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American Headache Society Annual Meeting

Access daily, concise peer-reviewed reports from the American Headache Society Annual Meeting selected by the Neurology Today editors.

Tuesday, June 30, 2020

 Most veterans treated at Headache Centers for Excellence in the Veterans Affairs (VA) health care system are designated as having a headache 'not otherwise specified (NOS)'— a catch-all diagnosis that may limit therapy options, researchers suggested in their presentation at the virtual annual scientific meeting of the American Headache Society.

The investigators wanted to determine differences in headache occurrence among the Headache Centers of Excellence based on comorbidities and gender.

About 16 percent of veterans were documented to have headache in at least one hospital code, creating a population of about 1.4 million individuals—and 85 percent of these headaches were classified as NOS, reported Jason J. Sico, MD,  director of the Congressional-mandated Headache Centers of Excellence Research and Evaluation Center at the Veterans Health Administration, and director of the Headache Center of Excellence at the Veterans Affairs Connecticut Healthcare System in New Haven, CT.

"We were surprised that more than half of headache diagnoses fell into the category of headache-NOS," Dr. Sico told Neurology Today At the Meetings. "This could be for a myriad of reasons, including varying degrees of familiarity with the International Classification of Headache Disorders-third edition (ICHD-3) classification system or uncertainty about making a more specific headache diagnosis until additional evaluations such as brain imaging are completed."

About 36 percent of the patients with headache were classified as having migraine—the two classifications were not mutually exclusive, said Dr. Sico, who also is associate professor of neurology and of internal medicine at Yale School of Medicine.

Over the course of 10 years, the researchers also identified 71,344 cases of individuals with headache who had a history of traumatic brain injury. That represented about 5 percent of the total headache cohort. Headache with traumatic brain injury history was reported in 5.4 percent of the men and 2.6 percent of women in the study (p<0.0001), Dr. Sico said.

But even in this group, the diagnosis of headache-NOS predominated, he said, with 85 percent of both men and women with traumatic head injury receiving the headache-NOS diagnosis compared with 67.3 percent of the women (p<0.0001).

Post-traumatic headache was diagnosed in 43,184 veterans or 3 percent of cohort; and that included 3.2 percent men and 1.8 percent women, (p< .0001). About 16 percent of both sexes who experienced traumatic brain injury were also diagnosed with post-traumatic headache.

At least one non-headache pain condition was present in 90 percent of veterans with headache, with no gender difference. The most common comorbid pain conditions for both genders were limb pain (77.5 percent) and back pain (62.6 percent). Women had significantly higher rates of pelvic pain and systemic pain. 

"We are now just understanding gender differences as they apply to headache among veterans," Dr. Sico said. "We found that women were more likely to be diagnosed with migraine than men. We know from decades of studies outside of the Veterans Health Administration that migraine occurs more commonly among women than men."

"We were also surprised by the low rate of post-traumatic headache within this population of veterans," he said. "We believe that the low post-traumatic headache rate can be partially explained by the current ICHD-3 definition that requires that post-traumatic headache begin within seven days of the head injury. As many headaches that appear later have the same characteristics as those appearing within seven days, perhaps a timeframe of within a year of injury, especially for persons leaving active duty and returning stateside following a traumatic brain injury, may be warranted."

"In considering both the high rates of headache NOS and low rates of post-traumatic headache, work is needed to assure that veterans get the best and most appropriate headache diagnosis," Dr. Sico added.

Commenting on the study, Peter Goadsby, MD, PhD, DSc, professor of neurology at King's College London, told Neurology Today At the Meetings, that the large percentage of men whose headaches were called 'not otherwise specified' or 'no specific cause' was disappointing.

"A headache diagnosis requires a history, so it is inexpensive, and there are good screening tools, such as ID-Migraine. The problem with headache-NOS is that there is no treatment. Diagnosis allows a treatment plan that will most often not involve simply using analgesics, so it is crucial to make a specific diagnosis as it is in the patients' best interest, noted Dr. Goadsby.

"One possible issue in the VA population is the predominance of men," Dr. Goadsby said. "Whereas migraine is more common in females in the population, and this is well known, it is possible this knowledge clouds the inclination to diagnose migraine in men. I would encourage the authors to study the NOS group as simply improving diagnosis is bound to improve their care."

