Drawing Upon Headache Research
What’s New in Migraine Science
The 57th Annual Scientific Meeting of the American Headache Society in mid-June drew more than 1,000 migraine specialists from around the world to Washington, DC for one of the largest scientific meetings on migraine and headache. They gathered to share important new science and clinical information on a disorder that affects more than 36 million Americans.
Although the meeting was mainly for medical professionals who came to hear the latest scientific and clinical information on headache disorders, much of the program may be interesting for patients—particularly when there’s new science about their headache condition.
Some of the most exciting and newsworthy research developments include news about CGRP, a bright new hope in migraine treatment now in clinical trials, the use of telemedicine in treating migraine patients, problems with doctor-patient communication, use of opioids in treating both adults and children with migraine, how traumatic brain injury affects veteran’s lives when they return home, and teen sports-related concussions, to name a few.
Some Migraine Patients Can Just Dial It In
Telemedicine—using information exchanged by electronic communications to deliver medical services to patients—can make seeing a doctor a lot more convenient, especially if you don’t live near the one you need. It can involve two-way video, email, smart phones, wireless tools, and other forms of technology.
Now, telemedicine may be getting set to play an important role in follow-up treatment of patients with migraine. In a new study, after a first in-person visit, some migraine sufferers will continue being cared for the old-fashioned way, by going to an office or a clinic. Others will be treated using telemedicine (online and by phone). Researchers will follow both groups for a year.
While the study is not completed, some of the early results look good for telemedicine. For example, no one in the telemedicine group has withdrawn. Having to travel has already knocked 14% of the in-person group out of the study, and the time savings is no contest. Patients are averaging six-plus hours on a single live visit to the doctor. The virtual group? A whopping 43 minutes. Not surprising, none of the telemedicine patients has had to take time off work for their virtual visits. More than a third of the in-person group has had to miss work.
Some findings hint at possible challenges. The telemedicine group has rescheduled more often than the in-person group. It might be easier to cancel because it’s easier to get another virtual appointment, but with enough missed appointments, the quality of migraine care might suffer.
It’s also possible that the telemedicine patients are more disabled by their condition than the group who regularly gets to see a doctor. Taking time out for healthcare can be a real hassle, but there is still something to be said for face-to-face consultations in migraine.
These findings are preliminary, and things may change as the months pass. For now, the patients who are “dialing it in” seem satisfied, and telemedicine is saving them time and money on migraine care. With more positive results, it is likely that the role of telemedicine in follow-up care for migraine patients will grow.
Teleheadache Program a Virtual Success
For Americans with migraine, there are usually two options when it comes to getting an appointment with a headache specialist—difficult and near impossible. The numbers tell the story. For each specialist, there are more than 86,000 migraine patients.
Some researchers are looking for solutions in technology. They’ve seen how telemedicine—where specialists can examine patients and prescribe electronically—can bring doctors and patients together. What they don’t know is whether a visit to a virtual headache specialist will work as well in migraine as it has in other conditions.
In a new program for migraine called TeleHeadache, researchers compared virtual specialists with live visits to local doctors. They wanted to see how the quality of care matched up between migraine patients in the TeleHeadache program, who were treated by a virtual specialist, with migraine patients who went to a live doctor near their home.
Since “quality of care” can mean a lot of things, these researchers decided to look at whether patients were prescribed the best possible medications, that is, treatments supported by clinical research and recommended by leading headache experts.
TeleHeadache worked very well. While still not perfect, patients in the program received the recommended medications about three quarters of the time. Patients who went to a local doctor only got the right drugs about one quarter of the time. The results were about the same whether patients needed acute or preventive medication.
That means participating in the TeleHeadache program roughly tripled the chances that a patient would receive expert-recommended treatments.
Since this was a small study, these positive results will keep the program going. Stay tuned for more news about this promising approach to migraine care.
Doctors Eavesdrop…And Are Disappointed By What They Hear
Ever have trouble being understood? Sometimes making others understand you can be a challenge. For doctors, making sure patients understand their condition and how it’s going to be treated is a central part of the job. After all, the Latin root of the word doctor, docere, means “to teach.”
Doctors who are good at it seem to share the ability to say the same thing in many different ways. They listen to patients, size up situations, and then adjust how they explain a condition like chronic migraine—but they never really change what they’re saying. Like good teachers, they get the main points across in a way that’s designed to stick.
Communicating well is hard work, particularly with something as complex as migraine, and not every healthcare professional excels at it. As if to confirm the point, a new study shows that there’s plenty of room for improvement.
The researchers used anonymous transcriptions of conversations between doctors and chronic migraine patients. They looked specifically for a style known as “ask-tell-ask,”in which:
- Physicians ask for information.
