Podcasts about cgrp

It's important to know the progression of muscle fiber dysfunction to better understand how to treat and how long it may take to correct the problem.   The analysis of current research provides substantial evidence supporting the progression of muscle fiber dysfunction as a significant contributor to musculoskeletal pain, aligning with the hypothesized sequence: sustained muscle tone leading to long-term muscle fiber shortening, which subsequently culminates in painful myofascial trigger points. The initial phase of this progression is rooted in the transition from normal physiological muscle tone to a state of pathological hypertonia or chronic muscle overload. Sustained low-level muscle contractions, even at submaximal levels, are shown to generate sufficient intramuscular pressure to compromise local capillary blood flow. This circulatory impairment leads to localized ischemia and hypoxia within the muscle fibers, precipitating a critical "energy crisis" due to insufficient ATP production. This energy deficit is pivotal for the subsequent development of muscle fiber shortening. ATP is indispensable not only for muscle contraction but also for the crucial process of muscle relaxation, specifically for the detachment of myosin heads from actin and the re-uptake of calcium ions. When ATP is depleted, these relaxation mechanisms fail, resulting in sarcomeres becoming locked in a state of sustained, pathological hypercontraction. This localized shortening at the sarcomere level forms the palpable "taut band" that is a hallmark of myofascial trigger points. Over extended periods, such sustained pathological shortening can also contribute to broader structural changes like muscle contractures, involving fibrosis and a permanent reduction in muscle length. The culmination of this progression is the development of painful trigger points. The sustained sarcomere hypercontraction, driven by the energy crisis and calcium dysregulation, creates a severely acidic local environment. This acidic milieu, coupled with tissue injury from prolonged ischemia, triggers the release and accumulation of various neuroactive and inflammatory mediators. These substances directly stimulate and sensitize muscle nociceptors, manifesting as the exquisite tenderness and characteristic referred pain associated with active myofascial trigger points. Furthermore, the pathophysiology of myofascial trigger points is characterized by a complex, self-perpetuating vicious cycle. The energy crisis and subsequent acidic environment inhibit acetylcholinesterase, leading to prolonged acetylcholine effects and further sustained muscle contraction. Concurrently, mediators like calcitonin gene-related peptide (CGRP) not only potentiate muscle contraction but also directly activate nociceptors. This intricate feedback loop ensures the chronicity of the condition, as the consequences of muscle shortening directly exacerbate the initial problem of sustained contraction and pain. This comprehensive understanding of the progression from sustained muscle tone to muscle shortening and painful trigger points has significant implications for both clinical practice and future research in musculoskeletal pain. For clinicians, it underscores the importance of early identification and intervention for chronic muscle tension and overuse, aiming to disrupt the energy crisis cycle before fixed structural changes or chronic pain states become entrenched. Therapeutic strategies should not only target pain relief but also address the underlying metabolic and biomechanical dysfunctions, including restoring proper muscle length, improving local circulation, and resolving the energy deficit. For researchers, the identified roles of specific molecules like CGRP and the intricate feedback loops within the "energy crisis" model present promising avenues for developing novel diagnostic markers and targeted pharmacological or rehabilitative interventions that can effectively break the self-perpetuating cycle of myofascial pain.   Online Courses: https://richardhazel.podia.com    

Autoren: "Im Blutsee" Vampire in Yucatans Höhlen – von Uwe KullnickForschung an Vampirfledermäusen ist nicht ungefährlich. Neben dem Wissensdurst des Menschen verbindet man mit Erkenntnissen über diese Tiere auch Vorteile für den Menschen.INFOWie Vampirfledermäuse Blut trinken, ohne krank zu werdenVampirfledermäuse bürsten sich gegenseitig auf, enthüllen komplexe soziale OrdnungFrühere Studien haben zwei wichtige gerinnungshemmende Verbindungen im Gift gewöhnlicher Vampirfledermäuse identifiziert: Toxine mit der Bezeichnung DSPA und das treffend als "Draculin" bezeichnete Toxin. Es ist wahrscheinlich, dass die Untersuchung der Tiere weitere faszinierende Verbindungen aufdecken wird."Diese Entdeckung ist ein weiteres Beispiel dafür, warum es so wichtig ist, die Natur auf breiter Basis zu schützen, da wir nicht vorhersagen können, woher die nächste grosse biologische Arzneimittelentdeckung kommen wird", sagte Fry. "Giftige Tiere sind auf der ganzen Welt bedroht, noch mehr als die meisten anderen bedrohten oder gefährdeten Arten, und zwar aufgrund vorsätzlicher Verfolgung aus Angst oder Missverständnissen.Während Vampirfledermäuse in der Populärkultur wegen ihrer blutsaugenden Tendenzen sehr verleumdet werden, hat ein internationales Team unter der Leitung von Forschern der Universität von Queensland (UQ), Australien, vor kurzem eine als vCGRP bekannte Verbindung in ihrem Gift identifiziert, die ihrer Meinung nach die Behandlung von Bluthochdruck und Herzinsuffizienz bis hin zu Nierenerkrankungen und Verbrennungen revolutionieren könnte.Laut Bryan Fry, einem der Forscher von UQ, handelt es sich bei der Verbindung um eine mutierte Form des Calcitonin Gene Related Peptide (CGRP) in unserem Körper - eine Verbindung, die die Blutgefäße entspannt. Peptide sind im Wesentlichen Substanzen, die aus Aminosäureketten bestehen und durch Amidbindungen miteinander verbunden sind."Die Peptide aus den Fledermäusen sind in ihrer Wirkungsweise ungewöhnlich selektiv, was sie noch therapeutisch nützlicher macht als das CGRP, da sie weniger Nebenwirkungen haben", sagte Fry in einer Erklärung. "Dies könnte Ärzten möglicherweise bei der Behandlung einer Reihe von Erkrankungen mit erhöhtem Druck in kleinen Blutgefässen helfen oder den Blutfluss zu beschädigtem oder transplantiertem Gewebe wie Hauttransplantationen verbessern.Bisher haben die Wissenschaftler an einem Standort in Mexiko Proben von Vampirfledermäusen gesammelt, die für ihre Forschung von entscheidender Bedeutung sind. Das Gebiet wurde jedoch vor kurzem von Drogenhändlern überrannt, was ihre Feldarbeit behindert.Quelle: NEWSWEEK ABONNEMENT-ANGEBOTE >Es gab zahlreiche Vorkommnisse, Gefahren und Erlebnisse  auf meinen viele Reisen. Menschen und Tiere begegneten mir in Afrika, Asien, USA, Kanada, Süd- und Mittelamerika, Arabien, Japan und Europa. Die vielen Geschichten zu erzählen wird den Rest meines Lebens dauern und ich freue mich darauf. Hier ist eine Geschichte aus Afrika. Ich rieche noch den besonderen Duft des Kraterrandes des Ngorongorokraters, höre noch das Stampfen der Büffel und habe selten so gefroren wie Mitten in Afrika, am Rand des Ngorongoro Kraters. Diesem Weltwunder der Natur.Uwe Kullnick ist Naturwissenschaftler.  Neben seiner biologischen Forschung, arbeitete er in der strategischen Unternehmensleitung und war Senior Manager eines internationalen Konzerns und zuständig für 150 Länder. Seine akademischen Schwerpunkte als Dr. rer. nat. sind Biologie (Zoologie), Neurophysiologie und Sexualpsychologie. Als Gründer und Betreiber des Literatur Radio Hörbahn produzierte er in den vergangenen Jahren rund 1000 Sendungen und erreichte damit hundertausende Hörer.Als Neurophysiologe und selbst Betroffener hat er ein vielbeachtetes Buch über das Restless Legs Syndrom geschrieben: Restless Legs - Pest in den Beinen Facebook: http://facebook.com/uwe.kullnickvormals Twitter: @Ukullnick Autor, Sprecher, und Realisation Uwe Kullnick

Story at-a-glance Women with chronic migraines and body-wide pain were far more likely to have poor oral health, with over half falling into the lowest oral health categories in a new study Specific oral bacteria, including Mycoplasma salivarium and Gardnerella vaginalis, were significantly more common in women who reported frequent migraines and widespread pain Harmful oral microbes don't stay in your mouth; once gum tissue is inflamed, these bacteria enter your bloodstream, disrupt the immune system, and trigger systemic pain A less diverse oral microbiome was found in women with migraines and gut pain, making it easier for pain-triggering bacteria to dominate and inflame nerve pathways Inflammatory chemicals produced by oral bacteria — like calcitonin gene-related peptide (CGRP) and vascular endothelial growth factor (VEGF) — are directly involved in migraine and fibromyalgia, showing how poor oral hygiene can set off whole-body pain responses

Drs. VanderPluym and Starling review the updated position statement from the American Headache Society indicating that CGRP-targeting migraine therapies should be considered as a first-line option.

Jo Cheah talks to Bronwyn Jenkins, consultant neurologist, about the role of calcitonin gene-related peptide (CGRP)–targeted therapies in migraine treatment. Bronwyn explains the difference between tension-type headaches and migraines, and outlines current treatment options. The conversation also covers adverse effects, patient eligibility, and other important considerations for prescribers. Read the full article in Australian Prescriber.

Text Dr. Lenz any feedback or questions This episode dives into the complex relationship between migraines and hormonal changes, particularly focusing on estrogen. The discussion covers the prevalence of migraines, the distinction between migraines with and without aura, and the significant impact of reproductive hormones on migraine patterns, especially in women. Key topics include the discovery of the estrogen threshold, the influence of estrogen on neurotransmitter systems like serotonin and glutamate, and the potential of hormone-based treatments. The episode also examines the role of the trigeminal vascular system, calcitonin gene-related peptide (CGRP), and the impact of oral contraceptives on migraine frequency and intensity. Practical strategies for managing menstrual migraines and the importance of using headache diaries for accurate diagnosis are highlighted.00:00 Introduction to Migraines00:20 Types of Migraines and Auras00:42 Sex Differences in Migraine Prevalence00:59 Hormonal Influence on Migraines01:53 Estrogen's Role in Menstrual Migraines02:05 Historical Breakthroughs in Migraine Research02:35 Estrogen Threshold and Migraine Triggers04:10 Estrogen's Impact on Brain Function07:29 Neurotransmitters and Migraine Pathways11:15 Oxytocin and Migraine Prevention13:20 Trigeminal Vascular System and Migraines16:46 Calcitonin Gene-Related Peptide and Inflammation20:38 Oral Contraceptives and Migraine Management24:59 The Importance of Headache Diaries26:45 Conclusion and Future Research Click here for the Fibromyalgia 101 link.Click here to connect with Joy Lenz. Support the showWhen I started this podcast—and the book that came before it—I had my patients in mind. Office visits are short, but understanding complex, often misunderstood conditions like fibromyalgia takes time. That's why I created this space: to offer education, validation, and hope. If you've been told fibromyalgia “isn't real” or that it's “all in your head,” know this—I see you. I believe you. You're not alone. This podcast aims to affirm your experience and explain the science behind it. Whether you live with fibromyalgia, care for someone who does, or are a healthcare professional looking to better support patients, you'll find trusted, evidence-based insights here, drawn from my 28+ years as an MD. Please remember to talk with your doctor about your symptoms and care. This content doesn't replace personal medical advice.* ...

"Kopfschmerzen sieht man nicht, also sind sie nicht real" - diese Haltung ist zum Glück überholt. Dennoch bleiben einige Rätsel offen, wenn es um Migräne, Spannungs- oder Clusterkopfschmerzen geht. Mindestens jeder zweite Mensch in Deutschland kennt Kopfschmerzen - in ganz unterschiedlicher Ausprägung: Es kann einige Stunden etwas hinter der Stirn drücken oder auch dazu führen, dass Betroffene etliche Tage des Monats mit starken Schmerzen im Bett verbringen müssen. Wie diese Schmerzen entstehen, wird schon lange beforscht und trotzdem stehen die Wissenschaftler*innen teilweise noch immer vor einer Blackbox. Synapsen-Autorin Nele Rößler hat in diese Box hineingeschaut und Host Maja Bahtijarević viele - auch unerwartete - Erkenntnisse mitgebracht: Woher kommen die verschiedenen Schmerzen, welche Ursachen haben sie? Wie kann man sie behandeln? Warum kann Trampolinspringen gegen Kopfschmerzen helfen? Und woher weiß unser Körper so genau, dass immer am Mittwoch die Migräne an der Reihe ist? HINTERGRUNDINFORMATIONEN 1. Das Gehirn und Schmerzempfinden. Das Gehirn. https://www.dasgehirn.info/aktuell/frage-an-das-gehirn/kann-das-gehirn-schmerzen-empfinden#:~:text=Was%20es%20generell%20f%C3%BCr%20eine,hat%20aber%20keine%20solchen%20Schmerzrezeptoren [Abgerufen Dezember 2024] 2. Kopfschmerzen. UniversitätsSpital Zürich. Abgerufen von https://www.usz.ch/krankheit/kopfschmerzen/ [Abgerufen Dezember 2024] 3. Trigeminusneuralgie (Gesichtsschmerzen). Neurologen und Psychiater im Netz. Abgerufen von https://www.neurologen-und-psychiater-im-netz.org/neurologie/erkrankungen/trigeminusneuralgie-gesichtsschmerzen/ [Abgerufen Dezember 2024] 4. Kurz dauernder einseitiger neuralgiformer Kopfschmerz mit konjunktivalen Injektionen und Tränenfluss (SUNCT-Syndrom). MSD Manuals. https://www.msdmanuals.com/de/profi/neurologische-krankheiten/kopfschmerz/kurzdauernder-einseitiger-neuralgiformer-kopfschmerz-mit-konjunktivalen-injektionen-und-tr%C3%A4nenfluss-sunct-syndrom [Abgerufen Dezember 2024] 5. Migräne und Spannungskopfschmerz. (2020). Robert Koch-Institut (RKI). https://www.rki.de/DE/Content/Gesundheitsmonitoring/Gesundheitsberichterstattung/GBEDownloadsJ/JoHM_S6_2020_Migraene_Spannungskopfschmerz.html#:~:text=57%2C5%20%25%20der%20Frauen%20und,M%C3%A4nner%20sind%20von%20Spannungskopfschmerzen%20betroffen [Abgerufen Dezember 2024] 6. Migräne. Gesundheitsinformation.de. https://www.gesundheitsinformation.de/migraene.html#:~:text=Von%20einer%20Migr%C3%A4ne%20spricht%20man,haben%20nur%20gelegentlich%20einen%20Migr%C3%A4neanfall [Abgerufen Dezember 2024] 7. Episodische Migräne. Leben und Migräne. https://www.leben-und-migraene.de/migraene/schweregrade/episodische-migraene [Abgerufen Dezember 2024] 8. Was passiert bei einer Migräne mit Aura im Kopf? (2020). Spektrum.de. https://www.spektrum.de/news/was-passiert-bei-einer-migraene-mit-aura-im-kopf/1809728 [Abgerufen Dezember 2024] 9. Status migrainosus – Wenn die Migräne einfach nicht aufhören will. Schmerzklinik. https://schmerzklinik.de/status-migraenosus-wenn-die-migraene-einfach-nicht-aufhoeren-will/ [Abgerufen Dezember 2024] 10. Wie Migräne das Gehirn verändert. (2020). scinexx. Abgerufen von https://www.scinexx.de/news/medizin/wie-migraene-das-gehirn-veraendert/ 11. Rolle des CGRP bei Migräne. (2020). Springer Link. https://link.springer.com/article/10.1007/s00739-020-00623-x#:~:text=Bereits%20zu%20Beginn%20der%20Migr%C3%A4neattacke,(CGRP)%20eine%20tragende%20Rolle 12. Komplexe Abläufe im Gehirn bei Migräne. Burstein R, Noseda R, Borsook D. Migräne: multiple Prozesse, komplexe Pathophysiologie. Neuroscientist. 2015;21(3):233-244. doi: 10.1177/1073858414539394 13. Clusterkopfschmerz – Einer der stärksten Schmerzen. Medizinische Hochschule Hannover. Abgerufen von https://www.mhh.de/presse-news/clusterkopfschmerz-einer-der-staerksten-schmerzen-1#:~:text=Wie%20lang%20dauert%20eine%20Attacke,etwas%20vermehrt%20in%20der%20Nacht [Abgerufen Dezember 2024] 14. Spannungskopfschmerz. DocCheck Flexikon. Abgerufen von https://flexikon.doccheck.com/de/Spannungskopfschmerz [Abgerufen Dezember 2024] 15. CGRP-Spiegel als Biomarker für Migräne (2022). Springer Link. https://link.springer.com/article/10.1007/s15005-022-3050-5 16. Vererbung der Migräne. Migräne Liga. https://www.migraeneliga.de/vererbung-der-migraene/ [Abgerufen Dezember 2024] 17. Kopfschmerzen bei Schülern. Straube A, Heinen F, Ebinger F, von Kries R. Kopfschmerzen bei Schülern: Prävalenz und Risikofaktoren. Dtsch Arztebl Int. 2013;110(48):811-8. doi: 10.3238/arztebl.2013.0811 18. Behandlung von Cluster-Kopfschmerz mit psychedelischen Drogen. Treatment of cluster headaches with psychedelics. (2022). Petrie-Flom Center Blog. https://blog.petrieflom.law.harvard.edu/2022/04/18/small-doses-of-psychedelics-for-cluster-headaches/ 19. Behandlung mit Medikamenten, die noch nicht zugelassen sind. vfa.de. https://www.vfa.de/de/patienten/artikel-patienten/behandlung-mit-medikamenten-die-noch-nicht-zugelassen-sind.html#:~:text=Individuelle%20Heilversuche,und%20aus%20eigener%20Initiative%20entscheidet [Abgerufen Dezember 2024]

