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Optimizing Migraine Care

Optimizing Migraine Care

The American Headache Society (AHS) recently joined the Choosing Wisely initiative of the American Board of Internal Medicine in an effort to draw attention to tests and procedures that are associated with low-value care in headache medicine. An AHS committee of headache specialists produced a list of five such tests and treatments, and their methods and rationale were published in Headache. “We wanted the list to address common but often unnecessary or potentially risky tests and treatments for headache that in many cases do not represent evidence-based strategies,” explains Elizabeth W. Loder, MD, MPH, FAHS, who was lead author of the study.   Imaging According to the AHS, neuroimaging studies should not be performed in patients with stable headaches who meet criteria for migraine. In addition, CT scans should not be used in non-emergency situations as a diagnostic tool for headache patients when MRI is available. “MRIs can diagnose more underlying conditions that may cause headache that can otherwise be missed with CT,” says Dr. Loder. In addition, MRIs do not expose patients to radiation like CT scans. The recommendations note that MRI is of better value and safer than CT for migraineurs in all but a few emergency situations.   Treatments The AHS also recommends against prescribing opioid or butalbital-containing medications as first-line treatment for recurrent headache disorders. “The effectiveness of opioids is not in question,” Dr. Loder explains, “but these agents pose serious long-term risks and should be reserved for select patients. Effective long-term treatments will in most cases be necessary to manage this chronic disorder.” In addition, the risk of dependency and abuse associated with opioid...
Optimizing Migraine Care

Optimizing Migraine Care

The American Headache Society (AHS) recently joined the Choosing Wisely initiative of the American Board of Internal Medicine in an effort to draw attention to tests and procedures that are associated with low-value care in headache medicine. An AHS committee of headache specialists produced a list of five such tests and treatments, and their methods and rationale were published in Headache. “We wanted the list to address common but often unnecessary or potentially risky tests and treatments for headache that in many cases do not represent evidence-based strategies,” explains Elizabeth W. Loder, MD, MPH, FAHS, who was lead author of the study. Imaging According to the AHS, neuroimaging studies should not be performed in patients with stable headaches who meet criteria for migraine. In addition, CT scans should not be used in non-emergency situations as a diagnostic tool for headache patients when MRI is available. “MRIs can diagnose more underlying conditions that may cause headache that can otherwise be missed with CT,” says Dr. Loder. In addition, MRIs do not expose patients to radiation like CT scans. The recommendations note that MRI is of better value and safer than CT for migraineurs in all but a few emergency situations. Treatments The AHS also recommends against prescribing opioid or butalbital-containing medications as first-line treatment for recurrent headache disorders. “The effectiveness of opioids is not in question,” Dr. Loder explains, “but these agents pose serious long-term risks and should be reserved for select patients. Effective long-term treatments will, in most cases, be necessary to manage this chronic disorder.” In addition, the risk of dependency and abuse associated with opioid or butalbital-containing...
New Evidence-Based Guidelines: 4 Signs of Concussion

New Evidence-Based Guidelines: 4 Signs of Concussion

The first part of new evidence-based guidelines, published in the September 2014 issue of Neurosurgery, sought to identify which signs, symptoms, and neurologic and cognitive deficits have the highest and most consistent prevalence in samples of individuals sustaining a potentially concussive event. The researchers, composed of a team led by Nancy Carney, PhD, Oregon Health & Science University, Portland, and Jamshid Ghajar, MD, Brain Trauma Foundation, New York, New York, sifted through over 5,000 studies and systematically narrowed the stack down to 26 that met their strict criteria. According to the results, the four indicators of concussion, observed in alert individuals (defined as a Glasgow Coma Scale Score, 13 to 15) after a force to the head are the following: 1. Observed and documented disorientation or confusion immediately after the event 2. Impaired balance within 1 day after injury 3. Slower reaction time within 2 days after injury 4. Impaired verbal learning and memory within 2 days after injury The main symptoms experienced by subjects with potential concussive events were headache (93%), blurred vision (75%), dizziness (64%), and nausea (61%). Other key findings from the review include: * Decrements in cognitive function decreased from 58% on day 1 to 8% on day 7, indicating that in the majority of cases, cognitive deficits resolve within 1 week. * Tests of reaction time, memory, and attention/processing speed/working memory most consistently showed deficits in cognitive function within the first week of injury. * Individuals with a history of previous concussions had lower scores on tests from baseline to 5 days after injury, compared to those without previous concussions. The research team hopes...
Guidelines Update: Preventive Treatments for Migraine

Guidelines Update: Preventive Treatments for Migraine

About 38% of people who suffer from migraine could benefit from preventive treatments, but less than one-third currently uses them. Some analyses have shown that migraine attacks can be reduced by more than half with preventive therapies. In 2000, the American Academy of Neurology (AAN) published guidelines for migraine prevention. In the April 24, 2012 issue of Neurology, the AAN and the American Headache Society issued updated guidelines to account for new evidence. One set of guidelines was developed specifically for prescription products, while another was created for OTC drugs and complementary therapies. In each guideline, the safety and efficacy of pharmacologic therapies for migraine prevention was addressed. The reviews addressed the strength of evidence backing a given drug’s superiority relative to placebo. Prescription Drugs for Migraine Among prescription medications, several β-blockers (metoprolol, propranolol, and timolol) and seizure drugs (divalproex sodium, sodium valproate, and topiramate) established “proven efficacy” for migraine prevention based on clinical research. One selective serotonin receptor agonist (frovatriptan) was also proven effective. It’s recommended that clinicians consider offering these medications to migraineurs to reduce the frequency and severity of attacks.             Topiramate was elevated to a Level A recommendation (indicating “proven efficacy”) on the strength of five randomized trials. Other drugs that had previously been used for migraine prevention were downgraded from higher recommendations in 2000 because the current evidence failed to clearly support their efficacy. OTCs & Complimentary Therapies for Migraine Petasites, also known as butterbur, were shown to be effective in preventing migraine. Several NSAIDs were found to be “probably effective,” including fenoprofen, ibuprofen, ketoprofen, naproxen and naproxen sodium,...
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