reversible cerebral vasoconstriction syndrome, or early aspects of low cerebrospinal fluid pressure syndrome. Anxiety on the part of the patient or the clinician is another area that can be addressed by future research, he said.

“If the clinician does a good job of explaining the odds of anything significant being found with a typical migraine history and normal examination, and the patient says [they] need an MRI with contrast to be sure, it will be difficult to dissuade them,” said Dr. Rapoport. “If you don’t order one, they will find a way to get one. If it is abnormal, you could be in trouble. Also, if the clinician has no good reason to do a scan but has anxiety about what is being missed, it will probably get done.”

There was no funding source for the guidelines. The authors reported personal and institutional relationships in the form of advisory board memberships, investigator appointments, speakers bureau positions, research support, and consultancies for a variety of pharmaceutical companies, agencies, institutions, publishers, and other organizations.

Patients with suspected migraine and a normal neurological examination without any atypical features or red flags do not need an MRI or CT, according to recent updated recommendations in a guideline released by the American Headache Society.

Migraine with atypical features may require neuroimaging, according to the guideline. These include an unusual aura; change in clinical features; a first or worst migraine; a migraine that presents with brainstem aura, confusion, or motor manifestation; migraine accompaniments in later life; headaches that are side-locked or posttraumatic; and aura that presents without headache.
 

Assessing the evidence

The recommendation to avoid MRI or CT in otherwise neurologically normal patients with migraine carried a grade A recommendation from the American Headache Society, while the specific considerations for neuroimaging was based on consensus and carried a grade C recommendation, according to lead author Randolph W. Evans, MD, of the department of neurology at Baylor College of Medicine in Houston, and colleagues.

The recommendations, published in the journal Headache (2020 Feb;60(2):318-36), came from a systematic review of 23 studies of adults at least 18 years old who underwent MRI or CT during outpatient treatment for migraine between 1973 and 2018. Ten studies looked at CT neuroimaging in patients with migraine, nine studies examined MRI neuroimaging alone in patients with migraine, and four studies contained adults with headache or migraine who underwent either MRI or CT. The majority of studies analyzed were retrospective or cross-sectional in nature, while four studies were prospective observational studies.

Dr. Evans and colleagues noted that neuroimaging for patients with suspected migraine is ordered for a variety of reasons, such as excluding conditions that aren’t migraine, diagnostic certainty, cognitive bias, practice workflow, medicolegal concerns, addressing patient and family anxiety, and addressing clinician anxiety. Neuroimaging also can be costly, they said, adding up to an estimated $1 billion annually according to one study, and can lead to additional testing from findings that may not be clinically significant.
 

Good advice, with caveats

In an interview, Alan M. Rapoport, MD, editor-in-chief of Neurology Reviews, said that while he generally does not like broad guideline recommendations, the recommendation made by the American Headache Society to avoid neuroimaging in patients with a normal neurological examination without any atypical features and red flags “takes most of the important factors into consideration and will work almost all the time.” The recommendation made by consensus for specific considerations of neuroimaging was issued by top headache specialists in the United States who reviewed the data, and it is unlikely a patient with a migraine as diagnosed by the International Classification of Headache Disorders with a normal neurological examination would have a significant abnormality that would appear with imaging, Dr. Rapoport said.

“If everyone caring for migraine patients knew these recommendations, and used them unless the patients fit the exclusions mentioned, we would have more efficient clinical practice and save lots of money on unnecessary scanning,” he said.

However, Dr. Rapoport, clinical professor of neurology at the University of California, Los Angeles, founder of the New England Center for Headache, and past president of The International Headache Society, said that not all clinicians will be convinced by the American Headache Society’s recommendations.

“Various third parties often jump on society recommendations or guidelines and prevent smart clinicians from doing what they need to do when they want to disregard the recommendation or guideline,” he explained. “More importantly, if a physician feels the need to think out of the box and image a patient without a clear reason, and the patient cannot pay for the scan when a medical insurance company refuses to authorize it, there can be a bad result if the patient does not get the study.”

Dr. Rapoport noted that the guideline does not address situations where neuroimaging may not pick up conditions that lead to migraine, such as a subarachnoid or subdural hemorrhage, reversible cerebral vasoconstriction syndrome, or early aspects of low cerebrospinal fluid pressure syndrome. Anxiety on the part of the patient or the clinician is another area that can be addressed by future research, he said.

“If the clinician does a good job of explaining the odds of anything significant being found with a typical migraine history and normal examination, and the patient says [they] need an MRI with contrast to be sure, it will be difficult to dissuade them,” said Dr. Rapoport. “If you don’t order one, they will find a way to get one. If it is abnormal, you could be in trouble. Also, if the clinician has no good reason to do a scan but has anxiety about what is being missed, it will probably get done.”