"Kopfschmerzen sieht man nicht, also sind sie nicht real" - diese Haltung ist zum Glück überholt. Dennoch bleiben einige Rätsel offen, wenn es um Migräne, Spannungs- oder Clusterkopfschmerzen geht. Mindestens jeder zweite Mensch in Deutschland kennt Kopfschmerzen - in ganz unterschiedlicher Ausprägung: Es kann einige Stunden etwas hinter der Stirn drücken oder auch dazu führen, dass Betroffene etliche Tage des Monats mit starken Schmerzen im Bett verbringen müssen. Wie diese Schmerzen entstehen, wird schon lange beforscht und trotzdem stehen die Wissenschaftler*innen teilweise noch immer vor einer Blackbox. Synapsen-Autorin Nele Rößler hat in diese Box hineingeschaut und Host Maja Bahtijarević viele - auch unerwartete - Erkenntnisse mitgebracht: Woher kommen die verschiedenen Schmerzen, welche Ursachen haben sie? Wie kann man sie behandeln? Warum kann Trampolinspringen gegen Kopfschmerzen helfen? Und woher weiß unser Körper so genau, dass immer am Mittwoch die Migräne an der Reihe ist? HINTERGRUNDINFORMATIONEN 1. Das Gehirn und Schmerzempfinden. Das Gehirn. https://www.dasgehirn.info/aktuell/frage-an-das-gehirn/kann-das-gehirn-schmerzen-empfinden#:~:text=Was%20es%20generell%20f%C3%BCr%20eine,hat%20aber%20keine%20solchen%20Schmerzrezeptoren [Abgerufen Dezember 2024] 2. Kopfschmerzen. UniversitätsSpital Zürich. Abgerufen von https://www.usz.ch/krankheit/kopfschmerzen/ [Abgerufen Dezember 2024] 3. Trigeminusneuralgie (Gesichtsschmerzen). Neurologen und Psychiater im Netz. Abgerufen von https://www.neurologen-und-psychiater-im-netz.org/neurologie/erkrankungen/trigeminusneuralgie-gesichtsschmerzen/ [Abgerufen Dezember 2024] 4. Kurz dauernder einseitiger neuralgiformer Kopfschmerz mit konjunktivalen Injektionen und Tränenfluss (SUNCT-Syndrom). MSD Manuals. https://www.msdmanuals.com/de/profi/neurologische-krankheiten/kopfschmerz/kurzdauernder-einseitiger-neuralgiformer-kopfschmerz-mit-konjunktivalen-injektionen-und-tr%C3%A4nenfluss-sunct-syndrom [Abgerufen Dezember 2024] 5. Migräne und Spannungskopfschmerz. (2020). Robert Koch-Institut (RKI). https://www.rki.de/DE/Content/Gesundheitsmonitoring/Gesundheitsberichterstattung/GBEDownloadsJ/JoHM_S6_2020_Migraene_Spannungskopfschmerz.html#:~:text=57%2C5%20%25%20der%20Frauen%20und,M%C3%A4nner%20sind%20von%20Spannungskopfschmerzen%20betroffen [Abgerufen Dezember 2024] 6. Migräne. Gesundheitsinformation.de. https://www.gesundheitsinformation.de/migraene.html#:~:text=Von%20einer%20Migr%C3%A4ne%20spricht%20man,haben%20nur%20gelegentlich%20einen%20Migr%C3%A4neanfall [Abgerufen Dezember 2024] 7. Episodische Migräne. Leben und Migräne. https://www.leben-und-migraene.de/migraene/schweregrade/episodische-migraene [Abgerufen Dezember 2024] 8. Was passiert bei einer Migräne mit Aura im Kopf? (2020). Spektrum.de. https://www.spektrum.de/news/was-passiert-bei-einer-migraene-mit-aura-im-kopf/1809728 [Abgerufen Dezember 2024] 9. Status migrainosus – Wenn die Migräne einfach nicht aufhören will. Schmerzklinik. https://schmerzklinik.de/status-migraenosus-wenn-die-migraene-einfach-nicht-aufhoeren-will/ [Abgerufen Dezember 2024] 10. Wie Migräne das Gehirn verändert. (2020). scinexx. Abgerufen von https://www.scinexx.de/news/medizin/wie-migraene-das-gehirn-veraendert/ 11. Rolle des CGRP bei Migräne. (2020). Springer Link. https://link.springer.com/article/10.1007/s00739-020-00623-x#:~:text=Bereits%20zu%20Beginn%20der%20Migr%C3%A4neattacke,(CGRP)%20eine%20tragende%20Rolle 12. Komplexe Abläufe im Gehirn bei Migräne. Burstein R, Noseda R, Borsook D. Migräne: multiple Prozesse, komplexe Pathophysiologie. Neuroscientist. 2015;21(3):233-244. doi: 10.1177/1073858414539394 13. Clusterkopfschmerz – Einer der stärksten Schmerzen. Medizinische Hochschule Hannover. Abgerufen von https://www.mhh.de/presse-news/clusterkopfschmerz-einer-der-staerksten-schmerzen-1#:~:text=Wie%20lang%20dauert%20eine%20Attacke,etwas%20vermehrt%20in%20der%20Nacht [Abgerufen Dezember 2024] 14. Spannungskopfschmerz. DocCheck Flexikon. Abgerufen von https://flexikon.doccheck.com/de/Spannungskopfschmerz [Abgerufen Dezember 2024] 15. CGRP-Spiegel als Biomarker für Migräne (2022). Springer Link. https://link.springer.com/article/10.1007/s15005-022-3050-5 16. Vererbung der Migräne. Migräne Liga. https://www.migraeneliga.de/vererbung-der-migraene/ [Abgerufen Dezember 2024] 17. Kopfschmerzen bei Schülern. Straube A, Heinen F, Ebinger F, von Kries R. Kopfschmerzen bei Schülern: Prävalenz und Risikofaktoren. Dtsch Arztebl Int. 2013;110(48):811-8. doi: 10.3238/arztebl.2013.0811 18. Behandlung von Cluster-Kopfschmerz mit psychedelischen Drogen. Treatment of cluster headaches with psychedelics. (2022). Petrie-Flom Center Blog. https://blog.petrieflom.law.harvard.edu/2022/04/18/small-doses-of-psychedelics-for-cluster-headaches/ 19. Behandlung mit Medikamenten, die noch nicht zugelassen sind. vfa.de. https://www.vfa.de/de/patienten/artikel-patienten/behandlung-mit-medikamenten-die-noch-nicht-zugelassen-sind.html#:~:text=Individuelle%20Heilversuche,und%20aus%20eigener%20Initiative%20entscheidet [Abgerufen Dezember 2024]

We are kicking off the new year and a new season with a great guest! Dr. Kristen Steenerson, MD brings her expertise to the conversation with a deeper dive into Vestibular Migraine and Persistent Postural Perceptual Dizziness. Whether you're a patient or a clinician, you surely don't want to skip this episode! Kristen K. Steenerson, MD is a board-certified neurologist with fellowship training in vestibular neurology. She graduated cum laude from Claremont McKenna College, received her MD from the University of Utah, completed neurology residency at Mayo Clinic Arizona, and fellowship at Barrow Neurological Institute. She directs the Vestibular Balance Disorders Program of the Stanford Balance Center. She has joint appointments in the departments of Otolaryngology--Head and Neck Surgery and Neurology & Neurological Sciences at Stanford. Her clinical interests include vestibular migraine, persistent postural-perceptual dizziness, benign paroxysmal positional vertigo, Ménière's disease, and international neurology. Episode Resources - Central and peripheral vestibular disorders overview (and how much they overlap!): https://www.nature.com/articles/nrneurol.2017.58 - CGRP position paper: https://pubmed.ncbi.nlm.nih.gov/38466028/ - VMPATHI survey:https://redcap.ucsf.edu/surveys/?s=CY893NJHCM - VMPATHI paper: https://pubmed.ncbi.nlm.nih.gov/32176141/ - Comprehensive analysis of VM treatments: https://pubmed.ncbi.nlm.nih.gov/35859353/ - Migraine influences tinnitus and hearing loss: https://aao-hnsfjournals.onlinelibrary.wiley.com/doi/pdf/10.1002/ohn.201?casa_token=pfzZz62NjqcAAAAA:u0enZoqzF6n8D1_o_7G4HyTY5qpjFd0cDutwNpFtigKXd7xo4Zo65Cuzy4qZWjHDeuMICp0RYuKrGQ - Cognitive failures improve when migraine improves: https://pubmed.ncbi.nlm.nih.gov/37525385/ - Treat MdDS as migraine: https://pmc.ncbi.nlm.nih.gov/articles/PMC5823515/ - Magazine article: https://www.bustle.com/p/what-actually-happens-in-your-brain-when-you-have-a-migraine-according-to-experts-16823975 Hosted by Dr. Abbie Ross, PT, NCS, and Dr. Danielle Tolman, PT For Episode Recommendations or Requests, email us info@balancingactrehab.com Where to find us: ⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠https://link.me/balancingactrehab⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠⁠www.BalancingActRehab.com⁠⁠⁠⁠⁠⁠⁠⁠⁠ ⁠⁠⁠Facebook: @BalancingActRehab Instagram: @BalancingActRehab Twitter: @DizzyDoctors TikTok: @BalancingActRehab

Interview with Wei-Hsuan Lo-Ciganic, PhD, author of Cardiovascular Safety of Anti-CGRP Monoclonal Antibodies in Older Adults or Adults With Disability With Migraine. Hosted by Cynthia E. Armand, MD. Related Content: Cardiovascular Safety of Anti-CGRP Monoclonal Antibodies in Older Adults or Adults With Disability With Migraine

Interview with Wei-Hsuan Lo-Ciganic, PhD, author of Cardiovascular Safety of Anti-CGRP Monoclonal Antibodies in Older Adults or Adults With Disability With Migraine. Hosted by Cynthia E. Armand, MD. Related Content: Cardiovascular Safety of Anti-CGRP Monoclonal Antibodies in Older Adults or Adults With Disability With Migraine

 Migraine Headache and Advances in Management Link for MOC credit: CME Link: https://cmetracker.net/UTHSCSA/Publisher?page=pubOpen#/getCertificate/10098103 Pediatric and Adolescent Migraine Headache and Advances in Management FACULTY: Asra Akbar, MD is an Assistant Professor, Pediatric Neurologist and Epileptologist, Pediatric Headache Management Specialist, Division of Neurology, Department of Pediatrics, UT Health San Antonio   OVERVIEW: Welcome to Pediatrics Now, where host Holly Wayment talks with Dr. Azra Akbar, a specialist in pediatric neurology, epileptology, and headache management.  Dr. Akbar shares her expertise on common headache disorders in children, with a special focus on migraines. Discover the intricate history of migraines, ranging from its ancient descriptions to groundbreaking modern research involving calcitonin gene-related peptides (CGRPs). The episode dives into the prevalence of migraines in young patients, exploring various types such as migraine with and without aura, and other headache disorders like chronic daily headaches and medication overuse headaches. Dr. Akbar emphasizes the importance of a multifaceted approach to treatment, discussing both conventional medications and innovative neuromodulation therapies like Botox and CGRP inhibitors. In addition to medical treatments, the conversation also highlights the significance of lifestyle modifications, including diet, exercise, and the use of supplements such as Coenzyme Q10 and magnesium. Learn how pediatric practitioners can effectively manage migraines with a thorough understanding of their complex nature and multifactorial triggers. OVERALL LEARNING OBJECTIVE: Increased awareness and education for pediatric providers DISCLOSURE TO LEARNERS: Asra Akbar, MD has no financial relationships with ineligible companies to disclose.   The Pediatric Grand Rounds Planning Committee (Deepak Kamat, MD, PhD, Steven Seidner, MD, Daniel Ranch, MD and Elizabeth Hanson, MD) has no financial relationships with ineligible companies to disclose. The UT Health Science Center San Antonio and Deepak Kamat, MD course director and content reviewer for the activity, have reviewed all financial disclosure information for all speakers, facilitators, and planning committee members; and determined and resolved all conflicts of interests. CONTINUING MEDICAL EDUCATION STATEMENTS: The UT Health Science Center San Antonio is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The UT Health Science Center San Antonio designates this live activity up to a maximum of 0.75 AMA PRA Category 1 Credits™. Successful completion of this CME activity, which includes participation in the activity, with individual assessments of the participant and feedback to the participant, enables the participant to earn 0.75 MOC point in the American Board of Pediatrics' (ABP) Maintenance of Certification (MOC) program. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABP MOC credit. Physicians should claim only the credit commensurate with the extent of their participation in the activity. CERTIFICATE OF ATTENDANCE: Healthcare professionals will receive a certificate of attendance and are asked to consult with their licensing board for information on applicability.

In this episode, I explore the diverse clinical and pathogenic dimensions of migraine with neurologist Mark Weatherall whose interests are the diagnosis and management of chronic migraine, facial pain, visual snow syndrome, and secondary headaches associated with systemic disorders.Our discussion covered the distinction between primary and secondary headaches, the distinctive features of the migraine aura and headache, and the non-headache manifestations of migraine. Mark Weatherall also traced the history of the development, and of the use, of the current acute and preventative migraine treatments, and highlighting the role of the CGRP pathway. He also explores the research into emerging drugs that work via the PACAP pathway.Mark is former Chair of the British Association for the Study of Headache and Trustee of The Migraine Trust, and who was a highly regarded historian of medicine before studying clinical medicine at Cambridge. His other interests are the historical, social, and cultural aspects of headache and facial pain disorders.

In this episode, I review the pathological and clinical dimensions of migraine, the most common disabling neurological disorder. I tried to capture migraine's diverse disabling recurrent symptoms, from its risk factors, triggers and prodrome to the aura, the headache, and multiple heightened sensitivities.To illustrate the lived experience of migraine, its classical manifestations, and its curious variants, I refer to such vivid patient memoirs as those of Monica Nelson titled Mere Sense, and Abby Reed titled The Color of Pain. I also cited Oliver Sacks classical book titled 'Migraine'.I also flavour the podcast with historical migraine patient anecdotes, such as those of Ann Conway, the enlightenment writer who was treated by the great physicians William Harvey and Thomas Willis, of Annie, who was treated with an astounding number of therapies by the famous Queen Square neurologist William Gowers, and of Alexander Pope who treated his migraines in a most unconventional way.In this regard, I relied on Migraine: A History, Katherine Foxhall's magnificent historical account of the medieval ideas and treatments of the disorder, and Soul Made Flesh, Carl Zimmer's exhilarating biography of Thomas Willis.The podcast also explores and the evolution of migraine's acute and preventative treatments, and how a better understanding of its pathology is leading to treatments such as those that influence the CGRP pathway.

