Proposed new diagnostic criteria for chronic migraine

Introduction ICHD-3 criteria for chronic migraine (CM) include a mixture of migraine and tension-type-like headaches and do not account for patients who have a high frequency of migraine but no other headaches. Materials and methods Patients from the Danish Headache Center and their relatives with ICHD-3 defined CM were compared with patients with high frequency episodic migraine (HFEM). Danish registries were used to compare the socioeconomic impact in these two groups. A Russian student population was used to determine the generalizability of the number of patients fulfilling CM and the proposed diagnostic criteria for CM. Results There was no difference in the demographic profile between the two groups in the Danish cohort. The number of lifelong or annual attacks ( p > 0.3), comorbid diseases, or self-reported effect of triptans ( p = 1) did not differ. HFEM patients purchased more triptans than CM patients ( p = 0.01). CM patients received more early pension ( p = 0.00135) but did not differ from HFEM patients with regard to sickness benefit ( p = 0.207), cash assistance ( p = 0.139), or rehabilitation benefit ( p = 1). Discussion Patients with HFEM are comparable to CM patients with regard to chronicity and disability. We therefore suggest classifying CM as ≥ 8 migraine days per month (proposed CM), disregarding the need for ≥ 15 headache days per month. The proposed diagnostic criteria for CM approximately doubled the number of patients with CM in both the Danish and the Russian materials. Extending the definition of CM to include patients with HFEM will ensure that patients with significant disease burden and unmet treatment needs are identified and provided appropriate access to the range of treatment options and resources available to those with CM. Conclusion Patients with migraine on eight or more days but not 15 days with headache a month are as disabled as patients with ICHD-3 defined CM. They should be included in revised diagnostic criteria for chronic migraine.

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The clinical and public health implications and risks of widening the definition of chronic migraine

Cephalalgia ◽

10.1177/0333102419895777 ◽

2019 ◽

Vol 40 (4) ◽

pp. 407-410 ◽

Cited By ~ 4

Author(s):

Martina Guglielmetti ◽

Alberto Raggi ◽

Raffaele Ornello ◽

Simona Sacco ◽

Domenico D’Amico ◽

...

Keyword(s):

Public Health ◽

Chronic Migraine ◽

High Frequency ◽

Episodic Migraine ◽

Headache Frequency ◽

Allocation Of Resources ◽

Independent Entity ◽

Definition Of ◽

The Impact

Background The definition of chronic migraine has long been debated. Recently, it was suggested to define subjects with at least 8/migraine days as chronic migraine; that is, incorporating so-called high frequency episodic migraine (eight or more migraine days but less than 15 headache days per month). Methods We addressed the possible problems that might arise based on this proposal accounting for clinical, pathophysiological, impact and public health aspects. Results and conclusions Defining chronic migraine on the basis of headache frequency alone does not account for clinical and pathophysiological aspects, as well as for the impact of chronic migraine in terms of disability and quality of life. Moreover, it is potentially harmful for patients in terms of allocation of resources. These issues are discussed in the present manuscript, and we support the idea of defining high frequency episodic migraine as an independent entity as a viable path to follow.

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Diagnosis of Migraine: Empirical Analysis of a Large Clinical Sample of Atypical Migraine (IHS 1.7) Patients and Proposed Revision of the IHS Criteria

Cephalalgia ◽

10.1046/j.1468-2982.2001.00210.x ◽

2001 ◽

Vol 21 (5) ◽

pp. 584-595 ◽

Cited By ~ 36

Author(s):

JC Rains ◽

DB Penzien ◽

GL Lipchik ◽

NM Ramadan

Keyword(s):

Chronic Migraine ◽

Diagnostic Criteria ◽

Empirical Analysis ◽

Clinical Sample ◽

International Headache Society ◽

Primary Headache ◽

Homogeneous Group ◽

Number Of Patients ◽

Daily Headache ◽

Ihs Criteria

The International Headache Society (IHS) diagnostic criteria for headache improved the accuracy of primary headache diagnoses, including migraine. However, many migraineurs receive an ‘atypical migraine’ diagnosis according to the IHS nosology (IHS 1.7), indicating that they approximate but do not fully meet all IHS criteria. This study characterized and sub-classified patients with atypical migraine. Within a clinical sample of 382 headache sufferers, 83 patients met IHS criteria for ‘atypical migraine’. Patients receiving the IHS 1.7 designation did not converge to form a homogeneous group. Rather, distinct and clinically relevant subgroups were empirically derived (e.g. migraine with atypical pain parameters, brief migraine, chronic migraine). The results call for revisions of the IHS diagnostic criteria for migraine that would minimize the number of patients receiving an atypical diagnosis. Revisions would include decreasing the minimum headache duration criteria from 4 h to 2 h, and developing a classification for ‘chronic migraine’ for migraine greater than 15 days per month. The proposed revision provides a means of diagnosing the daily and near-daily headache commonly observed in clinical populations.

