Galcanezumab (Emgality)

CADTH recommends that Emgality should be reimbursed by public drug plans for the prevention of migraine if certain conditions are met. Emgality should only be covered to prevent migraine attacks in adult patients who have tried at least 2 other types of oral preventive medications. Emgality should only be reimbursed if the patient is being cared for by a physician who has experience managing migraine headaches. Emgality will only be reimbursed for 6 months at a time. Emgality should not be more than the least costly drug of the same class used to prevent migraine.

Migraine Headaches after Major Surgery with General or Neuraxial Anesthesia: A Nationwide Propensity-Score Matched Study

Migraine headaches can be provoked by surgical stress and vasoactive effects of anesthetics of general anesthesia in the perioperative period. However, it is unclear whether general anesthesia increases the migraine risk after major surgery. Incidence and risk factors of postoperative migraine are also largely unknown. We utilized reimbursement claims data of Taiwan’s National Health Insurance and performed propensity score matching analyses to compare the risk of postoperative migraine in patients without migraine initially who underwent general or neuraxial anesthesia. Multivariable logistic regressions were applied to calculate the adjusted odds ratio (aOR) and 95% confidence interval (CI) for migraine risk. A total of 68,131 matched pairs were analyzed. The overall incidence of migraine was 9.82 per 1000 person-years. General anesthesia was not associated with a greater risk of migraine compared with neuraxial anesthesia (aORs: 0.93, 95% CI: 0.80–1.09). This finding was consistent across subgroups of different migraine subtypes, uses of migraine medications, and varying postoperative periods. Influential factors for postoperative migraine were age (aOR: 0.99), sex (male vs. female, aOR: 0.50), pre-existing anxiety disorder (aOR: 2.43) or depressive disorder (aOR: 2.29), concurrent uses of systemic corticosteroids (aOR: 1.45), ephedrine (aOR: 1.45), and theophylline (aOR: 1.40), and number of emergency room visits before surgery. There was no difference in the risk of postoperative migraine between surgical patients undergoing general and neuraxial anesthesia. This study identified the risk factors for postoperative migraine headaches, which may provide an implication in facilitating early diagnoses and treatment.

Cognitive Behavioral Therapy for Migraine Headache: A Systematic Review and Meta-Analysis

Background and Objectives: Migraine headaches are chronic neurological diseases that reduce the quality of life by causing severe headaches and autonomic nervous system dysfunction, such as facial flushing, nasal stuffiness, and sweating. Their major treatment methods include medication and cognitive behavioral therapy (CBT). CBT has been used for pain treatment and various psychogenic neurological diseases by reducing pain, disability, and emotional disorders caused by symptoms of mental illness and improving the understanding of mental health. This study aimed to evaluate the effectiveness and safety of CBT in treating migraines. Materials and Methods: Seven electronic databases were searched from the date of inception to December 2020. Randomized controlled studies (RCTs) using CBT as an intervention for migraine were included. The primary outcome of this study was to determine the frequency of migraines and the intensity of migraines on Visual Analog Scale (VAS), the frequency of drug use, Migraine Disability Assessment (MIDAS), and Headache Impact Test (HIT-6) index. The two authors independently conducted the data extraction and quality assessment of the included RCTs, and conducted meta-analysis with RevMan V.5.4. Results: Among the 373 studies, 11 RCTs were included in this systematic review. Seven out of the 11 RCTs were conducted in the USA, and four were conducted in the UK, Germany, Iran, and Italy, respectively. Headache frequency and MIDAS scores were statistically significant reduced. In the subgroup analysis, headache strength was significantly reduced. Two of the included studies reported adverse effects, including worsening of migraine intensity and frequency, respiratory symptoms, and vivid memory of a traumatic event. Conclusions: CBT for migraine effectively reduced headache frequency and MIDAS score in meta-analysis and headache intensity subgroup analysis, with few adverse events. Additional RCTs with CBT for migraine headaches are needed for a more accurate analysis.

Risk of Vestibulocochlear Disorders in Patients with Migraine or Non-Migraine Headache

Headaches, especially migraines, have been associated with various vestibular symptoms and syndromes. Tinnitus and hearing loss have also been reported to be more prevalent among migraineurs. However, whether headaches, including migraine or non-migraine headaches (nMH), are associated with vestibular and cochlear disorders remains unclear. Thus, we sought to investigate possible associations between headache and vestibulocochlear disorders. We analyzed 10 years of data from the Smart Clinical Data Warehouse. In patients with migraines and nMH, meniere’s disease (MD), BPPV, vestibular neuronitis (VN) and cochlear disorders, such as sensorineural hearing loss (SNHL) and tinnitus, were collected and compared to clinical data from controls who had health check-ups without headache. Participants included 15,128 with migraines, 76,773 patients with nMH and controls were identified based on propensity score matching (PSM). After PSM, the odds ratios (OR) in subjects with migraine versus controls were 2.59 for MD, 2.05 for BPPV, 2.98 for VN, 1.74 for SNHL, and 1.97 for tinnitus, respectively (p < 0.001). The OR for MD (1.77), BPPV (1.73), VN (2.05), SNHL (1.40), and tinnitus (1.70) in patients with nMH was also high after matching (p < 0.001). Our findings suggest that migraines and nMH are associated with an increased risk of cochlear disorders in addition to vestibular disorders.