Prof. ssa Simona Sacco & Prof.ssa Enrica BonanniSapevate che più del 20% degli emicranici soffre di insonnia? Nei pazienti con emicrania cronica, la prevalenza può raggiungere anche il 60%.​ Con questa associazione l'emicrania è più grave e difficile da curare. Vediamo insieme quali domande fare al paziente per capire di che tipo di insonnia soffre soffermandoci anche sui sintomi diurni e quali esami programmare. Una volta identificata la problematica è  fondamentale impostare una terapia adeguata con  gestione personalizzata, basata sul tipo di insonnia identificato e sulla presentazione clinica del paziente. La promozione di una buona igiene del sonno è fondamentale. La terapia di prima linea raccomandata è la terapia cognitivo-comportamentale per l'insonnia (CBT-I). ​Abbiamo a disposizione ipnotici efficaci come i nuovi non benzodiazepinici o gli antagonisti duali per il recettore dell'orexina che si sono mostrati idonei nel trattare l'insonnia anche nel paziente con emicrania. La melatonina a lento rilascio e consigliata nei soggetti con più di 55 anni. Nella pratica clinica è possibile provare a migliorare il sonno notturno e contemporaneamente prevenire gli episodi di emicrania ricorrendo ad alcuni specifici farmaci. Dobbiamo essere consapevoli che curare l'insonnia riduce l'impatto complessivo della emicrania e migliora sensibilmente la qualità di vita del paziente. Vedremo infine l'ultima affascinante ipotesi sul meccanismo patologico alla base dell'associazione tra emicrania e insonnia che vede il coinvolgimento del sistema glinfatico che ha il compito di ripulire il cervello da tutte le sostanze di scarto. Il sistema glinfatico gioca un ruolo nella modulazione del dolore eliminando ad esempio il peptide correlato al gene della calcitonina (CGRP), un mediatore chiave nella fisiopatologia dell'emicrania. Il sistema glinfatico funziona soprattutto durante il sonno, e in particolare durante il sonno profondo non-REM. Con l'età si riduce sia il sonno profondo, sia l'efficienza del sistema glinfatico e viene compromesso il potere restaurativo del sonno. I farmaci in grado di aumentare questo tipo di sonno potrebbero quindi avere un ruolo anche nel controllo dell'emicrania. 

Drs. Cooper and Ailani continue their discussion from the 2024 AAN annual meeting in Denver, Colorado. In this second episode, they cover the results of the OVERCOME and TANDEM trials; understanding patients' journeys prior to initiating CGRP inhibitors; and the prevalence and characteristics of menstrual migraines.

Migraine can make you miss out on so much of life, but the treatment landscape is changing. Hear what's changed for one long-time sufferer since she started taking a newer CGRP drug.

Send us a Text Message.Discover the future of migraine management with us in our final episode of Two Docs Talk Migraines. Feel the excitement as Dr. Michael Koren and Dr. Steven Toenjes delve into a world where CGRP antagonists and pharmacogenomics interlace to tailor therapies to individual needs. We're talking about groundbreaking approaches to chronic migraine care, from the FDA-approved botulinum toxin type A, also known as Botox, to the promising horizon of nerve-stimulation devices. This is your ticket to understanding the complexities of migraine pathophysiology and the innovative clinical trials shaping the hope for relief.Join an enlightening journey through the maze of headache treatment, where we illuminate the nuances of botulinum toxin dosing, the emergence of PACAP inhibitors, and the intriguing potential of prostaglandin-based therapies. With his profound expertise, Dr. Toenjes guides us through the patient selection process for these groundbreaking clinical trials and the profound impact research has on patient care. You're not just listening to another discussion; you're stepping into a realm where the future of migraine treatment unfolds in real-time, offering a beacon of hope to those awaiting new solutions.Talking Topics:Exploring Therapeutic Options for MigraineUpdates in Migraine Treatment and ResearchPart 1: Breaking Down Headache Myths - Release Date May 15, 2024Part 2: Treatments and Clinical Research Advancements - Release Date May 22, 2024Part 3: Breakthroughs in Migraine Research - Release Date May 29, 2024Recording Date: May 13, 2024Be a part of advancing science by participating in clinical researchShare with a friend. Rate, Review, and Subscribe to the MedEvidence! podcast to be notified when new episodes are released.Follow us on Social Media:FacebookInstagramTwitterLinkedInWant to learn more checkout our entire library of podcasts, videos, articles and presentations at www.MedEvidence.com Powered by ENCORE Research GroupMusic: Storyblocks - Corporate InspiredThank you for listening!

  Please listen to my other podcasts to learn about migraine. This is a podcast by Britt Talley Daniel MD, retired member of the American Academy of Neurology,  migraine textbook author, podcaster, and blogger. Check out my books on Migraine on Amazon. Follow my webpage at www.doctormigraine.com.

The majority of children and adolescents experience headache, with pooled estimates suggesting that approximately 60% of youth are affected. Migraine and tension-type headache are the leading cause of neurologic disability among children and adolescents 10 years and older. In this episode, Allison Weathers, MD, FAAN speaks with Serena Orr, MD, MSc, FRCPC, author of the article “Headache in Children and Adolescents,” in the Continuum® April 2024 Headache issue. Dr. Weathers is a Continuum® Audio interviewer and an associate chief medical information officer at Cleveland Clinic in Cleveland, Ohio. Dr. Orr is an assistant professor in the departments of Pediatrics, Community Health Sciences, and Clinical Neurosciences at Cumming School of Medicine, University of Calgary and a pediatric neurologist at Alberta Children's Hospital in Calgary, Alberta, Canada. Additional Resources Read the article: Headache in Children and Adolescents Subscribe to Continuum: continpub.com/Spring2024 Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Guest: @SerenaLOrr Transcript   Dr Jones: This is Dr. Lyell Jones, Editor-in-Chief of Continuum, the premier topic-based neurology clinical review and CME journal from the American Academy of Neurology. Thank you for joining us on Continuum Audio, a companion podcast to the journal. Continuum Audio features conversations with the guest editors and authors of Continuum, who are the leading experts in their fields. Subscribers to the Continuum journal can read the full article or listen to verbatim recordings of the article by visiting the link in the show notes. Subscribers also have access to exclusive audio content not featured on the podcast. As an ad-free journal entirely supported by subscriptions, if you're not already a subscriber, we encourage you to become one. For more information on subscribing, please visit the link in the show notes. AAN members, stay tuned after the episode to hear how you can get CME for listening.  Dr Weathers: This is Dr. Allison Weathers. Today, I'm interviewing Dr. Serena Orr on pediatric headache, which is part of the April 2024 Continuum issue on headache. Dr. Orr is an Assistant Professor at the University of Calgary, and a Pediatric Neurologist at Alberta Children's Hospital in Calgary, Alberta, Canada. Welcome to the podcast. So, thank you, Dr. Orr, for taking the time to speak with me about this fantastic article that covers such an important topic – headache in the pediatric population, in children and adolescents. First, I'd love to start by learning a little bit about you. Where do you practice, and how did you get interested in this topic? I love learning more about the authors of these incredible articles and how they became interested in their fields. So, you know, pediatric neurology is already a pretty subspecialized area of medicine – how did you become interested even further subspecializing in headache? Dr Orr: Well, thank you for the invitation. Nice to meet you, Dr. Weathers. I'm Serena Orr. I'm a clinician-scientist, pediatric neurologist, and headache specialist based in Canada at the Alberta Children's Hospital in Calgary, Alberta, just outside of the Rockies. I'm really passionate about headache medicine. I think I came to it because it allowed me to marry my interests in neurology and psychology together. I did my undergraduate studies at McGill in psychology and really wanted to take a biopsychosocial approach to my practice. The first child neurology patient I ever saw was a child who was experiencing migraine and having a lot of disability from it, with lots of impacts on her life - and I really saw an opportunity to take a holistic approach to the patient and marry my interests in neuroscience, neurology, and psychology together. So, I'm very excited to talk to you today about this topic that I'm really passionate about and that I think is underserved – um, hopefully get more people excited about it. Dr Weathers: But so great, and I'm sure we will do that just based on how excited I was just reading your article. So, I always like to start, actually, with what you feel is the most important clinical message of your article. What is your biggest takeaway you want to leave our listeners with? Dr Orr: Yeah, well I think this is a really big topic in neurology. So, if you look at the reasons for consulting a child neurologist, headache falls into the top three. 60% of youth experience headache in youth. If we look at what presents to neurology in terms of headache, the majority is migraine – and so that's a big focus of this article, because anywhere between a half to 88% of headache consultations in neurology are for migraine. And as I kind of alluded to in discussing my interests in this area, you know, it's really important to take a biopsychosocial approach to managing any chronic pain disorder, including migraine and headache disorders. Another big takeaway point from the article is that - specific to pediatric headache - there's really high placebo response rates that we're still trying to understand and grapple with in the field, and I think this underscores the importance in really doing patient-centered care and ensuring that you're educating patients and families about the level of evidence that we have about the placebo response rates and engaging in shared decision-making when you're choosing treatments together. So, I think those would be the main take-home points. Dr Weathers: I think both really critical. And I think even without – I'll put my plug in – even without the placebo effect, I think that shared decision-making is such an important concept for all of us in neurology to think about - but I think you make such the important point that with it, it becomes absolutely critical. I want to expand on a concept that you were just talking about. Pediatric headaches are so incredibly common, and you make the point in the article so well that they're one of the leading causes of neurological disability in pediatric patients. They have such a significant impact that really touches all aspects of these children's lives - both at school, how they impact their hobbies - pretty much everything that they do, and these long-reaching impacts. But then you go on to say that pediatric headache remains the most underfunded pediatric disease category when you take into account allocated public research dollars, which was just staggering to me. Why do you think this is? Dr Orr: I think there's a few reasons. So, one of the main reasons, I think, is that headache medicine has been underserved - there haven't been enough people who have gravitated to this field. I think this is rapidly changing as we train more people and show the world how important this topic is and how much exciting translational research is going on. But, historically, this has been a very small subspecialty that's been underserved relative to disease burden (so not enough scientists equals less research funding) - but there's another aspect to this as well. There was a paper published in 2020 by Mirin – who actually looked at research dollars in NIH based on disease burden and whether the diseases were male or female dominant - and found that there's a significant gender bias in research funding. Male-dominant diseases tend to be significantly overfunded relative to female-dominant diseases when you look at disease burden - and if you look at the female-dominant disease table, headache disorders and migraine are in the top three most underfunded disease categories amongst the underfunded female-dominant diseases. That data has been replicated looking at NIH dollars on the pediatric side as well. They didn't look at gender breakdown in the pediatric paper that was published a couple of years ago, but found, actually, that pediatric headache disorders are the most underfunded in terms of NIH research dollars to pediatric diseases – so, top underfunded relative to disease burden. So, yeah, being underserved as a field - and then, I think, gender bias has also played a significant role in what gets funded over time. Dr Weathers: Wow, that is hard to think about. And I think those are really insightful points and ones we really need to think about as we think about the bias in our research and our funding. Why is access to care and treatment for these children and adolescents so important? I know this seems like a super obvious one, but it feels like the answer is actually really much more complex. Dr Orr: Well, there's data to show that earlier diagnosis can lead to better long-term outcomes for youth with migraine - and this is really important, because if you look at the incidence curves for migraine, you see that at least a third, if not more, of incident cases occur before adulthood. We also know there's some GWAS data to show that youth-onset migraine has a higher genetic loading when looking at polygenic risk scores than adult-onset migraine, so people who have migraine onset in youth may be more genetically loaded (that may be important). And we also know that early access to diagnosis and treatment gives them a better long-term prognosis. We know that headache disorders and migraine are associated not only with long-term potential for disability on the physical side, but also increase the risk of psychiatric comorbidities developing over time, so there's really a huge opportunity in accessing a diagnosis and treatment early to improve long-term function - both on the medical side, but also potentially avert poor mental health outcomes - and also diagnose and treat a subset of people with the disease that may be more genetically loaded. We don't know if that impacts outcomes, but potentially, it does. So there's lots of reasons, I think, that we can get in there early and make a big impact – and even for those who it takes a while to find effective treatment for, really having access to education early so that they understand their disease and also ways that they can engage in self-management strategies, I think, is really empowering to the patient and really important (even if we're struggling to find the best medical therapy). Dr Weathers: You laid out a lot of really important reasons, and again, it goes back to the arguments made at the beginning about why it's so important to increase the funding so that this is no longer an area that's underserved, so that we are able to increase the access, and that everybody who needs this kind of care is able to get it. I want to shift a little bit and think about how we diagnose and work up patients who present with a headache. So as a neurologist - and also as a parent - one of the scariest considerations for me is figuring out if a headache is just a headache or if it's a sign of something else (you know, what we think of as a secondary headache disorder). What is your approach to distinguishing between the two? Dr Orr: We take a very clinical approach to diagnosis. We don't have specific biomarkers for different headache disorders, so we're still, you know, relying on a really detailed history and physical exam in order to sort out the diagnosis. As I discussed in the article, really the key first branch point (like you say) is, is this a primary headache disorder or a secondary headache disorder? There's some tools that we can use in practice to try to get at that, I think the most useful of which is the SNOOP tool - it's an acronym that goes over headache, red and orange flags. Every time I write an article where I discuss this, it's expanded to include more red or orange flags (it's in its probably third or fourth iteration now), but there's a nice table in the article that goes over some of these red and orange flags. It includes things like systemic feature (like headache, nuchal rigidity), if there's a history of cancer, if there's associated, you know, headache waking child up in the morning with vomiting - and a variety of features. I have to say the level of evidence for some of the features is relatively low, and our understanding of some of the red flags has changed over time. As one example, we used to think occipital headaches in youth were almost always associated with a secondary headache disorder, but now there's more emerging data to show that it's actually relatively common for youth with migraine to have an occipital location. So, really, using the tool is about kind of putting the whole picture together to try to risk stratify. In the majority of youth who present with recurrent headaches, who don't have any red or orange flags, and who have an unremarkable neurological examination without focal deficits, it typically is such that we don't have to do further investigation - but any red or orange flags (or a combination of them), any focal deficits on exam, would typically be where we would be considering neuroimaging. It's very unusual that we have an indication to do an EEG or large amounts of blood work in youth with headache, but it is context specific - for example, a case presenting with recurrent hemiplegia (you may have Todd's paralysis on the differential and you may want to do an EEG), or in a youth who also has GI symptoms (I picked up some youth with celiac disorder who have chronic headaches as well). So there are specific circumstances where blood work, EEG may be indicated (or obviously lumbar puncture in the case of suspected infection, et cetera), but for the most part, we're really relying on a very thorough history and physical exam to sort out our pretest probability of a secondary headache disorder and whether we need to do neuroimaging and further investigations. Dr Weathers: I think keeping in mind that systematic approach and really working through the algorithm is really reassuring and makes sense that, one, you won't miss something kind of worrisome, but on the other hand, that you're also not doing unnecessary testing, either. Along those lines, what do you think is the easiest mistake to make when treating children and adolescents with headache, and how do you avoid it? Dr Orr: I think the easiest mistake to make is undertreatment. Both for acute and preventive therapies, I often see undertreatment. I think families are often hesitant to give medication to their children, and so I have a lot of families say, “Oh, well, you know we typically wait the attacks out until they get more severe, we try to avoid medication, we use cold compresses, et cetera.” So, explaining to families that acute treatment (of course, we don't want to overuse it) and overusing simple analgesics (NSAIDS) more than three days a week can increase the risk of higher frequency of attacks and medication overuse headache - but undertreatment is a risk, too. And the way I like to explain it to families is in the scientific basis of pain chronification - so I'll say to families, “You know, we have these pain pathways in our brain. If we let them go off for long periods of time, they get stronger (and so that's where we want to get medication in quickly to try to shorten the exposure of the attacks). When you don't do that, those pain pathways may start out like a dirt road - and maybe then you have lots of long attacks, and then it gets paved, and then it becomes a highway.” I find it's a useful way to help families understand the concept of pain chronification and why we want them to treat attacks. The same thing goes for undertreatment on the preventive side. If you know a youth is having frequent attacks that are impacting their life and their ability to function, we really should be thinking about a daily preventive treatment, because we know that pill-based interventions will result in a significant reduction in headache frequency in at least two-thirds of youth - and again, allowing the youth to have frequent attacks contributes to that pain chronification (and explain it to families in a similar way to what I just explained for acute treatment) - but there can be a lot of hesitancy to engage with pill-based treatments, even though we know that they can be helpful. Dr Weathers: I think that's a really powerful point - and I think something we also, frankly, probably tend to do on the adult side as well – but, especially, I could see where there's even probably more hesitancy in children and adolescents (this concern that we're going to overtreat them and then end up inadequately treating, which leads to increased problems). And also goes back to the concept you were talking about earlier about the importance of shared decision-making and really engaging with the patient and their families in the discussion early on to help avoid that, as well to have everybody aware of the benefits and the side effects of all of the different options, I think is so critical. I was also really excited to see you (in the article) write about the importance of a trauma-informed care approach. This is an area I'm really passionate about in my work as a clinical informaticist and how we can leverage the electronic health record to support trauma-informed care and raising awareness of what a patient's triggers may be. Can you explain to our listeners who may not be knowledgeable about this approach what it means, and why you think that this might be applicable to children adolescents with headache? Dr Orr: Thanks for bringing that up. I think it's really important as well. We've done some work in my lab (and many others have as well) to show that there's a relationship between adverse childhood experiences and the development of headache disorders in youth and adults. By adverse childhood experiences, I mean exposure to highly stressful (like toxic stress) environments in early childhood, such as experiencing death of a parent, divorce, abuse, neglect. So, we know that adverse childhood experiences are associated with higher risk of developing migraine and headache disorders, and knowing that and how common these are amongst our patients - really think it's important to advocate for screening all children, adolescents coming in with recurrent headaches for adverse childhood experiences and exposure to trauma, because it really will impact not only how you interact with the patient, but also potentially what you will screen them for on the mental health side. And so providing trauma-informed care, I think - of course we want it to be targeted - but really taking this approach with all patients is actually a good way to think about it, because trauma is very common in our society, and some of the ways that we've measured trauma in the past (like some of the examples that I gave, divorce, death of a parent) are really narrow and don't encompass broader aspects of trauma (like systemic racism and other things that people are experiencing that haven't been adequately measured). So what trauma-informed care is - you know, there's a few core aspects, and one is screening all patients for trauma. The way I do that in clinic is just asking them if they've had any major stressful life events (and then I give a few examples), but there are standardized questionnaires that can be used for this as well. And then really trying to develop a nurturing rapport with the patient - an open listening strategy, asking open-ended questions, being empathic with patients and families - I know we all try to do this, anyway, but really focusing on that, especially in the context of trauma. And then thinking carefully about not only how you're talking to the patient, but how you're approaching them during the physical exam (so, for example, asking permission before touching the patient rather than just diving into the exam to be sensitive to that). And then also recognizing, like I said, that some of the ways that we've conceptualized trauma have been a little bit narrow, and that trauma may occur in context outside of what we traditionally think of. Dr Weathers: Again, I think that's so important and could be certainly much more broadly applied than even just to this one field, but thrilled to see that you're incorporating it into your work and your research (and again, it was discussed in the article) - and, absolutely, I think that the more that we incorporate it as well here, I think, that the better off for all of our patients and the improved care we provide. Moving on from that, I always like to end my interviews on a positive and hopeful note, and so I'd love to hear from you what you're most excited about in the field of pediatric headache. What breakthroughs do you think are coming, or what's giving you the most hope? Dr Orr: There's so much, there's so much exciting stuff going on in our field (and so, you know, I'll have to rein in myself in here), but one thing is there's been an explosion of novel treatment options on the adult migraine side in the last five to ten years, including agents targeted at the CGRP pathway, calcitonin gene-related peptide, some monoclonal antibodies, and receptor antagonists. There's been an explosion of neuromodulation options with now five devices that have various levels of FDA clearance for use in adults and/or youth with migraine. And there are, for most of these devices and novel drugs, either published studies or ongoing research into how they may be used in youth, so I'm hopeful that we will have more treatment options that are evidence based for youth going forward. This is in part due to the Pediatric Research Equity Act that came out a couple of decades ago now that has put requirements for pediatric studies when new drugs are approved by the FDA for adults - so I think that has had an impact, and I'm hopeful that we'll have an expanded treatment landscape in the years to come. There's also a lot of really exciting, more kind of fundamental research going on that I think will help us move the pediatric field forward more rapidly. In the past, we have really often borrowed from what the adult neurologists are doing for adults with headache disorders without really understanding some of the fundamental biological and psychosocial differences between headache disorders onset in youth versus adulthood, and so there is more and more research going on to understand the biology of migraine in youth and some of the risk factors at this age and some of the features that may make youth a little bit different, because it's very rare that youth are just little versions of adults for any disease or problem. And then, you know, I've seen a really large expansion in the number of trainees who are interested in headache medicine since I've entered this field (I've even got one of our residents who's going to do a headache fellowship, which is exciting), and seeing the growth and interest in headache medicine and the number of people being trained really gives me a lot of hope for the future, because there's so much work to be done in this area, and, really, that's where we're going to have the largest impact - is in mentoring and fostering the next generation of headache neurologists. So, there's lots of reasons to be excited, and I would say to the trainees listening that if you want an exciting career where there's lots of opportunity to make impact both clinically on your patients and in terms of educating the next generation and spearheading research initiatives, headache medicine is for you. Dr Weathers: I think that is incredibly inspiring and will hopefully get a lot of our listeners excited about joining this incredible field. Well, thank you for, again, this great article and for all of your time this evening, I've learned so much and really enjoyed speaking with you. Dr Orr: Thank you. Likewise, it was great to have this opportunity. I really enjoyed it.   Dr Weathers: Again, today, we've been interviewing Dr. Serena Orr whose article on pediatric headache appears in the most recent issue of Continuum on headache. Be sure to check out Continuum Audio podcasts from this and other issues. And thank you to our listeners for joining today. Dr Monteith: This is Dr. Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practice. And right now, during our Spring Special, all subscriptions are 15% off. Go to Continpub.com/ Spring2024, or use the link in the episode notes, to learn more and take advantage of this great discount. This offer ends June 30, 2024. AAN members: go to the link in the episode notes and complete the evaluation to get CME. Thank you for listening to Continuum Audio.