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Weight Regain after Bariatric Surgery

10.1093/med/9780190608347.003.0025 ◽

2018 ◽

Author(s):

Bartolome Burguera ◽

Amani Mohamed Hag ◽

Leslie J. Heinberg

Keyword(s):

Bariatric Surgery ◽

Weight Loss ◽

Weight Regain ◽

Scientific Evidence ◽

Treatment Options ◽

Behavioral Factors ◽

Number Of Patients ◽

Medical Therapies ◽

Successful Weight Loss ◽

Definition Of

Bariatric surgery is the most effective therapy for morbid obesity. Unfortunately, a significant number of patients experience significant postoperative weight regain, which undermines the metabolic and cardiovascular benefits of weight loss associated with surgery. When revisional procedures are not indicated and/or when behavioral factors are present (e.g., nonadherence, eating pathology), bariatric programs currently do not have any empirically evaluated treatment options to offer those burdened with less favorable outcomes. This chapter reviews the definition of successful weight loss after bariatric surgery, as well as some biologic and behavioral factors that could be implicated in weight regain after surgery. Finally, we outline the scientific evidence supporting the use of behavioral and medical therapies to prevent weight regain after surgery. Bariatric programs need to determine from clinical experience, as well as through clinical trials, what behavioral/medical therapies are the most effective for managing weight gain after bariatric surgery.

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When does chronic migraine strike? A clinical comparison of migraine according to the headache days suffered per month

Cephalalgia ◽

10.1177/0333102416636055 ◽

2016 ◽

Vol 37 (2) ◽

pp. 104-113 ◽

Cited By ~ 30

Author(s):

M Torres-Ferrús ◽

M Quintana ◽

J Fernandez-Morales ◽

J Alvarez-Sabin ◽

P Pozo-Rosich

Keyword(s):

Chronic Migraine ◽

High Frequency ◽

Daily Life ◽

Low Frequency ◽

Episodic Migraine ◽

Predictive Capacity ◽

The Poor ◽

Clinical Comparison ◽

Current Classification ◽

Poor Outcomes

Introduction According to the IHCD-3β classification, chronic migraine (CM) is headache occurring on 15 or more days/month. Episodic migraine (EM) can be divided into low frequency (LFEM) and high frequency (HFEM) depending on the headache days suffered per month. Methods We performed a clinical comparison of migraine characteristics according to monthly headache days suffered. Patients were divided into three groups: LFEM (1–9 headache days/month), HFEM (10–14 headache days/month) and CM (≥15 headache days/month). Results The analysis included 1109 patients. Previously reported differences between EM and CM were replicated. However, there were three times more clinical differences between LFEM and HFEM than between HFEM and CM (15 vs. 6). A new model that takes 10 headache days as a cut-off value for CM would have a minimally higher predictive capacity (72.8%) and no statistical differences (71.8%) when comparing it to the current classification. Conclusions HFEM patients have few clinical differences compared with CM patients. This includes the poor outcomes regarding headache-related disability and impact on daily life. According to these findings, neurologists and headache specialists should consider that the emotional and functional impact in HFEM patients could be as disabling as in those with CM.

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Long term outcome for onabotulinumtoxinA (Botox) therapy in chronic migraine: A 2-year prospective follow-up audit of patients attending the Hull (UK) migraine clinic

Cephalalgia Reports ◽

10.1177/2515816320985443 ◽

2021 ◽

Vol 4 ◽

pp. 251581632098544

Author(s):

Fayyaz Ahmed ◽

Alina Buture ◽

Taukir Tanvir ◽

Modar Khalil

Keyword(s):