Disclosures: Drs. Sico and Goadsby had no relevant disclosures.

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AHS Abstract: Fenton BT, Lindsey H, Grinberg A, et al. Prevalence of headache and comorbidities among men and women veterans across the Veterans Health Administration—A 10-year cohort study.

Tuesday, June 30, 2020

Men and women veterans who acknowledged being victims of sexual trauma while serving in the military had a higher risk of migraine and other pain-related complaints, researchers reported at the virtual annual scientific meeting of the American Headache Society.

John P. Ney, MD, MPH, assistant professor of neurology at Boston University, and colleagues analyzed administrative data from the Women's Veteran's Cohort Study, a sample of more than one million post-9/11 US veterans enrolled for Veterans Health Administration (VHA) care. A positive military sexual trauma screen in the VHA electronic medical record defined exposure.

Out of more than 800,000 veterans who were screened for the study, 37,375 were positive for military sexual trauma; approximately 66 percent were women and 34 percent men, Dr. Ney said. Overall, migraine was reported in 21.7 percent of veterans with a history of military sexual trauma compared with 9 percent of the veterans who did not report sexual trauma, said Dr. Ney.

Dr. Ney said that treatment of persons with migraine who have a history of military sexual trauma may vary from recommendations. "We found that these persons were more often using acute health care resources such as emergency departments for treatment of their migraines and were more prone towards using medications that were not recommended by the AAN and AHS for headache treatment, which may ultimately be deleterious to their care. 

Among the 80,696 veterans diagnosed with migraine headache, a history of military sexual trauma was associated with a significant 37 percent greater likelihood of ambulatory urgent/emergent care, a 10 percent greater likelihood of neurology visits, and a 21 percent greater likelihood of physiatry visits.

Notably, Dr. Ney said, the dataset includes both male and female former service members reporting military sexual trauma, albeit with a much lower reported rate in men. "We are confident that the identified cases are true positives, though the number of false negatives is likely to be large," he said.

"Although veterans in their course of care through the VA are asked questions regarding military sexual trauma, we believe that any attempts at determining prevalence will likely be an undercounting of the true numbers."

 "Our study can only show the association of military sexual trauma with migraine, but it does not purport to show causality, that migraine is 'caused by' or a 'manifestation of' sexual trauma," Dr. Ney told Neurology Today At the Meetings. "Having said that, migraine is a very common phenomenon, and most men and women who have served in the military are in the age category where migraines occur."

"Migraines are exacerbated by poor sleep, and prior studies show associations with psychiatric conditions from stress, including post-traumatic stress disorder," he said. "Military sexual trauma may precipitate a similar phenomenon, and headaches or other pain syndromes may be unmasked by the sequalae of sexual trauma."

These numbers may not tell the whole story, Dr. Ney said. "Even in 2020 there is considerable stigma to admitting to being sexually victimized in society, and likely more so in the military, that prizes strength and physical prowess in its members," he said.

"All active duty and veterans should be asked about military sexual trauma regardless of their health or disease conditions," Dr. Ney said. "Within the VA, it is mandated nationally to screen for military sexual trauma within primary care. At the same time, we are working to identify treatment modalities that are especially successful in the care of persons living with migraine and military sexual trauma."

Commenting on the study, Nina Riggins, MD, assistant clinical professor of neurology at the University of California, San Francisco, suggested that there are biological mechanisms that may be associated with both sexual trauma and migraine. "Migraine is a genetic neurologic disorder," she told Neurology Today At the Meetings.

"Multiple brain networks can be affected. Dysfunction of several systems is possible after sexual trauma, including the serotonergic, autonomic nervous system and hypothalamic-pituitary-adrenal axis, which is involved in response to stress. Stress, insomnia, hormonal changes, and serotonergic dysfunction can trigger migraine."

Dr. Riggins noted that the investigators reported a 9 percent prevalence rate of migraine in the gender-adjusted group without military sexual trauma. "We know that migraine affects about 12 percent of the population in the United States. We need to conduct more studies to see if sexual trauma is under-reported and accounts for at least some of this difference."

Dr. Riggins added, "Knowing the history and triggers can help to guide treatment options for these individuals with migraine. It is important to avoid opioids when possible in people living with migraine. The combination of behavioral therapy, migraine management, and addressing any other conditions potentially connected to sexual trauma, can be beneficial for improvement of functioning, symptoms, and quality of life."