Send us a Text Message.Imagine the impact of groundbreaking studies on your health as Dr. Koren unveils three revolutionary areas in medicine. From the persistent agony of refractory migraines to the swallowing difficulties caused by eosinophilic esophagitis, and the inherited dangers of lipoprotein(a) affecting heart health, he offers a beacon of hope. Witness the power of clinical research that goes beyond traditional treatments, as Dr. Koren introduces us to CGRP antagonists – a game changer in migraine management. He also highlights the strides being made to address the challenges of EOE and the promising treatments emerging for lipoprotein(a) that could drastically reduce this menacing cholesterol. Join us for today's MedEvidence Monday Minute into the future of healthcare, illuminated by Dr. Koren's passion and expertise.Be a part of advancing science by participating in clinical researchShare with a friend. Rate, Review, and Subscribe to the MedEvidence! podcast to be notified when new episodes are released.Follow us on Social Media:FacebookInstagramTwitterLinkedInWant to learn more checkout our entire library of podcasts, videos, articles and presentations at www.MedEvidence.com Powered by ENCORE Research GroupMusic: Storyblocks - Corporate InspiredThank you for listening!

New daily persistent headache is a syndrome characterized by the acute onset of a continuous headache in the absence of any alternative cause. Triggers are commonly reported by patients at headache onset and include an infection or stressful life event. In this episode, Aaron Berkowitz, MD, PhD, FAAN, speaks with Matthew Robbins, MD, FAAN, FAHS, author of the article “New Daily Persistent Headache,” in the Continuum® April 2024 Headache issue. Dr. Berkowitz is a Continuum® Audio interviewer and professor of neurology at the University of California San Francisco, Department of Neurology and a neurohospitalist, general neurologist, and a clinician educator at the San Francisco VA Medical Center and San Francisco General Hospital in San Francisco, California. Dr. Robbins is an associate professor of neurology and director of the Neurology Residency Program at New York-Presbyterian/Weill Cornell Medical Center in New York, New York. Additional Resources Read the article: New Daily Persistent Headache Subscribe to Continuum: continpub.com/Spring2024 Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @https://twitter.com/AaronLBerkowitz Guest: @ @mrobbinsmd Full Transcript Available: Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum, the premier topic-based neurology clinical review and CME journal from the American Academy of Neurology. Thank you for joining us on Continuum Audio, a companion podcast to the journal. Continuum Audio features conversations with the guest editors and authors of Continuum, who are the leading experts in their fields. Subscribers to the Continuum journal can read the full article or listen to verbatim recordings of the article by visiting the link in the Show Notes. Subscribers also have access to exclusive audio content not featured on the podcast. As an ad-free journal entirely supported by subscriptions, if you're not already a subscriber, we encourage you to become one. For more information on subscribing, please visit the link in the Show Notes. AAN members: stay tuned after the episode to hear how you can get CME for listening.   Dr Berkowitz: This is Dr Aaron Berkowitz, and today I'm interviewing Dr Matthew Robbins about his article on new daily persistent headache, from the April 2024 Continuum issue on headache. Dr Robbins is an Associate Professor of Neurology and Director of the Neurology Residency Program at New York-Presbyterian/Weill Cornell Medical Center, in New York. Welcome to the podcast. Dr Robbins: It's great to be with you, Dr Berkowitz. Dr Berkowitz: Well, thanks so much for joining us this morning. To start, what is new daily persistent headache? I think it's an entity maybe that might be new to some of our listeners. Dr Robbins: Yeah - it's an entity that also struck me when I was in training. I didn't hear much of it as a neurology trainee until I did a fellowship in headache, where, all of a sudden, we were seeing patients with this syndrome (and labeled as such) all the time. And that actually inspired me to begin a research project to better characterize it - a clinical project that ended up helping to broaden the diagnostic criteria. New daily persistent headache really is just defined by what it says - it's new; it's every day; it persists; it's a headache. It can't be from some other identifiable cause, which includes both secondary disorders (you know, something that, where headache is a symptom of) or a primary headache disorder; distinguishes itself from, say, migraine or tension-type headache because there's no real headache history and there's an abrupt onset of a daily and continuous headache that has to last for at least three months since onset. And the onset is typically remembered - it's usually acute or abrupt; there may or may not be some circumstances that surrounded the onset that might have some diagnostic or causal or associated implications that we can explore. Dr Berkowitz: Okay. So, I always find it challenging in headache medicine and some other areas where we don't have a biomarker, per se - an imaging finding, a lab finding; we have an eloquent and detailed clinical description - to know how comfortable to be making a diagnosis like this. In this case, particularly, right - you said it has to be going on for three months. What if I see a patient one month into something I think could be this, but I can't technically say, per the criteria, right (it's three months)? When do you start thinking about this diagnosis in patients, and what are some of the main considerations in confirming the diagnosis, and what needs to be ruled out or excluded for making the diagnosis?   Dr Robbins: I think traditionally, in headache, the term “chronic” has that three-month time period. The reasons are twofold: one is that, typically, if there's some secondary disorder that might have some distinguishing feature (something that really evokes the headache or some other neurological accompaniment that develops in addition to headache), it would pretty much be likely to declare itself by the three-month mark. Or if it was something that was very self-limited, it would probably go away before three months have elapsed. Or if it resolved after some days or weeks but then declared itself as a more episodic disorder, then we might say someone who begins with continuous headache that might, for example, resemble migraine (maybe it presented a status migrainosis but then it devolved into a more episodic disorder that might just be migraine overall). So, I think that's pretty much why the three-month mark has been so prevalent in the International Classification of Headache Disorders, including how new daily persistent headache is diagnosed. But at the same time, there's lots of disorders that might mimic (or might be misdiagnosed as) new daily persistent headache, and they really are a secondary disorder. Probably the most common one that we think about is a disorder of intracranial pressure or volume, mainly because routine MRI features could be normal or could be easily missed if they had subtle abnormalities. The defining symptom of those disorders are also continuous headache, often from onset, with an abrupt and remembered nature. So, that's often the main category of secondary headache that might be misdiagnosed as primary headache. I think, probably, idiopathic intracranial hypertension as the prototypical disorder of high pressure often declares itself with visual symptoms, pulsatile tinnitus, and other abnormalities. And nowadays, there's much more increasing recognition for MRI abnormalities or even MRV abnormalities with such patients. But spontaneous intracranial hypotension (despite increasing recognition of CSF leaks in the spine that lead to intracranial hypotension or hypovolemia) really remains an underdiagnosed entity. I think that's one disorder where - for example, if I'm seeing a patient with new daily persistent headache and there's no orthostatic or positional nature to their headache - I will still do an MRI, with and without contrast, to be sure. But that the chances of them having a spontaneous CSF leak are low if that scan is unremarkable. Dr Berkowitz: That's very helpful. Yeah. It's interesting; when you talked about the criteria for this condition - that it has an acute onset, which is a red flag, right, and it is persistent for months, which for a new headache would also be a red flag. So, this is a condition - correct me if I'm wrong – that, if you're considering it, there's no way that you're going to make this diagnosis without neuroimaging because there are two red flags, in a way, embedded in the criteria before we get to the other diagnoses being excluded. Is that right? So, this would only be a diagnosis made clinically but after neuroimaging is obtained, given that two red flags are part of the criteria – isn't that right? Dr Robbins That's absolutely right. So, I can't imagine there's anyone who has new daily persistent headache who hasn't had appropriate neuroimaging, and that typically should include an MRI, with and without contrast, unless there's some compelling reason to avoid that. There's some other workup that could be done that's not universal but - for example, in clinic-based studies of patients who have new daily persistent headache versus those who may have, say, chronic migraine or chronic tension-type headache, you may find more abnormalities. The biggest and more compelling example of that is hypothyroidism, which presumably would be somewhat subclinical if it hadn't been brought to someone's medical attention earlier. It doesn't mean that hypothyroidism is the cause of new daily persistent headache, but it could be some type of triggering or priming factor that leads to headache perpetuation in some patients. Sometimes, if that hasn't been done already, that would be a blood test I might think about sending. And, of course, the context of onset; if someone lived in a place where tick-borne illnesses are endemic, if there are other neurological symptoms, that might prompt looking for serological evidence of Lyme disease, as one example. Dr Berkowitz: We see a lot of headache. I'm a general neurologist; I know you're a headache specialist; we all see a lot of patients with headache. You and I both work closely with residents. Often, residents will come to present a headache patient to me and they'll say, “The patient seems to have a new daily persistent headache. They haven't been imaged yet. They have a completely normal exam. The history fits.” And I always ask them, “Okay, we have to get neuroimaging, right? There's at least one red flag of the chronicity, maybe the red flag of something beginning relatively abruptly. Even though you're looking at the patients - I'm pretty sure that imaging is going to be normal, but we've got to do it.” But I always encourage residents, “Try to predict - do you think the imaging is going to be normal (this is a rule out) or do you think you're going to see something (this is a rule in)? - just to sort of work on calibrating your clinical judgment.” I'd love to ask you - as a headache specialist, when you're looking at the patient and say, “I know I need to get neuroimaging here to fully make this diagnosis of exclusion,” or you've heard something that sounds like a red flag; you know you're obligated to image, but your clinical suspicion of finding anything more than something incidental is pretty low. How often are you surprised in practice in a sort of enriched tertiary headache population? Dr Robbins: That's a great way to frame such a presentation on how a resident would present to you the case and whether it's a rule in or rule out. I totally agree with your approach. I think much of it depends on the clinical story. I think if it was just a spontaneous onset of headache that kind of resembles migraine that just continued, then likely the MRI is being done to just be sure we're not missing anything else. However, if the headache started – really, say someone coughed vigorously or bent over and the headache started, and there was some clear change that you could perceive in - that was, say, the Valsalva or a transiently raised intracranial pressure, or some other maneuver; then you might really say, “Well, this really could be a spontaneous CSF leak,” for example. Even if the MRI of the brain, with and without contrast, is totally normal, I'm not really sure I'm convinced - that you might even take it further. For example, you might do an MRI of the total spine, with a CSF-leak-type protocol, to see if there's some sign of a spontaneous CSF leak or an extradural collection. So, I think in the cases where the preclinical suspicion is higher for a secondary headache, it might not stop at an MRI of the brain (with and without contrast) that's normal. Patients with spontaneous CSF leaks - about eighty percent of them have abnormal brain MRIs, but twenty percent don't. We found, from some observational studies, that a newer cause of intracranial hypotension, such as a CSF venous fistula in the spine, is more likely to present than other causes of CSF leak - with say, Valsalva-associated headache or cough-associated headache. That might prompt us to really take a workup more deeply into that territory, rather than someone where it really just sounds like chronic migraine that switched on. And maybe in those patients, when you dig around, they were carsick as a kid, or they were colicky babies, or they used to get stomachaches and missed school as a teenager here and there, and you think migraine biology is at play. Dr Berkowitz: So, if you're thinking of this diagnosis before you can make it, these patients are going to get an MRI, with and without contrast. And it sounds like the main things you're looking to make sure you're not missing are idiopathic intracranial hypertension or intracranial hypotension from some type of leak. Any other secondary headaches you worry about potentially missing in these patients or want to rule out with any particular testing? Dr Robbins: Yeah - I think sometimes we think of other vascular disorders, especially - when these patients come to medical attention, it's often a total change from what they're used to experiencing. They may present to the emergency room. So, it depends on the circumstance. You might need to rule out cerebral venous thrombosis. Or if there was a very abrupt onset or a relapsing nature of abrupt-onset headaches with sort of interictal persistent headache, we might think of other arteriopathies, such as reversible cerebral vasoconstriction syndrome. There's the more common things to rule out - or commonly identified conditions to rule out - like neoplasm and maybe a Chiari malformation in certain circumstances; those usually would declare themselves pretty easily and obviously on scan or even on clinical exam. Dr Berkowitz: Another question I'd love to ask you as a headache specialist, in your population - sometimes we see this type of new daily persistent headache presentation in older patients, and the teaching is always to rule out giant cell arteritis with an ESR and CRP, in the sense that older patients can present with just headache. Again, my clinical experience as a general neurologist - I wanted to ask you as a headache specialist – is, for the countless times I've done this (older patient has gotten their neuroimaging; we've gotten ESR and CRP), I've never made a diagnosis of giant cell arteritis based on a headache alone, without jaw claudication, scalp tenderness, visual symptoms or signs. Have you picked this up just based on a new headache, older person, ESR, CRP? I'm going to keep doing it either way, but just