Chronic Migraine ◽

Real World ◽

Episodic Migraine ◽

Sustained Response ◽

Term Outcome ◽

Long Term Outcome ◽

Large Patient ◽

Number Of Patients

Objective: The objective of this prospective audit was to determine the long term outcome of patients diagnosed with chronic migraine who were treated with onabotulinumtoxinA for the prevention of chronic migraine. Background: While long term and real-world studies have confirmed the safety and efficacy of onabotulinumtoxinA in CM, there remains limited information from large patient numbers on the number of cycles and duration of onabotulinumtoxinA needed to successfully convert chronic migraine to episodic migraine, development of resistance to treatment and sustainability of response after stopping treatment. Methods: A total of 655 adult patients diagnosed with chronic migraine who received onabotulinumtoxinA at the Hull Migraine Clinic were followed up prospectively for a minimum of 2 years. OnabotulinumtoxinA was delivered as per the PREEMPT study protocol and patients were asked to keep a headache diary for at least 30 days prior to and continuously after receiving onabotulinumtoxinA. The primary outcome assessed in this prospective real-world audit was either the number of patients who achieved a ≥50% reduction in headache days or migraine days or an increment in crystal clear days twice that of baseline in a 30-day period. Patients were also assessed for analgesic medication overuse. Results: Treatment data were available for 655 patients who commenced treatment between July 2010 and October 2016 and followed for at least 2 years (24–70 months), with the last follow-up taking place in September 2018. Of the 655 patients, 380 patients responded to treatment after two cycles and went on to receive the third cycle. Of these, 152 patients were still on active treatment at 2 years. A further 61 patients had relapsed and were on treatment at 2 years. Of the 228 patients who stopped treatment, 112 were successfully converted to episodic migraine and showed a sustained response, 28 reverted to chronic migraine after the initial response despite continuing treatment (developed resistance), 14 were lost to follow up and 61 patients after achieving remission relapsed after a mean of 9 months (range 4–24 months) and recommenced treatment with onabotulinumtoxinA. Conclusion: After a minimum of 2 years, 29.4% of patients with chronic migraine who initially responded to treatment were successfully converted to episodic migraine and maintained a sustained response. Forty percent of the initial cohort of responders continued therapy with onabotulinumtoxinA to manage their chronic migraine.

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Disability, burden, and symptoms related to sensitization in migraine patients associate with headache frequency

Scandinavian Journal of Pain ◽

10.1515/sjpain-2021-0050 ◽

2021 ◽

Vol 0 (0) ◽

Author(s):

Stefano Di Antonio ◽

Matteo Castaldo ◽

Marta Ponzano ◽

Francesca Bovis ◽

Paola Torelli ◽

...

Keyword(s):

Quality Of Life ◽

Chronic Migraine ◽

High Frequency ◽

Low Frequency ◽

Episodic Migraine ◽

Headache Frequency ◽

Headache Attack ◽

Burden Of Headache ◽

The Difference

Abstract Objectives This observational study aimed to assess the difference in disability, burden, and sensitization between migraine patients with low-frequency headache attack (1–8 headache days/month), high-frequency headache attack (9–14 headache days/months), and patients with chronic migraine (>14 headache days/months). Methods Migraine patients with or without aura were divided into three groups according to headache frequency (low-frequency episodic migraine; high-frequency episodic migraine; chronic migraine). Questionnaires were used to assess the burden of headache, quality of life, phycological burden, and symptoms related to sensitization (estimated by the Central Sensitization Inventory). Differences among migraine groups were assessed using Chi-Quadro test, ANOVA, or Kruskal–Wallis as appropriate. Results 136 patients were included (68 low-frequency episodic migraine, 45 high-frequency episodic migraine, 23 chronic migraine). Patients with high frequency episodic migraine and chronic migraine differed from patients with low frequency episodic migraine showing a worse burden of headache (p=0.002; p=0.002), worse level of physical (p=0.001; p<0.001) and mental (p=0.002; p=0.001) quality of life, worse level of depression (p=0.008; p=0.003), and increase presence of symptoms related to sensitization (p<0.001; p=0.003). No differences were found in any variables between patients with high-frequency episodic migraine and patients with chronic migraine (p>0.05). Conclusions Patients with high-frequency episodic migraine and chronic migraine could be considered in the same segment of the migraine population, with similar degrees of disability and sensitization related symptoms.

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Chronic migraine: Classification and comparisons

Cephalalgia ◽

10.1177/0333102410383590 ◽

2011 ◽

Vol 31 (5) ◽

pp. 520-529 ◽

Cited By ~ 54

Author(s):

Z Katsarava ◽

A Manack ◽

M-S Yoon ◽

M Obermann ◽

H Becker ◽

...