- Patients tell them the information.
- Physicians clarify what’s been said to make sure they understand, then ask the next question.
The cycle continues for as long as physicians need to figure out what patients need.
In the study, the team found that doctors asked lots of questions, an average of 17, but the rest of their findings were less than encouraging:
- More than 80% were “closed-ended” yes-no question or verbal multiple choice questions.
- Less than a quarter (23%) of questions dealt with disability, mainly missing work or school.
- The recommended ask-tell-ask style was barely used, showing up in only 4% of the conversations.1
Even though patients in this study were suspected of having migraine, only 9% of the questions mentioned a diagnosis of chronic migraine.
The research team concluded that most of the doctor-patient conversations they heard about chronic migraine were missing important elements. As a result, they suggest that better communication between doctors and chronic migraine patients might improve the overall level of care.
1 Lipton RB, Buse DC, Arctander K, Gillard PJ. Communication patterns in physician and chronic migraine patient dialogues during routine office visits. Headache. 2015. In press.
Teens and Sports-Related Concussion
A concussion is one of the more frightening injuries in sports, especially when the athlete is a teenager. While nearly all athletes (94%) have headaches in the days and weeks after their injury, no one really knows what kinds of headaches affect younger athletes who have had a concussion.
For clarification, new research looked at athletes between 12 and 19 years old who had a sports-related concussion. They played a variety of sports.
Like older athletes, headache after a concussion was very common in the teenagers—all of them had headaches. Most (80%) said the headaches were made worse by physical activity or tough mental challenges, and a few (5%) noted that they had lost consciousness.
The most common types of headache reported by the young athletes were migraine and probable migraine. Many also had symptoms typically seen in people with migraine, such as:
- Changes in vision.
- Sensitivity to light and sound.
Nearly three quarters of participants were dizzy or had trouble thinking. Before the current study, about a quarter the athletes had a concussion (i.e., a second or third event was being studied), and 12 percent had attention deficit hyperactivity disorder.
The study confirms that teenage athletes are prone to migraine and probable migraine after a concussion, perhaps even more than their older counterparts. It also shows that athletes who have headaches, a concussion, or attention deficit hyperactivity disorder before a concussion generally return to play more slowly than those who do not have these histories.
Concussion Doubles Migraine Risk in High School Football Players
High school football players may enjoy celebrity status at school, but there’s no cause for celebration when a young player suffers a concussion during a practice or game. With head injuries among pro football players grabbing headlines lately, it’s not surprising that medical experts would focus on younger players, especially given the potential for long-term consequences. What is surprising is how little is known about concussion and headaches in football players at the high school level.
A recent survey of 74 high school football players, ranging in age from 14 to 18, sheds some light on these important topics. Researchers asked them 20 questions about their personal experience and family history with concussion and headaches.
More than a third of the survey respondents had migraine. An even greater percentage (37.5%) had a concussion, with just under 30% experiencing more than one concussion. Just over 40% of players who had a concussion also have migraine or probable migraine—more than double the risk in the general population (16.2%). If players had more than one concussion, their risk of migraine or probable migraine was more than three times the rate in the general population (50%).
More studies will be needed to figure out what these troubling results really mean. Now that scientists know there’s a higher risk, they want to know why migraine is so much more common after concussion in high school football players. Could it be the result of greater awareness of sports-related headache? Or does concussion really make players more likely to develop migraine?
Veterans and the Long-Term Costs of Traumatic Brain Injury
One of the direst consequences of military deployment in war zones such as Iraq and Afghanistan is the high probability of traumatic brain injury (TBI). By some estimates, nearly a quarter of service personnel deployed in war zones in Iraq and Afghanistan suffer from TBI. Many veterans with TBI also deal with social and mental issues that affect their lives as civilians, like their marriages and jobs.
Thanks to new research comparing veterans who have had a TBI with veterans who haven’t been affected, doctors are moving toward a better understanding of how the condition can affect employment and marital status.
Researchers interviewed 67 veterans between 25 and 60 years old who had a combat-related TBI over the past 11 years. The second group of veterans was similar in most ways—age, sex, race, and when they were deployed—but they hadn’t experienced TBI during deployment. Both groups were asked about work, marriage, symptoms related to concussion, headaches, depression, and post-traumatic stress disorder. Those affected were also asked about the severity of their TBI.
The results were mixed. Veterans with TBI fared much worse in employment status. More than a third of the TBI group was unemployed compared with just 10% of the non-TBI group. However, on the home front, the groups were about the same, with no detectable differences between them. Frequency or severity of headache had no measurable impact on employment or marital status.