Determinants of migraine headache among regular undergraduate students, of Wollo University, Dessie, Ethiopia: cross–sectional study

Background The prevalence of migraine headaches varied from 2.4 to 48.5% worldwide among university students. As per the knowledge of the investigators, the study of migraine headaches is not done in this study area. Hence, this study aimed to assess determinates of migraine headaches among regular undergraduate students, of Wollo University, Dessie, Ethiopia, 2020. Method Institution-based cross-sectional study design was conducted from November 15–30 /2020 by using a self-administered questionnaire among 371 regular undergraduate students at Wollo University. A multistage sampling technique was employed to represent our study population. Identity migraine test, Migraine Disability Assessment Questionnaire, perceived stress scale, and Oslo social support scale was used. Descriptive statistics, binary and multiple logistic regression were employed. The adjusted odds ratio at a 95% confidence interval and level of significance (p-value < 0.05) was used to interpret the findings. Results From 371 participants, the prevalence of migraine headache in this study was 34% (95% CI: 29.2, 38.5). Variables statistically associated with migraine headache, were a family history of headache (AOR = 3.83, CI: 2.313, 6.366), suicidal thoughts in the past 3 months (AOR = 10.76, CI: 2.117, 54.74), and had low perceived stress 62.6% (AOR = 0.374, CI: 0.205, 0.683). Conclusion In this study, the prevalence of migraine headaches was very high. Family history of headache, suicidal thoughts, and low perceived stress were determinates for migraine headache. So special emphasis shall be given to those participants who had high perceived stress, a family history of migraine headache, and suicidal thoughts.

Episodic Hemiparesis, Cognitive Decline, and Seizures in a Woman With Pernicious Anemia

A 46-year-old woman with a history of pernicious anemia, sought care for intermittent episodes of weakness in her right upper extremity and speech difficulties followed by a headache. It was initially thought that she had migraine headaches. Blood tests showed increased thyrotropin and low free thyroxine levels, and she was diagnosed with Hashimoto thyroiditis. She initiated treatment with levothyroxine. One month later, the patient had a confusional episode and over the course of the following 2 months, the cognitive difficulties progressed. She was brought to the emergency department after a generalized tonic-clonic seizure. On examination, she was profoundly encephalopathic. Formal bedside cognitive testing could not be obtained. Findings of magnetic resonance imaging of the brain were normal. Electroencephalography revealed diffuse slowing. Cerebrospinal fluid analysis showed increased protein concentration and lymphocytic pleocytosis. Thyroid peroxidase antibody value was markedly increased. Thyroglobulin antibody value was also increased. Consistent with her history of pernicious anemia, she was positive for gastric parietal cell antibodies. The clinical presentation was compatible with steroid-responsive encephalopathy associated with autoimmune thyroiditis, also known as Hashimoto encephalopathy. The patient started levetiracetam therapy and had no further seizures. She received intravenous methylprednisolone. At the completion of treatment, her confusion rapidly and substantially improved. She was discharged home on oral prednisone. She also started pantoprazole, calcium, and vitamin D supplementation and Pneumocystis jirovecii prophylaxis. For long-term immunotherapy, she initiated methotrexate. Three months later, the patient and her family reported 90% improvement in her cognitive functioning and resolution of the episodes of hemiparesis. The patient continued tapering prednisone. It was recommended that she continue methotrexate for 5 years before discontinuing. Steroid-responsive encephalopathy associated with autoimmune thyroiditis, also known as Hashimoto encephalopathy, was initially described as strokelike episodes and subacute encephalopathy months after the onset of autoimmune (Hashimoto) thyroiditis.

Lesions Found by Chance

A healthy 26-year-old woman with a history of episodic migraine without aura since age 12 years had a first-ever event of transient visual impairment. She reported to her neurologist that she “lost vision” for 15 minutes and described a “black blob” with a bright jagged border that moved across her binocular visual field and resolved without sequelae. Minutes later, one of her typical migraine headaches developed. Given the patient’s history of typical episodic migraine, the new visual event’s clinical characteristics were highly consistent with a migraine aura. Because of the new transient visual symptoms, the neurologist ordered brain magnetic resonance imaging, which showed several periventricular white matter lesions, including some that involved the corpus callosum and were oriented perpendicular to the septocallosal surface. The patient was counseled about the magnetic resonance imaging findings and expressed the desire to fully evaluate her risk of multiple sclerosis. The patient was diagnosed with radiologically isolated syndrome. The patient was counseled regarding the relevance of the magnetic resonance imaging findings and risk of future development of multiple sclerosis. She was not prescribed a disease-modifying therapy for multiple sclerosis. This patient has radiologically isolated syndrome —incidentally found magnetic resonance imaging lesions consistent with demyelination in a patient with no symptoms or signs suggestive of multiple sclerosis.

The role of diet in the prevention of migraine attacks

The review provides information concerning the influence of dietary factors and different types of diet on the origin and frequency of migraine headaches according to the up-to-date scientific data. The relevance of the problem is associated with high prevalence of migraine, which is a common cause of disability amongst young people. Gut – brain axis takes a significant place in the pathophysiology of migraine. The concept of a gut-brain axis explains a bidirectional relationship between the gastrointestinal system and the central nervous system. It has been suggested that changes in the gut-brain axis functioning may play a role in the pathogenesis of migraine. The review describes possible mechanisms of gut microbiota involvement in the pathogenesis of migraine. Knowledge of the important role of food triggers in migraine has contributed to the development of a dietary therapeutic strategy for the prevention of migraine headache. The paper contains data concerning possible pathogenetically substantiated effects of various types of diet (elimination, epigenetic, ketogenic) in migraine prevention, given the lack of efficacy and side effects of current migraine drug therapy. The review discusses the possible positive effects of dietary approaches on migraine through their beneficial influence on the intestinal microbiota and functioning of the gut-brain axis. Conclusions. An update on the role of diet in the pathogenesis and prevention of migraine attacks is an extremely important and promising scientific field, which requires further research with the development of personalized approaches taking into account the individual characteristics of each patient.