There was no funding source for the guidelines. The authors reported personal and institutional relationships in the form of advisory board memberships, investigator appointments, speakers bureau positions, research support, and consultancies for a variety of pharmaceutical companies, agencies, institutions, publishers, and other organizations.

Key clinical point: Occurrence of headache is not associated with subsequent sleep period characterized by shorter sleep duration, higher sleep disruption, or poorer sleep quality in adults with episodic migraine.

Major finding: The average nightly objective sleep duration, efficiency, and wake after sleep onset (WASO) were 7.3±1.2 hours, 89.5%±3.3%, and 44.8±17.0 minutes, respectively. Objective sleep duration was 7.3 (95% confidence interval, 1.5-13.0) minutes longer on nights after a headache day vs. nights on headache-free days. Actigraphically assessed sleep efficiency and WASO did not differ on nights after headache days vs. headache-free days.

Study details: A prospective cohort study of 98 adults (mean age, 35 years, with an average of five migraine headaches/month) with episodic migraine who provided 4,406 days of data; actigraphic sleep data were assessed for six weeks.

Disclosures: This study was funded by grants from the National Institute of Neurological Disorders and Stroke and the American Sleep Medicine Foundation and received financial contributions from Harvard University and its affiliated academic healthcare centers. Dr. Bertisch reported receiving research support from Merck, Sharpe & Dohme, ApniMed and Lockheed Martin and served as a consultant for Verily.

Citation: Vgontzas A et al. Sleep. 2020 Jan 13. doi: 10.1093/sleep/zsaa001.

Key clinical point: Occurrence of headache is not associated with subsequent sleep period characterized by shorter sleep duration, higher sleep disruption, or poorer sleep quality in adults with episodic migraine.

Major finding: The average nightly objective sleep duration, efficiency, and wake after sleep onset (WASO) were 7.3±1.2 hours, 89.5%±3.3%, and 44.8±17.0 minutes, respectively. Objective sleep duration was 7.3 (95% confidence interval, 1.5-13.0) minutes longer on nights after a headache day vs. nights on headache-free days. Actigraphically assessed sleep efficiency and WASO did not differ on nights after headache days vs. headache-free days.

Study details: A prospective cohort study of 98 adults (mean age, 35 years, with an average of five migraine headaches/month) with episodic migraine who provided 4,406 days of data; actigraphic sleep data were assessed for six weeks.

Disclosures: This study was funded by grants from the National Institute of Neurological Disorders and Stroke and the American Sleep Medicine Foundation and received financial contributions from Harvard University and its affiliated academic healthcare centers. Dr. Bertisch reported receiving research support from Merck, Sharpe & Dohme, ApniMed and Lockheed Martin and served as a consultant for Verily.

Citation: Vgontzas A et al. Sleep. 2020 Jan 13. doi: 10.1093/sleep/zsaa001.

Key clinical point: Occurrence of headache is not associated with subsequent sleep period characterized by shorter sleep duration, higher sleep disruption, or poorer sleep quality in adults with episodic migraine.

Major finding: The average nightly objective sleep duration, efficiency, and wake after sleep onset (WASO) were 7.3±1.2 hours, 89.5%±3.3%, and 44.8±17.0 minutes, respectively. Objective sleep duration was 7.3 (95% confidence interval, 1.5-13.0) minutes longer on nights after a headache day vs. nights on headache-free days. Actigraphically assessed sleep efficiency and WASO did not differ on nights after headache days vs. headache-free days.

Study details: A prospective cohort study of 98 adults (mean age, 35 years, with an average of five migraine headaches/month) with episodic migraine who provided 4,406 days of data; actigraphic sleep data were assessed for six weeks.

Disclosures: This study was funded by grants from the National Institute of Neurological Disorders and Stroke and the American Sleep Medicine Foundation and received financial contributions from Harvard University and its affiliated academic healthcare centers. Dr. Bertisch reported receiving research support from Merck, Sharpe & Dohme, ApniMed and Lockheed Martin and served as a consultant for Verily.

Citation: Vgontzas A et al. Sleep. 2020 Jan 13. doi: 10.1093/sleep/zsaa001.

Key clinical point: In patients with migraine, flunarizine (Fz)-induced parkinsonism (FIP) is associated with older age, history of comorbidities, exposure to high dose of Fz, and longer duration of exposure to Fz.