Keyword(s):

Body Mass Index ◽

Chronic Migraine ◽

High Frequency ◽

Low Frequency ◽

Epidemiological Data ◽

Field Testing ◽

Episodic Migraine ◽

Case Definition ◽

Descriptive Statistics ◽

Chi Square

Objective: The objective of our study was to field test different chronic migraine (CM) criteria and compare CM epidemiological profiles, which include demographic, personal, and lifestyle characteristics, with high-frequency episodic migraine (HFEM) and low-frequency episodic migraine (LFEM). Methods: Questionnaires were mailed to a random sample of 18,000 18–65-year-olds in demographically diverse regions of Germany. The epidemiological data for the three classifications of CM, LFEM and HFEM were assessed using descriptive statistics, Pearson Chi-square, and analysis of variance tests. Results: Among 9350 respondents, CM_I was the most restrictive ( N = 37, 0.4%), followed by CM_II ( N = 45, 0.5%) and CM_III ( N = 185, 2.0%). CM groups did not differ in distribution by age, gender, body mass index, education or smoking and alcohol consumption. Compared to those with LFEM and HFEM, those with CM (CM_III) had significantly different epidemiological profiles. Conclusions: CM prevalence varies by case definition. The epidemiological profiles of the three CM groups are similar but differ significantly from those of HFEM and LFEM. Optimal definitions for clinical practice and epidemiological research require additional field testing.

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Anti-CGRP monoclonal antibodies for migraine prevention: A systematic review and likelihood to help or harm analysis

Cephalalgia ◽

10.1177/0333102421989601 ◽

2021 ◽

pp. 033310242198960

Author(s):

Konstantina Drellia ◽

Lili Kokoti ◽

Christina I Deligianni ◽

Dimitrios Papadopoulos ◽

Dimos D Mitsikostas

Keyword(s):

Clinical Trials ◽

Monoclonal Antibodies ◽

Chronic Migraine ◽

Episodic Migraine ◽

Randomised Clinical Trials ◽

Migraine Prevention ◽

Number Of Patients ◽

Calcitonin Gene ◽

Using Data ◽

Risk Ratios

Introduction and objective Monoclonal antibodies targeting the calcitonin gene-related peptide pathway (anti-CGRP mAbs) have shown promising efficacy in randomised clinical trials for the prevention of episodic and chronic migraine, but no head-to-head comparisons with established treatments are available. We aimed to examine absolute differences in benefit-risk ratios between anti-CGRP mAbs, topiramate and propranolol for the prevention of episodic migraine and between anti-CGRP mAbs, topiramate and onabotulinumtoxinA for the prevention of chronic migraine using a likelihood to help versus harm analysis. Methods The number of patients needed to be treated for a patient to achieve ≥ 50% reduction in migraine days (NNTB50%) was used as an effect size metric of efficacy. The number of patients needed to be treated for a patient to experience an adverse event that led to treatment discontinuation (NNTHD-AE) was used as a measure of risk. Likelihood to help versus harm values – which are the ratios of NNTH:NNTB – were calculated using data from phase 3 randomised clinical trials. Results All agents tested were more likely to be beneficial than harmful (likelihood to help versus harm > 1) with the exception of topiramate at 200 mg per day for the prevention of episodic migraine. Anti-CGRP mAbs in all tested doses had higher LHH values than propranolol or topiramate for episodic migraine and onabotulinumtoxinA or topiramate for chronic migraine prevention. Fremanezumab had the highest LHH ratio in episodic migraine and galcanezumab in chronic migraine. Conclusion This analysis showed that anti-CGRP mAbs exhibit a more favourable benefit-risk ratio than established treatments for episodic and chronic migraine. Head-to-head studies are needed to confirm these results.

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Chronic Migraine Pathophysiology and Treatment: A Review of Current Perspectives

Frontiers in Pain Research ◽

10.3389/fpain.2021.705276 ◽

2021 ◽

Vol 2 ◽

Author(s):

Tiffani J. Mungoven ◽

Luke A. Henderson ◽

Noemi Meylakh

Keyword(s):