The new study is another reminder of the potentially long-term costs of war injuries. Not only are service personnel who suffer a TBI less likely than their non-injured comrades to hold a job, there’s little change in the first decade following their injury. The good news? Their marriages don’t seem to be affected.
Do Doctors Know Which Migraine Drugs to Prescribe?
Opioids and barbiturates are widely used for easing pain and anxiety. Some people also use them for migraine. While migraine sufferers who take these drugs may get short-term relief, they may also find themselves dealing with a host of unexpected medical issues—sleepiness, constipation, nausea, decreased sex drive, and potential withdrawal symptoms. The problems can get worse over time.
But migraine patients don’t just start using these drugs on their own. Somewhere along the line, someone thought an opioid or a barbiturate-containing medication was the best choice. Who?
This question is the driving force behind a new study that’s trying to establish:
- Where headache patients received their first prescription for an opioid or barbiturate.
- What types of patients have been prescribed these drugs.
By revealing which doctors did the prescribing, it is hoped that the answers will show who might benefit from a refresher course in treating migraine.
Nearly 250 patients were surveyed. Anyone who said they had used opioids or barbiturates in the past was also asked if they were still using them, whether they were effective, and which doctor first prescribed the medicine.
Even though barbiturates and opioids aren’t recommended for migraine, doctors seem to prescribe plenty of both. More than half of the patients surveyed had received a prescription for barbiturates and/or opioids in the past. About one in five was still taking them.
Nearly two-thirds (63%) of the patients who had taken an opioid or a barbiturate-containing drug for migraine found them to be effective. While that might explain why the current users said they had been using them for more than two years, long-term use of any headache medication can lead to trouble, especially medication overuse headache.
Most patients had received their first opioid prescription from an emergency room or family physician.1 Neurologists were the most likely to start a migraine patient on barbiturates.
The main conclusion from this study is that at least some doctors don’t know which drugs they should prescribe for migraine. They certainly seem to need more education about when—and when not—to prescribe opioids and barbiturates. A key question that goes unanswered in this study: with better options available, why did doctors prescribe them in the first place?
Opioids for Migraine: Not for Adults, Not for Kids
Ask anyone if they think a child should be given opioid medications for headache. There’s a reasonably good chance they’ll say no. But even with professional guidelines discouraging their use, some doctors still prescribe them for migraine. What’s more, no one really knows how often.
Not much research had been done on the subject previously, but a team of researchers has taken on the job of finding out. They’ve reviewed the electronic medical records of more than 21,000 children between six and 17 years old. The youngsters had visited their own doctor, a specialist, an emergency room, or an urgent care center at some point over a five-year period.
The key finding is troubling. About one in six children (16%) who goes to a doctor complaining of headache or migraine gets an opioid on the first visit. A few types of children were even more likely to leave a first visit with an opioid3:
- 15 to 17-year-olds
- Children whose complaints were confirmed by a diagnosis
- Those who went to a specialist, emergency room, or urgent care center
In fact, young patients were nearly twice as likely to receive an opioid prescription if they were treated at a specialist’s office, emergency room, or urgent care center instead of their own regular doctor.
Opioids should be avoided in all migraine patients, if possible, but especially in children. This research is an important reminder that anyone who can prescribe migraine medications to children needs to be up to date on the potential danger of prescribing opioids. An important part of the education should be learning about courses of treatment best suited to their young patients.
Experts Often Ignored in Prescribing to Young Patients
Very few children with migraine receive medications supported by evidence that they work. Nearly half are not prescribed any medication at all. That’s according to new analysis of the electronic health records of nearly 39,000 young people between six and 17 years old who had visited doctor’s offices or emergency rooms complaining of headache or migraine.
Researchers launched the analysis to determine how often healthcare providers follow expert recommendations in determining which medications to prescribe for their young patients.
In this study, more than half of the children (55%) who complained of headache or migraine were formally diagnosed. Nearly half (46%) left without a formal diagnosis.
Almost all the children received drugs that migraine experts would not recommend—even the ones diagnosed with migraine. Slightly less than half of them received nothing.
Some kids got better care than others did. Girls were more likely than boys to be treated the way experts recommend. Children diagnosed with migraine had a better chance than those diagnosed with headache or not diagnosed at all. City-based doctors improved the chances of receiving care in line with expert recommendations.
Overall, researchers praised the level of care usually provided by primary care doctors. However, they concluded that many of their colleagues need to learn more about how to follow prescribing guidelines for migraine in children.
More Pain, Less Medication?
Imagine if doctors could see how their patients deal with migraine attacks in real-time. Sensing that one might be coming, realizing that it’s definitely on the way, and then taking their medication. The doctors could see what time of day the attacks happened, how long it took to go from a funny feeling to a full-blown attack, and—maybe most important—exactly when the medication they prescribed was taken.