Major finding: In patients aged 45-64 years and 65 years or older, FIP risk was 3.18 and 4.89 times, respectively, higher in the Fz-treated group than in the controls. Compared with control group, the risk for FIP in those with comorbidities, annual cumulative Fz dose ≥445 mg, and Fz use for ≥60 days was 4.54-, 7.69-, and 8.49-fold, respectively, higher than in the control group.

Study details: A population-based study used data from Taiwan’s National Health Insurance Research Database and included 6,470 patients with migraine who were divided into two groups, based on their exposure (n=3,235) or non-exposure to Fz (n=3,235).

Disclosures: This study was supported by grants from the Taiwan Ministry of Health and Welfare Clinical Trial Center; China Medical University Hospital; Academia Sinica Stroke Biosignature Project; MOST Clinical Trial Consortium for Stroke; Tseng-Lien Lin Foundation, Taichung, Taiwan; and Katsuzo and Kiyo Aoshima Memorial Funds, Japan. The authors declared no conflict of interest.

Citation: Lin W et al. Front Pharmacol. 2019 Dec 19. doi: 10.3389/fphar.2019.01495.

Key clinical point: In patients with migraine, flunarizine (Fz)-induced parkinsonism (FIP) is associated with older age, history of comorbidities, exposure to high dose of Fz, and longer duration of exposure to Fz.

Major finding: In patients aged 45-64 years and 65 years or older, FIP risk was 3.18 and 4.89 times, respectively, higher in the Fz-treated group than in the controls. Compared with control group, the risk for FIP in those with comorbidities, annual cumulative Fz dose ≥445 mg, and Fz use for ≥60 days was 4.54-, 7.69-, and 8.49-fold, respectively, higher than in the control group.

Study details: A population-based study used data from Taiwan’s National Health Insurance Research Database and included 6,470 patients with migraine who were divided into two groups, based on their exposure (n=3,235) or non-exposure to Fz (n=3,235).

Disclosures: This study was supported by grants from the Taiwan Ministry of Health and Welfare Clinical Trial Center; China Medical University Hospital; Academia Sinica Stroke Biosignature Project; MOST Clinical Trial Consortium for Stroke; Tseng-Lien Lin Foundation, Taichung, Taiwan; and Katsuzo and Kiyo Aoshima Memorial Funds, Japan. The authors declared no conflict of interest.

Citation: Lin W et al. Front Pharmacol. 2019 Dec 19. doi: 10.3389/fphar.2019.01495.

Key clinical point: In patients with migraine, flunarizine (Fz)-induced parkinsonism (FIP) is associated with older age, history of comorbidities, exposure to high dose of Fz, and longer duration of exposure to Fz.

Major finding: In patients aged 45-64 years and 65 years or older, FIP risk was 3.18 and 4.89 times, respectively, higher in the Fz-treated group than in the controls. Compared with control group, the risk for FIP in those with comorbidities, annual cumulative Fz dose ≥445 mg, and Fz use for ≥60 days was 4.54-, 7.69-, and 8.49-fold, respectively, higher than in the control group.

Study details: A population-based study used data from Taiwan’s National Health Insurance Research Database and included 6,470 patients with migraine who were divided into two groups, based on their exposure (n=3,235) or non-exposure to Fz (n=3,235).

Disclosures: This study was supported by grants from the Taiwan Ministry of Health and Welfare Clinical Trial Center; China Medical University Hospital; Academia Sinica Stroke Biosignature Project; MOST Clinical Trial Consortium for Stroke; Tseng-Lien Lin Foundation, Taichung, Taiwan; and Katsuzo and Kiyo Aoshima Memorial Funds, Japan. The authors declared no conflict of interest.

Citation: Lin W et al. Front Pharmacol. 2019 Dec 19. doi: 10.3389/fphar.2019.01495.

Key clinical point: Vitamin D3 supplementation might improve headache characteristics and protect against inflammation in migraine.

Major finding: Analysis of covariance adjusted for baseline values and confounders showed that vitamin D3 supplemented group had significantly lower headache days, attacks frequency, duration and severity, and reduced analgesics consumption compared with the placebo group
(P less than 0.05). Patients receiving vitamin D3 had a significant reduction in inducible nitric oxide synthase
(P=0.001) and serum levels of interleukin-6 (P=0.055) compared with placebo.

Study details: Study of 80 patients with episodic migraine randomly assigned to a daily dose of vitamin D3 2,000 IU (50 μg) or placebo for 12 weeks.

Disclosures: The study was supported by Tehran University of Medical Sciences & health Services grant. The authors declared no conflict of interest.

Citation: Ghorbani Z et al. Neurol Sci. 2020 Jan 2. doi: 10.1007/s10072-019-04220-8. 

Key clinical point: Vitamin D3 supplementation might improve headache characteristics and protect against inflammation in migraine.