curious - your experience. Dr. Robbins: Yeah. We're taught in the textbooks (I'm sure we're taught by past Continuum issues and maybe even in this very issue) about that dictum that's classically in neurology teaching. But I agree - I've never really seen pure daily headache from onset, without any other accompaniments, to end up being giant cell arteritis. Then again, someone like that might walk in tomorrow, and the epidemiology of giant cell arteritis supports doing that in people over the age of fifty. But almost always, it's not the answer; I totally agree with you. Dr Berkowitz: Good to compare notes on that one. Okay - so let's say you're considering this diagnosis. You've gotten your neuroimaging, you've gotten (if the patient is over fifty) your ESR and CRP, and you ruled out any dangerous secondary causes here. You have a nice discussion in your article about the primary headache differential diagnosis here. So, now we're sort of really getting into pure clinical reasoning, right, where we're looking at descriptions (colleagues like yourself and your colleagues have come up with these descriptions in the International Classification of Headache Disorders). Here again, we're in a “biomarker-free zone,” right? We're really going on the history alone. What are some of the other primary headache disorders that would be management changing here, were you to make a diagnosis of a separate primary headache disorder, as compared to new daily persistent headache? Dr Robbins: I think the two main disorders really are chronic migraine and chronic tension-type headache. Now, what we're taught about chronic migraine and chronic tension-type headache is that they are disorders that begin in their episodic counterparts (episodic migraine, episodic tension-type headache) and then they evolve, over time, to reach or culminate in this daily and continuous headache pattern, typically in the presence of risk factors for that epidemiologic shift we know to exist but that may happen on the individual level, which does include things that we can't modify, like increasing age, women more than men, some social determinants of health (like low socioeconomic status), a head injury (even if it didn't cause a concussion or clear TBI), a stressful life event, medication overuse, having comorbid psychiatric or pain disorders in addition to the headache problem, having sleep apnea that's untreated, and so on. New daily persistent headache - by definition, it should really be kind of “switched on.” Many years ago, Dr Bill Young and Dr. Jerry Swanson wrote an editorial where they labeled new daily persistent headache as the “switched-on headache.” Then, we're taught in headache pathophysiology that this chronification process happens over time because of, perhaps, markers of central sensitization that might clinically express itself as allodynia in trigeminal or extratrigeminal distributions. So, we're not comfortable with this new daily persistent headache, where we think the biology is like chronic migraine that gets switched on abruptly, but in so many patients, it seems to be so - it behaves like chronic migraine otherwise; the comorbidities might be the same; the treatments might still work similarly for both disorders in parallel. So, I think those are the two that we think about. Obviously, if there's unilateral headache, we might think of a trigeminal autonomic cephalalgia that's continuous, even if it doesn't have associated autonomic signs like ptosis or rhinorrhea (which is hemicrania continua) - and in those patients, we would think about a trial of indomethacin. But otherwise, I think chronic migraine and chronic tension-type headache are the two that phenotypically can look like new daily persistent headache. In patients with new daily persistent headache, about half have migraine-type features and about half have tension-type features. When I was a fellow, the International Headache Society and the classification only allowed for those who have more tension-type features to be diagnosed as new daily persistent headache. But we (and many other groups) have found that migraine-type features are very common in people who fulfill rigorously the criteria for new daily persistent headache otherwise. And then the latest iteration of the classification has allowed for us to apply that diagnosis to those with migraine features. Dr Berkowitz: That's very helpful. So, we've ruled out secondary causes and now you're really trying to get into the nuances of the history to determine, did this truly have its abrupt onset or did it evolve from an episodic migraine or tension-type headache? But it could be described by the patient as migrainous, be described by the patient as having tension features The key characteristics (as you mentioned a few times) should be abrupt onset and a continuous nature. Let's say, now you (by history) zeroed in on this diagnosis of new daily persistent headache. You've ruled out potential secondary causes. You're pretty convinced, based on the history, that this is the appropriate primary headache designation. How do you treat these patients? Dr Robbins: Well, that's a great question, Dr Berkowitz, because there's this notoriety to the syndrome that suggests that patients just don't respond to treatments at all. In clinical practice, I can't dispute that to a degree. I think, in general, people who have this syndrome seem to not respond as well, to those who have clear established primary headache disorders. Part of that might be the biology of the disorder; maybe the disorder is turned on by mechanisms that are different to migraine (even though it resembles chronic migraine) and therefore, the medications we know to work for migraine may not be as effective. In some, it could be other factors. There's just a resistance to appreciating that you have this headache disorder that - one day you were normal, the next day you're afflicted by headache that's continuous. And there's almost this nihilism that, “Nothing will work for me, because it's not fair - there's this injustice that I have this continuous headache problem.” And often people with new daily persistent headache may be resistant to, say, behavioral therapies that often are really helpful for migraine or tension-type headache because of this sort of difficult with adjustment to it. But at least there's observational studies that suggest that most of the treatments that work for migraine work for new daily persistent headache. There's been studies that show that people can respond to triptans. In my clinical experience, CGRP antagonists that work for the acute treatment of migraine may work. There is evidence that many of the traditional, older medicines (like tricyclic antidepressants, topiramate, valproate, beta-blockers, probably candesartan) and others that we use for migraine may work. There's observational studies specifically for new daily persistent headache that show that anti-CGRP therapies in the form of monoclonal antibodies and botulinum toxin can work for the disorder. Are there anything specific for some of the new daily persistent headache that might work? Not that we really know. There's been some attempts to say, “Well, if you get these people in the hospital early and try to reduce the risk of headache persistence by giving them DHE, or dexamethasone, or lidocaine, or ketamine, will you reduce the chances of headache persistence at that three-month mark or longer?” We don't really know (there's some people who believe that, though). Maybe there's good reason to do some type of elective hospitalization for aggressive treatment because we know that, notoriously, the treatment response is very mixed. There's been specific treatments that people have looked at. There's been some anecdotes about doxycycline as a broad anti-inflammatory type of treatment that might be used in a variety of neurological disorders, but there's really nothing in the peer-reviewed literature that suggests that is effective or safe, necessarily. And I think a lot of people in new daily persistent headache do develop a profile that resembles chronic migraine (they can develop medication overuse very easily). Often, goal setting is really important in the counseling of such patients. You really have to suggest that the goal for them might be difficult to have them pain-free at zero and cured, but we want this to be treated so the peaks of severity flatten out a bit, and then the baseline level of pain diminishes so that it devolves into a much more episodic disorder over time that looks like regular migraine or regular tension-type headache. Dr Berkowitz: I see. So, in addition to starting a migraine-type prophylactic agent based on the patient's comorbidities and potential benefits of the medication (the same way we would choose a migraine prophylactic), do you do anything, typically, to try to, quote, “break the cycle” - a quick pulse of steroids as an outpatient or a triptan in the office - and see how they do, or do you typically start a prophylactic agent and go from there? Dr Robbins: I think, like all things, it kind of depends on the distress of the patient and how they are functioning. If it's someone who's just out of work, cannot function - and someone like that might be very amenable to an elective hospitalization or some parenteral therapy, or maybe an earlier threshold to use a preventative treatment than we would be doing otherwise in someone with migraine overall - I think that it really depends on that type of a disability that's apparent early. I think it's compelling that, with new daily persistent headache, about a third of people report some antecedent infection that was around at the time. When new daily persistent headache was first described by this Canadian neurologist, Dr Vanast, in the 1980s, it was described in the context of Epstein-Barr virus infection, or at least a higher rate of serologies that are positive for, perhaps, recent Epstein-Barr exposure. And we know that Epstein-Barr is obviously implicated in lots of neurological diseases, like multiple sclerosis. And I mean, I think about these things all the time, and especially with COVID now. So, it's compelling - as a postinfectious disorder, do we, as neurologists (who are so comfortable with using pulse-dose steroids, IVIG) - do we use these things for a new daily persistent headache? But there's no great evidence that enduring inflammation in the dura that would spill into CSF analyses is really present in such patients. There was one study that looked at markers, such as TNF-alpha, in the CSF, but the rates of seeing that were the same in new daily persistent headache and chronic migraine, so there isn't really a specificity to that. Many people we see with new persistent headaches since 2020 may have it as part of a long COVID syndrome (or postacute COVID syndrome), and in those cases, often it's more like “new daily persistent headache-plus.” They might have something that resembles POTS (postural orthostatic tachycardia syndrome); they might have something that resembles fibromyalgia, chronic fatigue. Often in those patients, it takes management of the whole collection of neurological syndromes to get them better, not just the headache alone. Dr Berkowitz: Well, this sounds like such a challenging condition to treat. How do you counsel patients when you've made this diagnosis - what to expect, what the goals are, what this condition is, and how you developed your certainty? It's often challenging (isn't it?) sometimes with patients with headache disorders, when we're not relying on an MRI or lab test to say, “This is the diagnosis”; telling them, it's just our opinion, based on their collection of symptoms and signs. So, how do you give the diagnosis and how do you counsel patients on what it means to them? Dr Robbins: Yeah, it's a great question because it's high stakes, because people will read online, or on social media, or on support groups that this is a dreadful condition - that no one gets better, that they're going to be afflicted with this forever, and the doctors don't know what they're doing, and, “Just don't bother seeing them.” And the truth is not that; there's so many people who can get substantially better. I tell people that it's common; in some epidemiologic studies, one in one thousand people in any given year develop new daily persistent headache, and most of those people get better (they don't seek medical care eventually, or they do, just in the beginning, and then they don't have follow-up because they got all better) - and I think that really happens. I think the people who we see in, say, a headache clinic (or even in general neurology practice) are typically the ones who are the worst of the worst. But even amongst those, we see so many stories of people who get better. So, I really try to reset expectations - like we mentioned before about assessing for treatment response and understanding that improvement will not just mean one day it switches off like it switched on (which seems unfair), but that the spikes will flatten out of pain (first), that the baseline level of intensity will then improve (second); that we turn it into a more manageable day-to-day disorder that really will have less of an impact on someone's quality of life. Sometimes people embrace that and sometimes people have a hard time. But it does require, like many conditions in neurology, incremental care to get people better. Dr Berkowitz: Fantastic. Well, Dr Robbins, thanks so much for taking the time to speak with us today. I've learned so much from your expertise in talking to you and getting to pick your brain about this and some broader concepts and challenges in headache medicine. And I encourage all our listeners to seek out your article on this condition that has even more clinical pearls on how to diagnose and treat patients with this disorder. Dr Robbins: Thanks Dr. Berkowitz - great to be with you. Dr Berkowitz: Again, for our listeners today, I've been interviewing Dr Matthew Robbins, whose article on new daily persistent headache appears in the most recent issue of Continuum, on headache. Be sure to check out other Continuum Audio episodes from this and other issues. And thank you to our listeners for joining today. Dr. Monteith: This is Dr Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practice. Right now, during our Spring Special, all subscriptions are 15% off. Go to Continpub.com/Spring2024 or use the link in the episode notes to learn more and take advantage of this great discount. This offer ends June 30, 2024. AAN members: go to the link in the episode notes and complete the evaluation to get CME. Thank you for listening to Continuum Audio.

In this episode, leading researcher Dr. Messoud Ashina explains what PACAP is and how it is involved in migraine pathophysiology. He also talks about how it differs from CGRP and why it could be a promising target for migraine and other headache disorders.   Read the transcript at www.migrainedisorders.org/podcast/s6ep5-pacap-as-a-future-migraine-target   *The contents of this podcast are intended for general informational purposes only and does not constitute professional medical advice, diagnosis, or treatment. Always seek the advice of a physician or other qualified health provider with any questions you may have regarding a medical condition. AMD and the speaker do not recommend or endorse any specific course of treatment, products, procedures, opinions, or other information that may be mentioned. Reliance on any information provided by this content is solely at your own risk.

Neurology Today Editor-in-Chief Joseph E. Safdieh, MD, FAAN, highlights new articles that discuss program directors' response to the use of generative AI for personal statements, the good news for neurology based on the 2024 Match Day, and the AHS statement on CGRP-targeting therapies as a game changer for migraine treatment.