Or not taken.
Technology has made real-time a reality. In a new study, 267 patients with migraine completed a web-based daily headache diary for at least 30 days.1 Researchers were trying to learn:
- How often patients who have been prescribed a triptan for migraine take them.
- What factors prompt them to use the medication.
With the interactive diary, patients could report events as they were happening (or shortly thereafter—known as “near-time”). By the end of the study, the team had plenty to work with: information from almost 7500 migraine attacks had been collected.
When they ran the analysis, some results were expected. For instance, patients felt better (i.e., had less disability) on days when they took their triptan medication than when they didn’t. Also, those with pulsating or throbbing pain, nausea, or light sensitivity were more likely to take their medication.
There were two surprises:
- Patients hadn’t taken their triptan medication for more than 40 percent of all attacks.
- Patients with the most severe pain were the least likely to take their medication.
The unexpected “more pain-less medication” relationship was true across the board. Patients with moderate pain were also less likely to take medication than patients with mild pain.
The web-based technology in this study, which had never been used before, was considered a success, however, the results revealed some disappointing realities. More work needs to be done to figure out how to convince patients to take the medications that will ease their suffering.
No “Image” Problem for Migraine Experts
When diagnosing headache patients, many doctors rely on specific sets of criteria developed by headache experts. Everyone agrees they’re right (for the most part), but there’s never been a scientific way to confirm their accuracy. Headaches simply don’t show up on blood tests or x-rays—or any other kind of test—in a way that’s useful for diagnosis. A simple tool to sort out what kind of migraine a patient might have, for instance, has always been out of reach. That’s why doctors still have to rely on a physical exam and a thorough history in headache patients.
The results of a new study may start to change things. Using magnetic resonance imaging (MRI), scientists compared specific brain structures in migraine patients and healthy volunteers. Their goal was to see if they could tell which patients had episodic migraine (less than 15 headache days per month) and which had chronic migraine (15 or more headache days per month). They were also trying to see if MRI could tell them if 15 days per month—the number agreed upon by experts—is the best cut-off for determining which patients have chronic migraine.
The study yielded several interesting results:
- The MRI-assisted diagnoses were surprisingly accurate, correct 67% of the time in recognizing patients with episodic migraine and 86% of the time in identifying chronic migraineurs.
- The brain structures chosen to help with diagnosis worked — researchers were looking in the right places.
- 15 headache days per month is the ideal dividing line between episodic and chronic migraine.
That last point shows that, long before the MRI confirmed it, headache experts had it exactly right. No image problem there!
Note: The study’s lead author, Todd J. Schwedt, MD, FAHS, associate professor of Neurology at the Mayo Clinic in Scottsdale, AZ, has been recognized by the American Headache Society for his research. This year, Dr. Schwedt received the Society’s Harold G. Wolff Lecture Award for the best paper on headache, head or face pain.
Once-a-Month Injections for Migraine?
Migraine is a disease that never goes away, but many patients have days without pain. Their attacks happen occasionally, and in between, they have no symptoms.
Other migraineurs have frequent attacks, and in some patients, painful, disabling attacks become the norm. The days without migraine pain and other symptoms are occasional.
Treating patients with frequent migraine attacks can be a challenge. In fact, when they happen more than once or twice a week, doctors tend to switch strategies. Their goal becomes reducing the number of attacks rather than treating each one as it happens, and they prescribe medications that have to be taken every day. While there are safe and effective drugs for migraine prevention, none of them has ever been developed specifically for that purpose.
Soon, there may be three. Especially given the results of early experiments unveiled at this year’s Scientific Assembly of the American Headache Society.
Here are the highlights:
- The drugs are still known by their experimental names: AMG 334, LY48125, TEV48125.
- All of them are once-a-month injections.
- All three drugs successfully reduced the number of migraine attacks.
- So far, they all seem to be safe (safety was an issue with an earlier compound that has since been withdrawn).
One drug (TEV48125) started working within a week—the fastest response ever seen.
The still-experimental drugs are part a family of medications designed specifically for migraine prevention. The new “designer” drugs for migraine prevention work by finding and attaching to a protein that helps the brain and the immune system “talk” to each other. During attacks, this protein (known as CGRP) transmits pain signals, and interfering with the connection reduces migraine pain.
This approach has been tried before, and one of these drugs (LY2951742) has also shown promise in treating the pain of osteoarthritis. While the earlier versions didn’t work out, recent technological advances have opened up new possibilities.
Next, the compounds must undergo more tests on human subjects before being submitted to the Food and Drug Administration (FDA) for approval. If approved by the FDA, then doctors would be able to prescribe the new drugs to their migraine patients.
The future of migraine prevention is looking bright!