Major finding: Analysis of covariance adjusted for baseline values and confounders showed that vitamin D3 supplemented group had significantly lower headache days, attacks frequency, duration and severity, and reduced analgesics consumption compared with the placebo group
(P less than 0.05). Patients receiving vitamin D3 had a significant reduction in inducible nitric oxide synthase
(P=0.001) and serum levels of interleukin-6 (P=0.055) compared with placebo.

Study details: Study of 80 patients with episodic migraine randomly assigned to a daily dose of vitamin D3 2,000 IU (50 μg) or placebo for 12 weeks.

Disclosures: The study was supported by Tehran University of Medical Sciences & health Services grant. The authors declared no conflict of interest.

Citation: Ghorbani Z et al. Neurol Sci. 2020 Jan 2. doi: 10.1007/s10072-019-04220-8. 

Key clinical point: Vitamin D3 supplementation might improve headache characteristics and protect against inflammation in migraine.

Major finding: Analysis of covariance adjusted for baseline values and confounders showed that vitamin D3 supplemented group had significantly lower headache days, attacks frequency, duration and severity, and reduced analgesics consumption compared with the placebo group
(P less than 0.05). Patients receiving vitamin D3 had a significant reduction in inducible nitric oxide synthase
(P=0.001) and serum levels of interleukin-6 (P=0.055) compared with placebo.

Study details: Study of 80 patients with episodic migraine randomly assigned to a daily dose of vitamin D3 2,000 IU (50 μg) or placebo for 12 weeks.

Disclosures: The study was supported by Tehran University of Medical Sciences & health Services grant. The authors declared no conflict of interest.

Citation: Ghorbani Z et al. Neurol Sci. 2020 Jan 2. doi: 10.1007/s10072-019-04220-8. 

Key clinical point: Sleep fragmentation (defined by low sleep efficiency) is associated with a higher risk of migraine onset on day 1; short sleep duration and low sleep quality are not temporally associated with migraine.

Major finding: Low sleep efficiency was associated with 39% higher odds of headache on day 1. Sleep duration ≤6.5 hours and poor sleep quality were not associated with migraine onset on the day immediately following the sleep period (day 0) and the following day (day 1).

Study details: The data were obtained from a prospective study of 98 adults with episodic migraine.

Disclosures: This study was funded by grants from the National Institute of Neurologic Disorders and Stroke and the American Sleep Medicine Foundation; received financial contributions from Harvard University and its affiliated academic healthcare centers. Dr. Bertisch reported receiving research support from Merck, Sharpe & Dohme and Lockheed Martin and served as a consultant for Verily.

Citation: Bertisch SM et al. Neurology. 2019 Dec 16. doi: 10.1212/WNL.0000000000008740.

Key clinical point: Sleep fragmentation (defined by low sleep efficiency) is associated with a higher risk of migraine onset on day 1; short sleep duration and low sleep quality are not temporally associated with migraine.

Major finding: Low sleep efficiency was associated with 39% higher odds of headache on day 1. Sleep duration ≤6.5 hours and poor sleep quality were not associated with migraine onset on the day immediately following the sleep period (day 0) and the following day (day 1).

Study details: The data were obtained from a prospective study of 98 adults with episodic migraine.

Disclosures: This study was funded by grants from the National Institute of Neurologic Disorders and Stroke and the American Sleep Medicine Foundation; received financial contributions from Harvard University and its affiliated academic healthcare centers. Dr. Bertisch reported receiving research support from Merck, Sharpe & Dohme and Lockheed Martin and served as a consultant for Verily.

Citation: Bertisch SM et al. Neurology. 2019 Dec 16. doi: 10.1212/WNL.0000000000008740.

Key clinical point: Sleep fragmentation (defined by low sleep efficiency) is associated with a higher risk of migraine onset on day 1; short sleep duration and low sleep quality are not temporally associated with migraine.

Major finding: Low sleep efficiency was associated with 39% higher odds of headache on day 1. Sleep duration ≤6.5 hours and poor sleep quality were not associated with migraine onset on the day immediately following the sleep period (day 0) and the following day (day 1).

Study details: The data were obtained from a prospective study of 98 adults with episodic migraine.

Disclosures: This study was funded by grants from the National Institute of Neurologic Disorders and Stroke and the American Sleep Medicine Foundation; received financial contributions from Harvard University and its affiliated academic healthcare centers. Dr. Bertisch reported receiving research support from Merck, Sharpe & Dohme and Lockheed Martin and served as a consultant for Verily.

Citation: Bertisch SM et al. Neurology. 2019 Dec 16. doi: 10.1212/WNL.0000000000008740.