Disclosures: Drs. Ney and Riggins had no relevant disclosures.

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AHS Abstract: Ney JP, Fenton BT, Sico J, et al. Survivors of military sexual trauma face increased risk of migraine headaches and worse headache care.

Tuesday, June 30, 2020

The risk of developing dementia later in life appears to be greater in people who have migraine attacks accompanied by aura, researchers reported at the virtual annual scientific meeting of the American Headache Society.

The findings, which were based on a Danish population-based cohort study, support the hypothesis that migraine is a midlife risk factor for dementia in later life, the study authors wrote. While migraine and a risk of dementia had previously been reported, those studies did not differentiate between patients with or without aura, they said.

For the analysis, the researchers retrieved data from a national Dutch register from 1988–2017, scrutinizing records for people born between 1935 and 1956 for a total of 1,657,890 people before they turned 59 years old; approximately 18,135 had migraine. They followed the individuals for dementia from age 60, matching them on the basis of sex and birth date with individuals without migraine. In total, 62,578 were eligible for the analyses.

"Compared with individuals without migraine, we found a 50 percent higher rate of dementia among individuals with migraine (HR = 1.50; 95% CI: 1.28-1.76)," reported Jakob Moller Hansen, MD, PhD, MSc, director of the Danish Headache Knowledge Center and a consultant at the Danish Headache Center at Rigshospitalet in Copenhagen, Denmark.

But in individuals without aura, the hazard ratio was 1.19, and that failed to achieve statistical significance, Dr. Hansen told Neurology Today At the Meetings. On the other hand, in individuals whose migraine was accompanied by aura the hazard ratio was 2.11 (95% CI: 1.48-3.00), a significant difference, he said.

Dr. Hansen said that the risk of dementia among the patients diagnosed with migraine did not differ by sex. He noted that migraine with aura is a risk factor for ischemic stroke, whereas no increased risk is found for migraine without aura. 

"Our data suggest that individuals with migraine with aura had the highest hazard ratio of dementia, which aligns with previous evidence that support strong vascular mechanisms in migraine with aura," he said. "This also adds to the knowledge on severe long-term consequences of migraine with aura."

Dr. Hansen said the researchers are working on assessing the impact of migraine with or without aura by analyzing potential modifying factors such as attack frequency and types of treatment. "In general, modifiable risk factors for cardiovascular diseases should be tended to," he said. "We are currently looking at just that—the impact of migraine treatment on dementia in migraine patients."

Commenting  on the study, Jessica Ailani, MD, FAAN, associate professor of neurology at MedStar's Georgetown University and MedStar Georgetown Medical Center in Washington, DC, said, "When we look at patients with migraine with aura and those without aura, we wonder if the mechanism of both disorders is similar or if there are some major changes. We know that cortical spreading depression is involved with migraine with aura. We know that in migraine with aura there are changes in white matter in the brain. We question if there is an effect with aura on the vascular system because of changes in endothelial cells. We want to know if there may be a greater 'stickiness' of cells with aura."

"Patients are always asking us about a correlation of dementia with migraine," Dr. Ailani told Neurology Today At the Meetings. "We do know that the greatest risk for dementia is not Alzheimer's disease but is vascular disease caused by high blood pressure and other factors that can cause long-term changes in the brain that can cause memory issues and trouble functioning.

"This study by Dr. Hansen makes one think that there could be a connection between migraine with aura and vascular changes, which may lead to dementia," she said.

"If we could reduce the frequency of migraine attacks, could we reduce the risk of having more of these events such as mini-blood clots and vascular stickiness?" Dr. Ailani asked. "We need to treat migraine early and aggressively. We also need to keep patients under good blood pressure control, keep diabetes in check, and reduce hyperlipidemia as well," Dr. Ailani said.

Disclosures: Dr. Hansen has received speakers' fees from Teva, Novartis, and Eli Lilly. Dr. Ailani receives an honorarium for consulting and serving on the advisory board for Allergan, Amgen, Alder/Lundbeck, Biohaven, Eli Lilly, Teva, Impel, Satsuma, Revance, and Zosano. She serves on the speaker's bureau for Allergan, Amgen, Biohaven, Eli Lilly, Lundbeck, and Teva, and has received research funding from clinical trials from  the American Migraine Foundation, Allergan, Biohaven, Eli Lilly, Satsuma, and Zosano.