The trigeminal autonomic cephalalgias are a group of headache disorders that appear similar to each other and other headache disorders but have important differences. Proper diagnosis is crucial for proper treatment.  In this episode, Gordon Smith, MD, FAAN, speaks with Mark Burish, MD, PhD author of the article “Cluster Headache, SUNCT, and SUNA,” in the Continuum April 2024 Headache issue. Dr. Smith is a Continuum Audio interviewer and professor and chair of neurology at Kenneth and Dianne Wright Distinguished Chair in Clinical and Translational Research at Virginia Commonwealth University in Richmond, Virginia. Dr. Burish is an associate professor at UT Health Houston in Houston, Texas. Additional Resources Read the article: Cluster Headache, SUNCT, and SUNA Subscribe to Continuum: continpub.com/Spring024 Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @gordonsmithMD Transcript Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum, the premier topic-based neurology clinical review and CME journal from the American Academy of Neurology. Thank you for joining us on Continuum Audio, a companion podcast to the journal. Continuum Audio features conversations with the guest editors and authors of Continuum, who are the leading experts in their fields. Subscribers to the Continuum journal can read the full article or listen to verbatim recordings of the article by visiting the link in the Show Notes. Subscribers also have access to exclusive audio content not featured on the podcast. As an ad-free journal entirely supported by subscriptions, if you're not already a subscriber, we encourage you to become one. For more information on subscribing, please visit the link in the Show Notes. AAN members: stay tuned after the episode to hear how you can get CME for listening.   Dr Smith: This is Dr Gordon Smith. Today, I'm interviewing Dr. Mark Burish on cluster headache, which is part of the April 2024 Continuum issue on headache. Dr Burish is an Associate Professor of Neurology at the University of Texas Health Science Center at Houston, which is located in Houston, Texas. Mark, thanks so much for joining me today on Continuum Audio. I was really excited to be asked to talk with you about this article. When I recertified from my boards the last time (and actually, it will be the last time I have to take the exam), I did the AAN course on all of neurology. And I'm a neuromuscular guy, right, and so I was actually kind of worried about the headache part because I thought, “How interesting could that be?” And I was blown away at how fascinating headache has become, and in particular, your topic (cluster, SUNCT, SUNA, the trigeminal autonomic cephalalgias) - such a great topic. But before we start talking about them, I'd love to just hear more about how you got interested in this area - both headache, this topic in particular. What's your story, Mark? Dr Burish: Well, thank you very much for having me. I'm honored to be part of this. I got into headache probably the way many people do; is, in residency, you figure out what you like, and your residency clinic tends to start collecting patients that you like (not that you're trading them with other residents, but you see certain patients). And mine (by the end of residency) had a lot of headache and pain patients into it. Then, I was very fortunate and had the opportunity to do some research as part of my career. I'm an MD-PhD, and I spend about half my time now doing research on cluster headaches, so I'm very fascinated by these types of diseases. Dr Smith: Can you tell us really briefly what you're working on in your research? Dr Burish: Cluster headache is such a poorly researched area. There's not a lot of people in it, so we do a little bit of everything: we have a clinical trial going; we do some basic science on the circadian mechanisms (cluster gets this very weird timing to it, where the headaches happen same time every day); and we do a little bit of starting to wade into the genetics. Dr Smith: Well, super exciting. I was actually blown away by the statistics on cluster (as common as multiple sclerosis), and the severity of pain I was amazed to learn is above that of childbirth (it was, like, between nine and ten out of ten, which is really crazy). And I'm worried that I missed these patients in my neuromuscular clinic. So, maybe we can begin by - just tell us what you think our listeners need to know. If they have to drop off right now, what message do they need to remember from our conversation? Dr Burish: I think there's two things. First of all, the first-line treatments for these headaches have not changed recently. For cluster headache, you still treat it with oxygen, the triptans (the faster triptans; not the oral ones, but the injectables and nasals), and you prevent them with verapamil. For SUNCT and SUNA, you use lamotrigine. So, those have not changed over time. There are some new treatments, which we'll talk about later. Then the second point is, there are four different types of headaches in this family and they all look very, very similar (one-sided pain, autonomic features, ipsilateral lacrimation, rhinorrhea - that type of thing). They differ in the treatments and how long they last. If you get them wrong (if you misdiagnose them), you're probably not going to give them correct treatment. Indomethacin works very well for two of them (the ones with hemicrania in the name, so not the ones we're going to discuss today). And then SUNCT, SUNA, and cluster headache - indomethacin does not work very well. So, it's important to distinguish them and get them right. Dr Smith: Maybe we can start there, Mark. I mean, I was kind of appalled to learn that the average delay in diagnosis is four to nine years in your article, and given the severity of pain and the impact it has on these patients, that's clearly a challenge. What's so hard about this? And do you have pearls on how we can recognize these patients? And how do you sort this out practically in clinic? Dr Burish: For cluster headache patients especially, it is a lot more common than we would think it is, but it still goes misdiagnosed, partly because most cluster headache patients are episodic. So, there's an episodic version where you get them every day for a few weeks and then they might go away for a year. So, I think what happens is that patients start to get into a cycle and they either get confused for sinusitis (because it happens in the spring), or they schedule a visit with a neurologist or somebody else, but the headaches are over by the time they see them, and they cancel the visit. So, I think they get misdiagnosed partly because it's either confused or they don't see doctors fast enough. I think a little bit more awareness of what this disease is and then, somehow, a mechanism to get these patients in a little bit more urgently is probably what's necessary. Dr Smith: Well, Mark, access is a real issue in neurology more broadly, and I'd love to talk to you about that in a moment, but I wonder if we could go back. You talked about how similar these are to one another, yet the treatments are different. How do you sort out the diagnosis when you're seeing a patient? Let's say you have someone who comes in who has episodic, unilateral, very severe pain and some of these autonomic features. What are the pearls for differentiating cluster, SUNCT, and SUNA from each other? Dr Burish: The big difference between all these different headaches is the timing. As a general rule, SUNCT and SUNA attacks last seconds (they're very similar to trigeminal neuralgia); paroxysmal hemicrania (that's one of the hemicrania ones, where indomethacin helps) - those attacks last minutes; cluster headache attacks last about an hour; and the hemicrania continua is constant (that's the other hemicrania one where indomethacin works). The other part is how often they happen. Again, SUNCT and SUNA - very similar to trigeminal neuralgia, may happen hundreds of times a day; paroxysmal hemicrania - dozens of times a day; cluster headache - maybe a handful of times; and then, hemicrania is constant. Based on how long the attacks are and how frequent the attacks are, you can generally separate them out. And if you're not sure, just try indomethacin. And then if it doesn't work, you're trying to distinguish between SUNCT and SUNA, which lasts seconds, and cluster headache, which lasts an hour, so fairly easy to distinguish those. Dr Smith: How long does it take to medicine to work in a patient with hemicrania continua or paroxysmal hemicrania? I'll remind our listeners - there's a separate article in the same issue of Continuum on that topic - but for our purposes, let's say you try that; how long do you need to try it? Dr Burish: Yeah, there's a great, another article about how much to give and how it works. It is generally pretty quick. I have noticed with most patients that the onset is twenty-four to forty-eight hours. And then, if you stop the medicine, the same thing - offset is kind of twenty-four to forty-eight hours. So, patients know pretty quick whether it's going to work. Dr Smith: Wow - that's awesome. One of the things I was interested in was so-called “secondary cluster.” So, you've seen your patient and let's say you've diagnosed them with cluster (primary cluster). Do you do additional testing? Do they need imaging or other laboratory workup? Dr Burish: Yeah. The differential for cluster (and cluster is the one that we know the most about; it is the most common of all the trigeminal autonomic cephalalgias) - it's a fascinating differential. If you don't know much about them, migraine is probably the most common. If you do know a lot about them, hemicrania continua and paroxysmal hemicrania are very common. But there's all these secondary headaches that can look identical to cluster headache; these pituitary hormone-secreting tumors (prolactinomas) - things like that. So, because all these other secondary causes can happen, they generally recommend everybody gets an MRI of the brain, with or without contrast. If that is normal and the patients continue to not respond to the medicines like you expect them to (verapamil doesn't work, oxygen doesn't work, and so forth), then you might do some additional testing for pituitary bloodwork. So, just kind of a panel of hormones, looking at blood vessels (because there are some cases that dissections or AVMs can cause cluster headaches). And then sometimes get imaging of the apex of the lung because there's some data that - with the Horner syndrome - that that might be relevant. Dr Smith: I'll refer our listeners to your article, just in general, because they really need to read it. It's fantastic. But your discussion about the neuroanatomy is really cool, and probably more than we want to get into right now, but the intersection of the neuroanatomy with therapeutics, and some of these other potential etiologies. So, one thing I was really amazed by (or appalled by, frankly) was the frequency with which these patients have suicidal ideation, given the severity of the pain and, I assume, the long time it often takes to get this sorted out. How do you handle that in clinic? Do you have conversations with people about this? How often do you appreciate it? And any words of wisdom for those of us who might encounter these patients? Dr Burish: Yeah. It's not hard to imagine why patients would be suicidal with this. When you have pain that is a ten out of ten - and patients who have also had childbirth and cluster, they consider childbirth more around a seven - so you can imagine how painful this is and what thoughts might be going through people's heads. It tends to be (in my personal experience and some emerging data) that they are suicidal during a cycle. So, for these episodic patients (most patients are episodic with cluster headache for a few weeks), they are suicidal during those weeks. And when the headaches go away, much less risk of suicide. So, during the cycle, I try to get my patients in as fast as possible, get the medications in as fast as possible, but basically just be there to let them know that we have options, and so that they consider me as their first option, rather than something darker. Dr Smith: How successful is first-line therapy in these patients and what's your success rate with your initial attempt at treatment? Dr Burish: On the acute side, the as-needed medicines (sumatriptan, oxygen) - if you give an injection (not the oral; that takes too long) - incredibly effective; for most patients, one or both of those will work. We usually prescribe both because the injections - usually you can't get that many (they can be quite expensive, realistically speaking). But also, just practically speaking, patients can have headaches up to eight times a day and you're not really supposed to be taking sumatriptan eight times a day, so we also give oxygen (but then again, oxygen is not very portable, so that's where the sumatriptan comes in). On the preventive side - not great. There's been some studies suggest maybe fifty percent is as good as any preventive is going to work for you, and that's not considering side effects and other things that patients might stop them. So, we do need to have a few different preventive options and you may have to go through a few different things. Chronic cluster headache (which is the more rare version, where patients have them year-round) is anecdotally much more refractory to treatment. Dr Smith: Can you talk a little bit about bridge therapy? You differentiate bridge from prophylactic therapy in your article. Dr Burish: Yeah. When you're approaching one of these patients - let's say they're completely naive to any medications - usually we will give them a couple of as-needed, acute medications (sumatriptan injections and oxygen). We'll give them a preventive like verapamil, but the verapamil takes a few weeks to kick in. So, the obvious question is, “What am I supposed to do in the meantime, while you're ramping it up and it's kicking in?” So, we use these short-term preventives, which we call bridge therapies or transitional therapies. These are short-acting preventives; they kick in quick, but you can't take them for very long. The most common by far is prednisone. Or an occipital nerve block with some sort of steroid (so, steroids in some sort of fashion). We will usually give them right at the beginning of a cycle (right at the beginning of a flare for chronic cluster headache patients) while we are uptitrating something like verapamil. Dr Smith: This may be a really silly question, but the next time I see one of these folks and I want to start oxygen, how do I do it? What are the logistics of giving someone oxygen for this, and how do patients navigate that, right? If you're having eight attacks a day during a cluster and you work as a nurse in the headache clinic, you probably have oxygen there. But you get where I'm going, right? - it's logistically challenging. How do you order it, and do you have words of wisdom to make it easier for patients to use? Dr Burish: There's a whole kind of system of oxygen, durable medical equipment - stuff that I've had to learn. To boil it down, there are basically two types of oxygen. There's a concentrator - kind of just a machine that takes room air and turns it into about ten percent oxygen - that is sometimes effective for patients. But sometimes ten liters per minute (which is the highest that can give) is not enough and you need fifteen liters per minute. In that case, you need an oxygen tank (the big metal cylinders that you see with a extra device on top called a regulator, that can crank it up to fifteen liters a minute. For both of these - fifteen liters a minute - you're going to need a mask. The nasal canula is just - it doesn't get up to fifteen; it's not going to be enough, so we give you this bag mask (the non-rebreather mask, or the bag hanging out below it). You really need high dose, pure oxygen for these things to work, so you have to write orders that say, “fifteen liters a minute, with regulator and non-rebreather mask.” Dr Smith: I'll refer our listeners to your Continuum article. I know a lot of our listeners use Continuum at point of care. And, of course, you can access it electronically, so there's really great pearls there. Another question for you: CGRP agents have really transformed migraine; what role do they play, if any, in management of these headaches (cluster, SUNCT, and SUNA)? Dr Burish: I think this is a fascinating emerging area of cluster headache research. One of the studies in the last three years came out that it was successful for episodic cluster headache, called galcanezumab, and it did not work for chronic cluster headache. Meanwhile, a couple other CGRP companies have tried them and they were unsuccessful, at least according to the data on ClinicalTrials.gov. And some other CGRP studies are still emerging. We know that both migraine and cluster headache work on the trigeminal system (I mean, this is a trigeminal autonomic cephalalgia - it's in the name) and CGRP is involved in the trigeminal system. That's probably where the commonality between migraine and cluster headache come from - they both work on the same pain system. But why all of them seem to work for migraine and only some of them – you know, some of these medicines work for cluster headache - is a fascinating thing. Does that mean that we don't have the dose right? Does that mean that we don't have the timing of these clinical trials right? Does that mean it's just not as effective? And there's other things that are involved in cluster headache - it's an interesting mechanism that we can start to explore. Dr Smith: I wanted to learn more about the circadian aspects of this - I found that really interesting, and you commented that you're interested in that in a research perspective. Can you describe that phenomena a little bit and just tell us what your thoughts are? Dr Burish: The interesting thing about cluster headaches, specifically, is that the headaches happen, for most patients, the exact same time every day – so, within an hour each day. So, my patient usually will say, “They're at two AM.” Across different time zones, every study that's been done - well, not every study, but many studies have been done - two AM is the most common time of day. But if you ask an individual patient, patient number one will say, “They happen every day at two AM; patient number two will say, “They happen every day at three in the afternoon.” I had a patient who was, I think, kind of getting fed up with all the questions I was asking about his headaches, and he said, “Dr Burish, it's three o'clock; if you want to wait until three fifteen, I'm going to get a headache - you can see what it's like.” That's how sure he was about when the headaches were going to happen. And other than maybe hypnic headache, there are a few other headaches that have that level of circadian predictability. So, it's just an odd, curious, unique thing to these headaches and we don't quite understand why yet. Dr Smith: So, I'm curious if the time of day patients get their headaches is in any way correlated with other aspects of sleep phenotype, right? There's broad variability in your sleep phase - the length of it, when it starts and ends. Is there any relationship, in your experience, between the time of day (two AM, ten PM) and other aspects of their sleep? Dr Burish: We haven't seen that, to my knowledge. People have looked, for example, at sleep studies while patients are having attacks. These attacks occur out of REM sleep, non-REM sleep - it doesn't seem to matter. Anecdotally, patients will say, “My cycle last year - I had headaches every day at two AM. But my cycle this year - I have headaches every day at five in the afternoon.” So, even a same patient who, theoretically, is not having big sleep changes over different years, has different timing of attacks. Dr Smith: Mark, what's the latest thing? What's most exciting in the field that you can tell our listeners about? Dr Burish: There are a lot of new treatments for cluster headache. There's the galcanezumab, which we discussed a little bit. There is a new dose for prednisone. We weren't sure how effective it was; now we're using kind of neuroimmunology-level doses of prednisone (100 milligrams daily; kind of titrating down from there). And then there's an occipital nerve stimulator for the chronic cluster headache patients. Since the last Continuum review on this topic, these three trials have been successful, and I think what gets lost is how impressive each one of these is in different ways. The prednisone study is impressive because you had to study that medicine (which we thought worked but didn't have a good clinical trial), and it's really hard to enroll patients in a placebo-controlled study where you already think it works. Another was done by a large pharmaceutical company. This is not an advertisement for or against, but these companies have rarely ventured into studying cluster headache until recently. The third study, the stimulator study, was a ten-year, multisite study involving surgeons and neurologists - just a monumental effort. It's because of these impressive studies that we now have data on how to treat the patient. Dr Smith: Just so interesting. I tell you what - I mean, if you told me twenty years ago I would be this interested in headache, I would have said, “You're crazy.” But now I see why our residents are so interested in it and why you are. This is fascinating. I could keep going for another hour or two asking you questions, Mark, but maybe we can pivot back to where we began. You told us your story about enriching your resident clinic - and for those residents listening, those are words of wisdom right there, my friend. But here's my question for you: we've already talked about access to care and how you manage access for these patients, but we have a huge access issue in neurology broadly and we desperately need more neurologists. As you're probably aware, there are some of our colleagues that don't think pain is neurology (I'm not one of them, but I know some of them and respect them otherwise). If there's an access issue for neurology, there's a access crisis for pain neurologists. And you don't just see headache, as I understand it; you see other patients with pain. So, I want to give you the last few minutes of our Continuum Audio episode to do your pitch, right? What do you have to say to the residents that are listening to us (or students) about why you find managing pain so rewarding and why they should consider this as a field? Dr Burish: Yes - I also did a fellowship in pain medicine, in addition to my headache research, so I see a little bit of both. For me, the patients are very appreciative because you are talking with them about what they are interested in. They are not interested in the change in the MRI between last time - I mean, they are interested in it, but not as much as, “I hurt today.” So, patients are more than happy - they're very grateful that you are addressing their primary concern, the thing that they're going home with that day that they're worried about. For me, seeing these patients has been very rewarding. From the research side. I think it's fascinating that there's just not enough research in this area - you can create your own niche; you can look into your own mechanisms - there's just not a lot of people in this field. And then, I think from a clinical side, other than the rewarding nature of it, there's a lot of options that we have. There's all of these neuropathic medications; there's all these different headache medications. If you want to wade into the procedural side of things (which I did with pain management), you can get into fluoro-guided procedures and spinal cord stimulators and all these different options that we have for these patients that help them, in addition to whatever they're going through. I have patients that then come back and say, “Well, by the way, I have these seizures; do you mind helping me kind of just go through my antiepileptics.” And they're generally well controlled and they consider me kind of a general neurologist for them. So, I've found it extremely rewarding and I wouldn't do anything different. Dr Smith: Well, that's really great information and I hope our resident listeners will take that to heart. Your article is truly amazing, Mark. I can't tell you how much I was impressed with it, and for our listeners - you gotta check it out. I've got a list of ten other things on my piece of paper here I could ask Mark about, but I think we're probably at time. So, Mark, thank you so much. Congratulations on an amazing article and really fascinating and exciting area of neurology. Dr Burish: Thank you. Thank you very much for having me. Dr Smith: Again, today we've been interviewing Dr Mark Burish whose article on cluster headache - appears in the most recent issue of Continuum, which is on headache. Be sure to check out Continuum audio podcasts from this and other issues, and thank you very much to our listeners for joining us today.   Dr. Monteith: This is Dr Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practice. Right now, during our Spring Special, all subscriptions are 15% off. Go to Continpub.com/Spring2024 or use the link in the episode notes to learn more and take advantage of this great discount. This offer ends June 30, 2024. AAN members: go to the link in the episode notes and complete the evaluation to get CME. Thank you for listening to Continuum Audio.

