Migraine & Stroke Risk
Migraines affect more than 10% of all Americans and are three times more common in women than in men, according to data from the National Institute of Neurological Disorders and Stroke (NINDS). Although the link between migraine and stroke is not fully understood, research suggests that the two conditions have some clinical features that overlap. The NINDS has reported that risk factors for stroke with migraine-like features include being female, being older than 40, and having low cardiovascular risk profiles. Over the years, many studies have suggested that migraine is a risk factor for stroke. Some analyses have shown that stroke risks are twice as high in people who suffer from migraine with aura than those without aura. For women, stroke risks have been reported to be three times higher when they have migraine with aura. “To date, most of the research examining the link between stroke and migraine has shown that there is a correlation in migraineurs with aura,” says Teshamae S. Monteith, MD. Taking a Deeper Look For a study published in Neurology, Dr. Monteith and colleagues aimed to determine the association between migraine and stroke and a combination of vascular events, including stroke, heart attack, and death. Participants in the study were from the Northern Manhattan Study, a population-based cohort of stroke incidence. The participants were from an older, ethnically-diverse community in which the population was predominately Hispanic, a patient group that has historically been at a higher risk for stroke. The association between migraine and the combination of vascular events was estimated over an average follow-up of 11 years. After reviewing 1,292 people who reported...
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...Imaging Use & Atraumatic Headache in the ED
Atraumatic headache is one of the most common complaints in EDs, but only a small subset of patients who present to the ED with this complaint are found to have life-threatening intracranial pathology (ICP) upon imaging. Additionally, imaging guidelines for these patients remain unclear. As a result, emergency physicians face a serious diagnostic dilemma when managing atraumatic headache, says John W. Gilbert, MD. “Imaging infrequently reveals significant findings, but results from these tests nevertheless have the potential to detect life-threatening pathology.” [polldaddy poll=6862787] Several studies have demonstrated that overall use of diagnostic imaging in the ED is increasing. The causes are thought to be multifactorial, ranging from medicolegal concerns and patient demand to the availability of diagnostic scanners that operate at ever-faster rates. This has the potential to lead to imaging overutilization with little benefit and may potentially harm patients. In clinical studies, increased use of imaging has been associated with higher costs, longer patient wait times, greater exposure to ionizing radiation, and decreased ED flow and efficiency. “In the absence of clear evidence-based guidelines and given the potential consequences of misdiagnosis, many physicians understandably struggle when deciding whether to pursue further workup,” explains Dr. Gilbert. “In some cases, they may err on the side of increased testing. It’s important for physicians to be aware of recent trends in imaging utilization, particularly when there’s a sharp increase without obvious corresponding evidence of benefit. This information can help guide efforts toward better defining imaging criteria so that diagnostics are used appropriately.” Imaging & Diagnostics in Atraumatic Headache In the July 2012 Emergency Medicine Journal, Dr. Gilbert and colleagues had a...