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AHS Abstract: Islamoska S, Hansen JM, Hansen AM, et al. Migraine as a risk factor for dementia: A national register-based follow-up study.

Tuesday, June 30, 2020

Adding monoclonal antibody-based medication to treatment for patients whose migraine is not controlled by onabotulinumtoxinA reduces the number of headache days, researchers reported at the virtual annual scientific meeting of the American Headache Society.

Patients who received combined therapy reported an average of 8.69 monthly headache days, which represented a decrease of an average of 16.60 monthly headache days, reported Fred Cohen, MD, a resident physician in internal medicine at the Montefiore Medical Center and Albert Einstein College of Medicine in the Bronx, NY.

Dr. Cohen said that the difference translated to a highly significant 65.6 percent reduction from baseline (p=0.0001). The improvement also was achieved without a great cost in adverse events, he said.

"Only 13 patients or 8.5 percent of the total reported side effects to the novel calcitonin gene-related peptide monoclonal antibodies (CGRP) medications. Those adverse events were mainly constipation, injection site reactions, and/or fatigue," he said. Patients were administered the CGRP medications: fremanezumab, galcanezumab or erenumab.

"While our study does show patients having fewer monthly headache days with both onabotulinumtoxinA and a CGRP compared with onabotulinumtoxinA alone, it ultimately is a retrospective chart review," Dr. Cohen said. "That means this study suffers from weaknesses such as possible confounders and recall bias. Therefore, I do not think these data would be high enough quality to change or create a protocol."

"However," he added, "I do think this study provides insight for providers who have patients already receiving onabotulinumtoxinA that require further preventive therapy. Prior to this study, there was very little to no information on patients receiving both onabotulinumtoxinA and a CGRP. Part of that is because patients who were taking onabotulinumtoxinA were excluded from the CGRP trials. Our data show that adding a CGRP would provide a further reduction in monthly headache days and headache pain severity, as well as being safe and tolerable."

For the trial, Dr. Cohen and colleagues conducted a retrospective chart review of patients with chronic migraine receiving treatment with onabotulinumtoxinA who had been prescribed a CGRP medication. Inclusion criteria included adult patients who were diagnosed with chronic migraine, and were receiving onabotulinumtoxinA and a CGRP medication from May 2018 to May 2019. Patients were excluded if they received another new therapy during the study period or treatment with a CGRP medication for less than two months.

The researchers included 153 patients in the study. In addition to onabotulinumtoxinA, Dr. Cohen reported that 889 patients–or 58 percent of the group—were treated with erenumab, either 70 mg or 140 mg; 51 patients were taking galcanezumab, and 13 patients were receiving on fremanezumab.

Nearly three-fourths of the patients in the study reported a decrease in either monthly headache days or headache pain severity, with quantitative data documented in 66 patients. Of these 66 patients, the average monthly headache days prior to initiating onabotulinumtoxinA treatment was 25.30. After onabotulinumtoxinA treatment, an average decrease of 10.96 monthly headache days was reported, but patients continued to have an average of 14.34 monthly headache days despite successful treatment. After the addition of a CGRP medication, patients experienced a further decrease of 5.64 monthly headache days, an additional 22.3 percent reduction from onabotulinumtoxinA alone (p=0.0001).

"Our next step is to conduct a prospective chart review, which would provide higher quality data," Dr. Cohen said. "A randomized clinical trial would be a step I would like to take, for that provides the highest quality of data."

He suggested that more data is needed before considering a first-line CGRP therapy in patients with chronic migraine. "I do think it is a possibility," he said. "This would also benefit patients who would want an alternative to onabotulinumtoxinA injections. These injections could be cumbersome for patients due to the need to return to the clinic every three months to receive treatment, whereas a CGRP could be taken monthly or quarterly at home."

In commenting on the study, Robert Cowan, MD, the Higgins Professor of Neurology and Neurosciences and chief of headache medicine at Stanford School of Medicine in Palo Alto, CA, said: "These findings are compelling and they are also consistent with our own experience at Stanford and with that of many colleagues."