Headache is among the most common neurologic disorders worldwide. The differential diagnosis for primary and secondary headache disorders is broad and making an accurate diagnosis is essential for effective management. In this episode, Lyell K. Jones Jr, MD, FAAN, speaks with Amy Gelfand, MD, who served as the guest editor of the Continuum® April 2024 Headache issue. They provide a preview of the issue, which publishes on April 3, 2024. Dr. Jones is the editor-in-chief of Continuum: Lifelong Learning in Neurology® and is a professor of neurology at Mayo Clinic in Rochester, Minnesota. Dr. Gelfand is an associate professor at Benioff Children's Hospitals, University of California San Francisco in San Francisco, California. Additional Resources Continuum website: ContinuumJournal.com Subscribe to Continuum and save 15%: continpub.com/Spring2024 More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @LyellJ Guest: @aagelfand Full transcript available here Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum, the premier topic-based neurology clinical review and CME journal from the American Academy of Neurology. Thank you for joining us on Continuum Audio, a companion podcast to the journal. Continuum Audio features conversations with the guest editors and authors of Continuum, who are the leading experts in their fields. Subscribers to the Continuum journal can read the full article or listen to verbatim recordings of the article by clicking on the link in the Show Notes. Subscribers also have access to exclusive audio content not featured on the podcast. As an ad-free journal entirely supported by subscriptions, if you're not already a subscriber, we encourage you to become one. For more information on subscribing, please visit the link in the Show Notes.   Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum Lifelong Learning in Neurology. Today, I'm interviewing Dr Amy Gelfand, who recently served as Continuum's guest editor for our latest issue on headache disorders. Dr. Gelfand is a child neurologist at the University of California, San Francisco, where she is an associate professor of neurology, and she also happens to be Editor-in-Chief of the journal Headache. Dr Gelfand, welcome, and thank you for joining us today. Dr Gelfand: Thank you so much for having me. Dr Jones: Dr Gelfand, this issue is full of extremely helpful clinical descriptions and treatment strategies for headache disorders. With your perspective as the editor for this issue - and you've just read all these wonderful articles and edited these articles - what were you most surprised to learn? Dr Gelfand: I would say that the medication overuse headache article I think is where you'll find the most surprising content. This is an area in headache medicine that has been controversial. I think what we've got is new data - relatively new data, published in Neurology (in the Green Journal) in 2022 - the MOTS trial, showing that what we all thought was not necessarily true. In headache medicine, there was this mantra that, if somebody is overusing (too frequently using) a certain kind of headache acute medication, you've got to stop them; you've got to have them stop it completely before you can get them on a preventive treatment if you expect it to work. Turns out, in this trial, that's not the case. People were randomized to either stopping the overused acute medicine and starting a preventive versus continuing it and starting a new preventive, and they did equally well. I think that's really taught us that that dogma was not based in evidence (was not true), and what really matters is getting a patient started on an effective migraine preventive treatment. Dr Jones: Wow, that is really – that is kind of ground shaking, isn't it? That's going to change a lot of practices for a lot of neurologists out there. Do you think that's going to be well received, or has it been well received so far? Dr Gelfand: I think it has. I want it to get out there further, so I hope everybody will read in that chapter and really pick up on that piece. I think it's helpful for patients, too - that we don't necessarily need to disrupt what makes them feel like they're getting some acute, in-the-moment relief. We just need to make sure we're getting a good-quality migraine preventive therapy started. That's the most important thing. We don't necessarily need to ask them to change something about their acute treatment. Dr Jones: That's fantastic, and it certainly could make things a little more straightforward, I think for people who are helping patients manage this. To be honest with you, the term, “medication overuse” almost sounds like it's putting the onus on the patient a little bit. Dr Gelfand: It very much does sound that way. It is a very challenging term for a lot of reasons. And I agree with you that that's a problematic part of this whole terminology. Dr Jones: Well, just three minutes into the interview here and, Dr Gelfand, you've already changed people's practice. I think that's wonderful, and we'll look forward to reading that specific article in the issue. Again, from your view as a headache specialist and a leader in the field, what do you think the biggest debate or controversy is in headache medicine right now? Dr Gelfand: I think where we're really a little bit stuck in trying to figure out how to move forward is how to take care of patients who have continuous headache. It's not even really a fully defined term, but if you imagine a person who - they wake up, headache is present; it continues to be present throughout the entire day; they go to bed- it's still present; if they happen to wake up in the middle of the night to go to the bathroom, it's there then - it's just there all the time. It can be hard to imagine that situation is real - that somebody could have a headache that is continuously present for weeks, months - but this is true of some of our patients who have chronic migraine, our patients who have new, daily, persistent headache, certain other headache disorders. This entire group of patients who have continuous headache have historically been excluded from treatment trials, so our existing data don't necessarily generalize to how to treat their condition. And we need to change that, because this is a group that is arguably most in need of research, most in need of effective therapies. The question is how? Who exactly should be included in the inclusion criteria? And then, what are your outcome measures? Historically, in migraine treatment trials, we use headache days per month or migraine days per month. Days of headache per month may or may not be the right primary outcome measure for somebody who's starting from a point of continuous headache. Maybe more appropriate is, how many severe headache days you're having in a month, or how much disability you have from your headache disease. It's an area that's evolving and really does need to evolve, because this is a patient population that has been underserved in research thus far. Dr Jones: I learned that, I think, in reading one of the articles talking about continuous headache at onset – so, the headaches that are continuous from day one, which is, as I understand it, pretty uncommon. But really very little of the clinical trial data speak to how to care for those patients - is that right? Dr Gelfand: That is exactly right. And, epidemiologically, maybe not as common. But in a headache clinic, we certainly see patients who have had these headache disorders where it starts on one particular day, it becomes continuous within twenty-four hours of onset and has now been going for at least three months, and we would call that new, daily, persistent headache. Or equally commonly, people with chronic migraine where it ramped up over maybe a short to medium-long period to daily and continuous. And now they have been experiencing continuous headache for some number of months, if not longer. Dr Jones: This question may be a little bit of an unfair question. One of the challenges with headache is that, unlike some other areas of a diverse specialty of neurology, there aren't as many biomarkers as you might have for dealing with patients who have cerebral ischemia or neuromuscular disease. Do you find that that leads to more differences of opinion or more variability in diagnosis and management than you might see in other areas? Dr Gelfand: I'm so glad you asked that question. What I find that leads to is more stigma. Many of our patients are not believed, including by medical professionals who they've met before. People might think they are faking their symptoms, or that there's some sort of secondary gain, or this is something related to - they just don't know how to manage stress. This is a real problem for patients with migraine to be encountering so much stigma. As a headache medicine clinician, when I'm meeting a patient, oftentimes I need to make sure to acknowledge that, almost certainly, they've encountered that before. I need to reassure them that they're not going to be experiencing that in our headache clinic, and really try to undo some of that harm to be able to build trust that we're going to have a collaborative relationship moving forward - we're going to be a team; we're going to be determining the next steps in treatment together - and that I 100% believe them that the symptoms they are experiencing are real, are very challenging. Because migraine and other primary headache disorders are real neurologic diseases that can be quite severe. But because we have a paucity of biomarkers, it's hard for some people outside the field to recognize that. And that, I think, has been really difficult for patients historically. Dr Jones: So, a challenge for clinicians has become really more of a burden for patients. Dr Gelfand: Yes - well said. Dr Jones: Yeah. That's too bad, and maybe someday that will change, and probably can be approached from a couple of different directions, right? - from educating clinicians' perspective and also pursuing the science. This might be a related question, Dr Gelfand - what do you think the biggest misconception you've encountered in - I'm thinking mostly from the provider of the clinician community - what do you think the biggest misperception or misconception there is about patients who have headache and the management of those patients? Dr Gelfand: Well, I think it is tied in, in some way, to this notion that the patients are somehow causing their problem; that it's something about - well, I'm a child neurologist; I see adolescents and children – so, their parent is causing their problem because they're a helicopter mom or whatever it is, or they're just not managing stress in an appropriate way. I think that that is really an issue that patients are sort of handed from the medical community. Whereas if I step back and think about it, before 2018, no migraine-specific preventive therapies existed. We were borrowing from all other corners of medicine. We were borrowing from antihypertensives, antiseizure medicines, antidepressant medicines, but there was no actual migraine-specific therapy. Then came the monoclonal antibodies targeting CGRP (calcitonin gene-related peptide) - they're targeting either the ligand or the receptor. We now also have the oral forms that target the receptor, the gepants. So, we do have this one or two classes, depending on how you break that out, that are migraine-specific preventive therapies. But that's not enough for a complex disease like migraine - we need twenty of them. Look at epilepsy; there are probably twenty-plus antiseizure medicines, and yet, some patients still seize. Is that because they're anxious or stressed, or their mothers are too stressed? No - it's because some people have terrible epilepsy. And yet that same explanation has not been afforded to people with difficult migraine disease, that with just one class of migraine-specific preventive (or two, if you break out the monoclonals and the gepants) - that, somehow, they're supposed to have magically stopped with this treatment. That really doesn't make any sense. It's because we don't have enough effective therapies that they're still having difficult migraine - it's not because they're causing their disease. Dr Jones: Thank you - that's a great example. That is important to understand - that misconception about causation. And we may come back to causation here in a moment. It really doesn't make any sense that there are few specific, disease-modifying therapies for migraine, which affects tens of millions of people in the United States alone, right? Why is that? Why are there so few? Dr Gelfand: First of all, Dr Jones, I love it that you called it disease-modifying therapy, because that's how I think about it, too. The term, “preventive migraine therapy,” which is the more commonly used therapy, is not always really useful because - some people who have continuous headache will say, “Well, what are you trying to prevent? I've got headache all the time.” But this is really just treatments that are designed to dampen down disease activity in any form - how frequent, how long of duration, how intense - and I think it is really better conceptualized as disease-modifying therapy, so I love that you use that term. Why have there been so few? I think that it comes down to a paucity of research. Historically, NIH has underfunded migraine and other primary headache disorder research quite a bit, compared to how much disability those diseases cause in Americans each year. Hopefully, that will be getting better soon; I think there are some positive signs that that could be moving in a more positive direction. But I think, because migraine and other primary headache disorders are “invisible” illnesses - can't show you an x-ray with a broken bone; can't show you a lab readout with what your disease activity is; like you said, there's not a lot of biomarkers. Because of that, it's been hard for funders to really get behind it, and I think that's put us a little bit behind where we need to be. More research will lead to more therapies. Dr Jones: Let's hope so. It certainly is very common and affects, again, millions upon millions of people and leads to impaired quality of life and disability, as you point out. You are also the editor-in-chief of a leading journal in your field, Headache. I know many of our listeners who are neurologists and perhaps interested in editorial work as a career path might be curious - what led you to that, and how has it helped you as a clinician (being in that role)? Dr Gelfand: Yeah - I love being the editor of Headache. It's the journal of the American Headache Society. I think it's where the most interesting new science and work in headache medicine is coming out of. I have always found that reading helps me learn. If I want to learn about a topic, I need to read about it and I need to synthesize everything I read about. Being an editor makes that so accessible and fun. I really enjoy reading all of the articles that are coming in. It really helps me to think about everything I know, and thought I knew, in the field. And keeps my mind really questioning – do I really know that that's true or did I just think that's true? - and now this new data shows me that, actually, it's something else. And I really enjoy being challenged that way, on a daily basis, by new science that's coming in. So for anybody out there who has an interest in editing and playing an editorial role, I definitely encourage you to pursue that. There are programs - I know that the Green Journal has a resident and fellow section; that's where I started out, and I really had a wonderful experience in that. And then in our journal, in Headache, we have an assistant editor program for junior people - residents, fellows, postdocs - people who want to learn more about how to be an editor. I think that you learn so much about how to be a better writer, how to be a better scientist, how to communicate your findings in the most effective way. It's just invaluable and it's very fun. Dr Jones: It is kind of selfishly fun, isn't it? Dr Gelfand: Right, right. Dr Jones: Yeah, and it's important work, obviously - to put good information out into the world. At Continuum, we also have - on our editorial board, we have two residents and fellow positions, again, for that career development. I have to ask you a really hard question here, Dr Gelfand. You mentioned you read to learn; if you had to make a choice - electronic or print - what would it be? Dr Gelfand: Electronic. I know that many journals, including ours, are having to make some of these decisions right now. But I read my PDFs and I store them so that I can come back to them and search for them, and make sure, when I'm citing them, that they actually say what I thought they said because sometimes I need to look back at that. So, I am an electronic person. How about you? Dr Jones: I think I'm print. Dr Gelfand: Uh huh. Dr Jones: And I'm just sitting here thinking, there are so many people listening to this interview, and they're screaming at their device, saying, “Electronic is the answer,” or “Print is the answer.” Like you, we want to meet our subscribers where they are, and I think neurologists are very clear in their preferences. Let's just say we'll agree to disagree, and no one is right and no one is wrong – how about that? Dr Gelfand: Fair enough - I can respect that. Dr Jones: All right. I have one more question for you. This might sound like a strange question in an interview between two neurologists talking about headache - what can you tell us about chicken farming? Dr Gelfand: Well, I'd be delighted to tell you about chicken farming. As you know, because they were squawking earlier in our chat, I've got a little flock of chickens in our backyard and they are an absolute joy in my life. One thing I can tell you is that chickens respond to the photo period (how long the daylight is in a year). Now that it's November, it's the time of year when they don't get a lot of light, so they stop laying very much. I find that between Thanksgiving and about Valentine's Day, we actually start to need to buy eggs, which makes me very sad because I love having our egg supply come completely from our chickens. But we want them to rest and so that's what they're doing. Chickens will not lay very much at this time of year. During the summer and the spring and the fall (in the earlier part of the fall), they will lay almost daily, depending on which breed and how old they are. But at this time of year, it's really quiet - really, just one or two a week, I would say, right now. Dr Jones: It sounds like a fun hobby. Hopefully the chickens don't mind that you're buying chickens in the winter, and they don't feel offended by that or jealous. Dr. Gelfand: I worry that they do. I try not to show them the grocery bags. Dr Jones: Well, Dr Gelfand, thank you so much for joining us today, and thank you for such a thorough and fascinating discussion on headache disorders from your unique position as a guest editor for Continuum, I do encourage all of our listeners to check out that issue. It's really full of phenomenal pointers on practice-changing tips and tricks for managing patients who have headache disorders. I'm really grateful for your time today. And thank you for telling me a little bit about chicken farming. Dr Gelfand: Thank you so much for having me. It was really fun. And thank you for your interest. Dr Jones: Again, we've been speaking with Dr Amy Gelfand, guest editor for Continuum's most recent issue, on headache. Please check it out and thank you to our listeners for joining today. Dr. Monteith: This is Dr Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practice. Right now, during our Spring Special, all subscriptions are 15% off. Go to Continpub.com/Spring2024, or use the link in the episode notes to learn more and take advantage of this great discount. This offer ends June 30, 2024.

Hui Yang is a returning VIP podcast guest. As an MD PhD in training, she recently completed her research track residency interviews with major academic medical centers and research institutes. She has observed an increased receptiveness and dedication to research on alternative nutraceutical strategies, including the ketogenic diet and increased animal meat/fat intake. She hopes to make the Carnivore.Diet community aware of this positive overall change and of certain specific academic centers that are actively pursuing this field. In addition, just recently, there have been major discoveries published in the journal Nature concerning the gut microbiome, the evolutionary history of genetic risks for multiple sclerosis and rheumatoid arthritis, and post-natal neuronal migration to the brain region most susceptible to Alzheimer's Disease. These discoveries are certainly important for those in academia. From her previous experiences, she knows they are also of interest to the Carnivore community. She hopes to bring one or more of these discoveries in an "easily digestible" language to their audience. Timestamps: 00:00 Trailer. 01:05 Introduction. 07:09 Study shows gluten-free diet benefits schizophrenia patients. 10:07 Study shows potential link between diet and schizophrenia. 13:15 Vitamin B for neuron balance and activation. 15:07 Exercise motivation and endurance tied to dopamine. 18:20 Restricted access to high-sugar food. 22:57 IgE and mast cells cause food allergies. 27:01 Anorexic effect in brain regions. 29:13 Perplexed by brain's activation on liking food. 31:13 PBM center signals satiety and aversion. Neuroscience tool discovery: PBN, CGRP neurons. 36:22 Complexity of autoimmune diseases and genetic evolution. 39:44 Scandinavians and Eurasians have high MS risk. 41:35 Comparison of MS genes in different populations. 44:42 Immune response, sanitation, and parasitic infections impact health. 48:12 Genetic risk increases likelihood of developing MS. 49:32 Doctors embracing ketogenic diet. 52:41 Where to find Hui. See open positions at Revero: https://jobs.lever.co/Revero/ Join Carnivore Diet for a free 30 day trial: https://carnivore.diet/join/ Carnivore Shirts: https://merch.carnivore.diet Subscribe to our Newsletter: https://carnivore.diet/subscribe/ . ‪#revero #shawnbaker #Carnivorediet #MeatHeals #HealthCreation   #humanfood #AnimalBased #ZeroCarb #DietCoach  #FatAdapted #Carnivore #sugarfree  ‪

Disclaimer: Our young hosts are experts in fun, not facts! They love exploring medical and scientific topics, but remember, they're learning just like you. For the real deal, always check with a grown-up expert. Now, let's dive into today's adventure with imagination on full blast! This episode's topics include: Venus spins backwards! What is vertigo? What medicine should you take for a headache?