Chronic Migraine ◽

Current Knowledge ◽

Treatment Options ◽

Episodic Migraine ◽

Current Treatment ◽

Future Research ◽

Socioeconomic Outcomes ◽

Risk Factor Modification ◽

Evidence Based Treatments ◽

Migraine Pathophysiology

Chronic migraine is a disabling neurological disorder that imposes a considerable burden on individual and socioeconomic outcomes. Chronic migraine is defined as headaches occurring on at least 15 days per month with at least eight of these fulfilling the criteria for migraine. Chronic migraine typically evolves from episodic migraine as a result of increasing attack frequency and/or several other risk factors that have been implicated with migraine chronification. Despite this evolution, chronic migraine likely develops into its own distinct clinical entity, with unique features and pathophysiology separating it from episodic migraine. Furthermore, chronic migraine is characterized with higher disability and incidence of comorbidities in comparison to episodic migraine. While existing migraine studies primarily focus on episodic migraine, less is known about chronic migraine pathophysiology. Mounting evidence on aberrant alterations suggest that pronounced functional and structural brain changes, central sensitization and neuroinflammation may underlie chronic migraine mechanisms. Current treatment options for chronic migraine include risk factor modification, acute and prophylactic therapies, evidence-based treatments such as onabotulinumtoxinA, topiramate and newly approved calcitonin gene-related peptide or receptor targeted monoclonal antibodies. Unfortunately, treatments are still predominantly ineffective in aborting migraine attacks and decreasing intensity and frequency, and poor adherence and compliance with preventative medications remains a significant challenge. Novel emerging chronic migraine treatments such as neuromodulation offer promising therapeutic approaches that warrant further investigation. The aim of this narrative review is to provide an update of current knowledge and perspectives regarding chronic migraine background, pathophysiology, current and emerging treatment options with the intention of facilitating future research into this debilitating and largely indeterminant disorder.

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Fremanezumab in the Prevention of High-Frequency Episodic and Chronic Migraine: A 12-Week, Multicenter, Real-Life, Cohort Study (The FRIEND Study).

10.21203/rs.3.rs-1175049/v1 ◽

2021 ◽

Author(s):

Piero Barbanti ◽

Gabriella Egeo ◽

Cinzia Aurilia ◽

Florindo d'Onofrio ◽

Maria Albanese ◽

...

Keyword(s):

Chronic Migraine ◽

High Frequency ◽

Rating Scale ◽

Numerical Rating Scale ◽

Real Life ◽

Drug Effects ◽

Episodic Migraine ◽

Primary Study ◽

Life Study ◽

Younger Age

Abstract Background Fremanezumab has demonstrated to be effective, safe, and tolerated in the prevention of episodic or chronic migraine (CM) in randomized, placebo-controlled trials (RCTs). Real-life studies are needed to explore drug effects in unselected patients in routine circumstances and to provide higher generalizability results. This study explores the effectiveness, safety, and tolerability of fremanezumab in a real-life population of individuals affected by high-frequency episodic (HFEM: 8-14 days/month) or CM. Methods This is a 12-week multicenter, prospective, cohort, real-life study. We considered all consecutive patients affected by HFEM or CM visited at 9 Italian headache centers from 28/07/2020 to 11/11/2020. Eligible patients were given subcutaneous fremanezumab at the doses of 225 mg monthly or 675 mg quarterly, according to their preference. Primary study endpoints were the change in monthly migraine days (MMDs) in HFEM and monthly headache days (MHDs) in CM patients at weeks 9-12 compared to baseline. Secondary endpoints encompassed variation in monthly analgesic intake (MAI), Numerical Rating Scale (NRS), HIT-6 and MIDAS scores, and ≥50%, ≥75% and 100% responder rates at the same time intervals. Results 67 migraine patients had received ≥1 subcutaneous fremanezumab dose and were considered for safety analysis, while 53 patients completed 12 weeks of treatment and were included also in the effectiveness analysis. Fremanezumab was effective in both HFEM and CM, inducing at week 12 a significant reduction in MMDs (-4.6, p<0.05), MHDs (-9.4, p<0.001), MAI (-5.7, p<0.05; -11.1, p<0.001), NRS (-3.1, p<0.001; -2.5, p<0.001), and MIDAS scores (-58.3, p<0.05; -43.7; p<0.001). HIT-6 was significantly reduced only in HFEM patients (-18.1, p<0.001). Remission from CM to episodic migraine and from MO to no-MO occurred in 75% and 67.7% of the patients. The ≥50%, ≥75% and 100% responder rates at week 12 were 76.5%, 29.4% and 9.9% in HFEM and 58.3%, 25% and 0% in CM. Younger age emerged as a positive response predictor (OR=0.91; 95% CI 0.85-0.98, p=0.013). Treatment-emergent adverse events were uncommon (5.7%) and mild. No patient discontinued fremanezumab for any reason. Conclusions Fremanezumab seems more effective in real-life than in RCTs. Younger age emerges as a potential response predictor.

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