"Moreover, there is no theoretical reason for concern in combining the two therapies, although onabotulinumtoxinA does lower CGRP levels. However, to establish a firm evidence base for a protocol, a prospective study needs to be done," Dr. Cowan said.

Dr. Cowan was also cautious about using CGRP upfront. "Until we have data on the impact of these monoclonal antibodies in subpopulations over time, I would not be comfortable using them as a first-line treatment. Until we know the impact on patients who have monoclonal antibodies on board and then experience acute events such as stroke, myocardial infarction, bowel infarction, closed head trauma, etc., questions will remain. Similarly, we need data on the impact of monoclonal antibodies on patients with other comorbid chronic conditions such as arthritis, lung disease, and so forth."

Disclosures: Dr. Cohen had no disclosures. Dr. Cowan has received honoraria for serving as an advisory board member to Amgen, Alder, Allergan, and Teva.

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AHS Abstract: Cohen F, Armand C, Vollbracht S. Efficacy and tolerability of CGRP monoclonal antibody medications in patients with chronic migraine undergoing treatment with onabotulinumtoxinA.

Tuesday, June 30, 2020

Visual snow, a mostly spontaneous phenomenon that may be related to migraine, appears to be triggered by inciting events, systemic illness, or lesions along the visual pathway, researchers reported at the virtual annual scientific meeting of the American Headache Society.

Patients often describe visual snow as similar to seeing black and white or colorful flickering dots like 'television static,' said the lead study author Dev Mehta, DO, a fellow in neurology at the Mayo Clinic in Rochester, MN.

To learn more about possible causes, the researchers performed a retrospective chart review of patients who presented to the Mayo Clinic between January 1994 and January 2020; they looked for the search term "visual snow." They also collected demographic data including age at symptom onset, duration of follow-up, history of migraine, visual snow characteristics, comorbid diagnoses, treatments and their response, and neurologic and ophthalmologic evaluations.

Among the 248 patients who met study criteria, comorbid migraine was present in 79 percent; 33.5 percent had tinnitus, 29.4 percent, depression, and 49.6 percent, anxiety, said Dr. Mehta, who will soon be moving to do a fellowship in psychiatry at the University of Washington in Seattle.

The research team scrutinized the cases of 88 individuals who had underlying causes for visual snow phenomena or could identify an inciting event. Among those events, one person attributed visual snow to a neoplastic occurrence, three to infections, and four to intracranial hypertension. Visual snow occurred with ocular pathology in seven people, posterior cortical atrophy in one person, and hallucinogen-persistent perception disorder in 10 persons.

"We also identified 41 patients with transient visual snow, including 37 with visual snow as their migraine aura," Dr. Mehta said. "Some patients had partial improvement with lamotrigine, topiramate, acetazolamide, and benzodiazepines. No patient experienced complete remission."

Commenting on the study, Marc Dinkin, MD, director of neuro-ophthalmology and associate professor of ophthalmology and of neurology at Weill Cornell Medical College and NewYork Presbyterian Hospital, said: "As researchers such as Dr. Mehta and his colleagues describe visual snow and show the gamut of triggers, they shine a light on the possibility that there is a true inciting event, which would help us understand the mechanism and allow us to manage it."

Dr. Dinkin said he sees patients with visual snow frequently. "In some cases, visual snow may occur contemporaneously with other medical conditions. Whether all of the 88 of 248 cases in Dr. Mehta's study—where there was an inciting event—reflected true causation as opposed to association remains to be seen," Dr. Dinkin said.

"In either case, it should be recognized that what the authors were looking at was just the symptom 'visual snow' as opposed to the 'visual snow syndrome,' which tends to be accompanied by other symptoms such as after images, trailing images, photophobia, nyctalopia, entopic phenomena, photopsia, tinnitus, and migraine. 

"In some of their cases, especially those with ocular pathology, the symptom may reflect structural retinal pathology and therefore encompass a pathological process quite different from visual snow syndrome, which appears to be related to changes in regions of the cortex," he said. "I look forward to reading the study authors' full manuscript when it is published."

Disclosures: Drs. Mehta and Dinkin had no relevant disclosures.

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AHS Abstract: Mehta D, Garza I, Robertson CE. Visual snow case series: Review of 248 cases with attention to underlying causes or inciting events.