The March 2024 recall includes three episodes taken from the 2023 November Headache Series. In part two of this two-part recall, Dr. Tesha Monteith begins with a discussion with Dr. Messoud Ashina on the mechanisms of migraine. The episode continues with Dr. Peter Goadsby talking about updates on migraine treatments and CGRP inhibitors. Finally, the episode concludes with an interview with Dr. Stewart Tepper discussing rapid developments in neuromodulation. Related Podcast Links: https://directory.libsyn.com/episode/index/id/28721028 https://directory.libsyn.com/episode/index/id/28812568   https://directory.libsyn.com/episode/index/id/28868248 Disclosures can be found at Neurology.org

Join Dr. Aniket Natekar, a neurologist and headache specialist, for an enlightening discussion on the stigmas and complexities surrounding headache disorders. Navigating the world of migraine treatment can be as bewildering as the condition itself. Dr. Natekar lends his expertise, revealing how a well-considered medication regimen and lifestyle changes can transform patient outcomes. We also examine the latest advancements in acute migraine treatments, including CGRP inhibitors and triptan prescription practices, providing a comprehensive look at the options available. Completing our journey, we reflect on the language we use in headache medicine and the diverse, fulfilling career paths within this subspecialty. Find Dr. Aniket Natekar on X at @Natekar_MD Check out our website at www.theneurotransmitters.com to sign up for emails, classes, and quizzes! Would you like to be a guest or suggest a topic? Email us at contact@theneurotransmitters.com Follow our podcast channel for The Neurotransmitters @neuro_podcast for future news! Find me on Twitter @DrKentris (https://twitter.com/DrKentris) https://linktr.ee/DrKentris The views expressed do not necessarily represent those of any associated organizations. The information in this podcast is for educational and informational purposes only and does not represent specific medical/health advice. Please consult with an appropriate health care professional for any medical/health advice.

Mei Mei Hu, the CEO and Co-Founder of Vaxxinity, focuses on an approach to vaccines that aims to break immune tolerance to get the body to produce the antibodies to target self-antigens causing chronic conditions. Initial trials are being conducted to slow the progression or prevent the onset of Alzheimer's, Parkinson's, and hypercholesterolemia. Motivating this effort is the desire to democratize health and make transformative medicines available to a larger population at a lower cost.   Mei Mei explains, "Interestingly, in 1900, the average global life expectancy was 32. Today, when you hear someone died at 79, you're like, oh my gosh, what happened? We get these two bonus lifetimes now, and those three lives total for three main reasons. The first is the Green Revolution feeding us all. The second is hygienic plumbing, and the third is vaccines. But when we think of vaccines, they're usually crying babies or kids pre-COVID. What they did was able to banish the biggest diseases of our early lives." "What we're looking to do now at Vaxxinity is do the same thing but for the diseases plaguing us in our second and third lives. That's why we go after things like Alzheimer's, Parkinson's, hypercholesterolemia, which is a leading cause of heart disease. We're going after big population health things, and the best way to do them is with a vaccine approach." "One of the main attributes of a vaccine is that it trains your body to attack pathogens or causes of disease. In our case, we're just teaching your body to produce drugs that help neutralize things like cholesterol, plaques, or CGRP, which is the culprit of migraines. That's what we mean when we talk about creating a vaccine for a chronic condition."  #Vaxxinity #Vaccine #Parkinsons #Alzheimers #ChronicDiseases #ClinicalTrials #DemocratizeHealth vaxxinity.com Download the transcript here

Mei Mei Hu, the CEO and Co-Founder of Vaxxinity, focuses on an approach to vaccines that aims to break immune tolerance to get the body to produce the antibodies to target self-antigens causing chronic conditions. Initial trials are being conducted to slow the progression or prevent the onset of Alzheimer's, Parkinson's, and hypercholesterolemia. Motivating this effort is the desire to democratize health and make transformative medicines available to a larger population at a lower cost.   Mei Mei explains, "Interestingly, in 1900, the average global life expectancy was 32. Today, when you hear someone died at 79, you're like, oh my gosh, what happened? We get these two bonus lifetimes now, and those three lives total for three main reasons. The first is the Green Revolution feeding us all. The second is hygienic plumbing, and the third is vaccines. But when we think of vaccines, they're usually crying babies or kids pre-COVID. What they did was able to banish the biggest diseases of our early lives." "What we're looking to do now at Vaxxinity is do the same thing but for the diseases plaguing us in our second and third lives. That's why we go after things like Alzheimer's, Parkinson's, hypercholesterolemia, which is a leading cause of heart disease. We're going after big population health things, and the best way to do them is with a vaccine approach." "One of the main attributes of a vaccine is that it trains your body to attack pathogens or causes of disease. In our case, we're just teaching your body to produce drugs that help neutralize things like cholesterol, plaques, or CGRP, which is the culprit of migraines. That's what we mean when we talk about creating a vaccine for a chronic condition."  #Vaxxinity #Vaccine #Parkinsons #Alzheimers #ChronicDiseases #ClinicalTrials #DemocratizeHealth vaxxinity.com Listen to the podcast here

Contributor: Jorge Chalit, OMS II Educational Pearls: Migraine pathophysiology Primarily mediated through the trigeminovascular system Serotonin, dopamine, and calcitonin gene-related peptide (CGRP) Trigeminovascular system is linked to the trigeminal nucleus caudalis, which relays pain to the hypothalamus and cerebral cortex One effective treatment for acute migraines is -triptan medications 5-HT1D/1B agonists such as sumatriptan Often combined with NSAIDs and dopamine antagonists (as antiemetics) in migraine cocktails Diphenhydramine (Benadryl) was shown to be ineffective in a randomized controlled trial comparing it with placebo and a dopamine antagonist antiemetic.  The -triptan medications carry significant risk for peripheral vasoconstriction and are therefore avoided in cardiovascular disease One serotonin agonist specifically approved for use in vascular disease Lasmiditan - 5-HT1F agonist Slightly different mechanism of action avoids peripheral vasoconstriction CGRP antagonists are also used in patients who are unresponsive to -triptans References 1. Friedman WB, Cabral L, Adewunmi V, et al. Diphenhydramine as adjuvant therapy for acute migraine. An ED-based randomized clinical trial. Ann Emerg Med. 2016;67(1):32-39.e3. doi:doi:10.1016/j.annemergmed.2015.07.495 2. Lasmiditan (Reyvow) and ubrogepant (Ubrelvy) for acute treatment of migraine. (2020). The Medical letter on drugs and therapeutics, 62(1593), 35–39. 3. Robbins MS. Diagnosis and Management of Headache: A Review. JAMA - J Am Med Assoc. 2021;325(18):1874-1885. doi:10.1001/jama.2021.1640 4. Vanderpluym JH, Halker Singh RB, Urtecho M, et al. Acute Treatments for Episodic Migraine in Adults: A Systematic Review and Meta-analysis. JAMA - J Am Med Assoc. 2021;325(23):2357-2369. doi:10.1001/jama.2021.7939 Summarized by Jorge Chalit, OMSII | Edited by Meg Joyce & Jorge Chalit, OMSII

This week Kate, Mark, Henry and Gary talk about how long it takes for lower extremity cellulitis to improve, how long it takes for CGRP monoclonal antibodies to take effect in adults with chronic migraine, whether CBT is effective for fatigue in patients with long COVID, and outcome data for various lipid lowering therapies. Plus a painful quiz, and Gary learns what an umbrella review is!

We thought we had endometriosis all figured out. After all, we know it's a chronic pain syndrome that's hormone responsive. But there's more to it than that. Within the last few years, including this year 2023, we have grown even more in our understanding of this pelvic pain condition. We now have new data explaining the link between endometriosis and migraine attacks. Are you familiar with CGRP? While most attention has focused on this biochemical messenger's role in migraines, CGRP is also related to endometrial implants. In this episode, we will do a deep dive into the shared pathophysiology of endometriosis and migraine headaches. We will look at the role that CGRP and TRPV1 play in both of these pain conditions.

Around 1 billion people around the world suffer from a mysterious neurological condition called migraine. Far more than just a headache, migraine is abnormal processing of the world around us that can have symptoms like loss of sight and speech, dizziness, nausea and extreme fatigue.There are drugs which can help those struggling with the condition like anti-depressants and anti-convulsants. However, they weren't developed specifically for migraine and can come with quite a lot of side effects or simply not work.For a long time migraine medication has been a process of trial and error. But a new class of drugs called anti-CGRPs are being hailed as a breakthrough migraine medication. Anti-CGRPs have a small side effect profile and were designed specifically to target migraine. They work by blocking CGRP (Calcitonin Gene-Related Peptide) from building up in the body and triggering a receptor in the brain which turns on a head pain pathway causing the migraine attack.Earlier this year the National Institute of Health and Care Excellence - or NICE – in England cleared the use of an anti-CGRP called Rimegepant to use as both a preventive and acute treatment. Clinicians are hoping this will massively improve the lives of those living with the condition.So this week on The Inquiry were asking ‘Have we reached a turning point with migraine medication?'Contributors: Dr. Amaal Starling, neurologist and headache specialist at Mayo Clinic in Scottsdale, in the US state of Arizona. Dr Faraidoon, researcher at the Georgian Institute for Global Health at the University of New South Wales, Sydney, Australia. Peter Goadsby , Director of the NIHR King's Clinical Research Facility and a professor of neurology at King's College London, England. Dr Lise Rystad Oie, researcher at the government funded Norwegian Centre for Headache Research - also known as NorHead.Presenter: Charmaine Cozier Producer: Anoushka Mutanda-Dougherty Editor: Tara McDermott Researcher: Matt Toulson Technical Producer: Craig Boardman Broadcast Co-ordinator: Jordan KingImage: eternalcreative - Getty Images: 1372323487

Dr. Tesha Monteith talks with Dr. Peter Goadsby about updates on migraine treatments and the integration of CGRP inhibitors into clinical practice. Disclosures can be found at Neurology.org

Dr. Tesha Monteith talks with Dr. Messoud Ashina about the mechanisms of migraine.   Articles Referenced in this Episode: Calcitonin Gene-related Peptide Causes Migraine Aura An Exploratory Analysis of Clinical and Sociodemographic Factors in CGRP-induced Migraine Attacks: A REFORM Study Disclosures can be found at Neurology.org

Welcome to the SYNC Your Life podcast episode #188! On this podcast, we will be diving into all things women's hormones to help you learn how to live in alignment with your female physiology. Too many women are living with their check engine lights flashing. You know you feel "off" but no matter what you do, you can't seem to have the energy, or lose the weight, or feel your best. This podcast exists to shed light on the important topic of healthy hormones and cycle syncing, to help you gain maximum energy in your life.  In today's episode, I dive into the new science of CGRP for the preventative treatment of menstrual migraine. As a migraine sufferer myself, I know the value of modern medicine advances in treatment of this debilitating neurological condition.  Read the research here: Article 1 Article 2 I also mentioned this previous episode of the podcast on Muscle Testing. If you feel like something is "off" with your hormones, check out the FREE hormone imbalance quiz at sync.jennyswisher.com.  To learn more about the SYNC Digital Course, check out jennyswisher.com.  Let's be friends outside of the podcast! Send me a message or schedule a call so I can get to know you better. You can reach out at https://jennyswisher.com/contact-2/.

Join us on this special episode of the Heads Up Podcast as we mark Migraine Awareness Week. In a heartfelt tribute to those who battle migraines, we spotlight three remarkable women and their journeys of resilience. Tune in and lend your support to #MigraineVoices, because together, we can shed light on the silent pain that so many endure. Visit the National Migraine Centre's website and learn more about the life changing anti-CGRP treatments available. Book an appointment to see a headache specialist. 

Does this sound familiar? Are you experiencing frequent migraines that are disrupting your daily life? Have you been told to simply power through the pain, only to find that it doesn't provide the relief you desperately need? We understand the frustration and agony you're going through. It's time to break free from ineffective actions and find real solutions. In this episode, we'll look at recent studies that examine the causes of migraines during perimenopause and provide you with examples of effective management techniques. Say goodbye to the pain that's been holding you back and reclaim your quality of life. In this episode, you will be able to: Dive deep into understanding the causes of migraines during perimenopause and how to control them. Get insight into how hormonal fluctuations can impact migraines and what it means for you. Unravel various treatment paths for perimenopausal migraines, including medications and hormone therapy. Find out about alternative migraine management techniques like acupuncture, massage, and essential oils. Grasp the need to seek medical consultation and support during perimenopausal migraines.   The articles mentioned in this episode are: Pavlović JM. Evaluation and management of migraine in midlife women. Menopause. 2018 Aug;25(8):927-929. doi: 10.1097/GME.0000000000001104. PMID: 29787480; PMCID: PMC6527322. American Academy of Neurology. "Migraines during menstruation: Low estrogen levels paired with higher CGRP levels may jump start migraine." ScienceDaily. ScienceDaily, 22 February 2023. .   Other notables: Visit the Pause To Go podcast website and listen to the episode on perimenopausal migraines. (Also, leave me any questions or feedback there!) Join the Pause To Go Podcast Facebook Group HERE! Keep a headache diary to track your migraines and identify potential triggers. Talk to your healthcare provider about potential treatment options, including hormone therapy and preventative medications. Consider making lifestyle changes such as maintaining a regular sleep schedule, engaging in regular exercise, and keeping a food diary to identify trigger foods. Stay hydrated throughout the day by sipping water, and consider using a water bottle that you enjoy. Consult with your healthcare provider to explore natural treatment options, such as herbal supplements, that may help with migraines. Take a proactive approach to managing your migraines and seek support and guidance from healthcare professionals.   If you liked this episode, try these next: Change Is Coming For Womens Health: A Conversation With Jeff Goldsmith, President of Health Futures Havva Mahler on the Chines Medicine Perspective of Perimenopause and Menopause

For chronic migraine sufferers, there's a progression of migraine medications - first your doctor is going to start with the triptans, or now, perhaps the oral CGRP antagonists like Nurtec or Ubrelvy. But once those start to fail you, and you have to take more than is advised, your doctor is going to put you on daily preventative medication. Usually you'll start with things like propranolol or Topamax. But once those start to fail you - then your doctor is going to want to add in antidepressants like Amitriptyline or Nortriptyline - or maybe even Prozac, Wellbutrin, or Cymbalta. But are antidepressants treating the root cause of your migraines or just suppressing the symptoms? Do you really have an Amitriptyline deficiency? In this podcast, Dr. Leslie and Mari go pretty deep into the lack of efficacy of these meds and the problems that many women have when they want to get off these meds. And - as always - they talk about the 3 things you need to do instead to restore and maintain your health – because when we are in a state of health – our body doesn't generate migraines. Finally, Dr. Leslie shares some profound information about how her health was destroyed when she took a suppressive medication and her journey of recovery and restoration. Here are the links to other resources we talked about today: Free training on why drugs stop working eventually: https://www.drlesliecisar.com/StopWorking Podcast on why medications cause side effects: https://www.drlesliecisar.com/podcasts/healing-migraines-naturally/episodes/2147771700 Podcast on why drugs stop working: https://www.drlesliecisar.com/podcasts/healing-migraines-naturally/episodes/2147736839 Are you ready to get off the migraine rollercoaster and rediscover a migraine free life? Let's see if I can help. Schedule your free migraine consult call here: https://www.drlesliecisar.com/apply Stay connected: Join my free Facebook group: https://www.facebook.com/groups/healingmigrainesnaturally Check out my website: https://www.drlesliecisar.com/ Want to learn more? Check out my free trainings especially for women with migraines: https://www.drlesliecisar.com/free-resources

This episode features two renowned experts in the field of headache medicine, Dr Katy Munro, and Dr Rebecca Walker, as they delve into the fascinating world of anti-CGRP treatments for migraine. They explore the science behind anti-CGRP and its role in migraine pathophysiology, shedding light on how these innovative treatments work to prevent and alleviate migraine attacks. They discuss the therapeutic benefits, potentially low side effects, and the overall efficacy of these treatments, providing valuable insights for both patients and healthcare providers. Learn more about the evolving landscape of migraine management and the challenges and opportunities that lie ahead, anti-CGRP treatments such as eptinezumab (Vyepti), the gepants like rimegant (Vydura) and other upcoming treatments. Whether you are a migraine sufferer seeking new treatment options, a healthcare professional eager to stay up to date with the latest advancements, or simply someone interested in the fascinating world of neurology, this episode offers a comprehensive and accessible exploration of anti-CGRP treatments for migraine, complemented by a poignant patient experience that highlights the transformative power of these therapies. Visit the National Migraine Centre's website to learn more about the life changing anti-CGRP treatments available. 

In this week's podcast, Neurology Today's editor-in-chief discusses the newly approved zavegepant for migraine, the potential/caveats of ultrasound ablation for Parkinson's disease, the transational potential of a new therapeutic target for Duchenne muscular atrophy.

The April 2023 replay of past episodes showcases our November 2022 headache series hosted by Dr. Tesha Monteith. The first episode features a conversation with Dr. Peter Goadsby about value offered by headache classifications, followed by and interview with Drs. Simona Sacco and Jessica Ailani about an update on migraine guidelines. Next in the episode, Dr. Lars Edvinsson discusses CGRP and role of sex hormones. The April recall closes out with an interview with Dr. Rebecca Burch about hot topics in headache medicine.  

Dr. Lars Edvinsson discusses CGRP and migraine therapies. This podcast is sponsored by argenx. Visit www.vyvgarthcp.com for more information.  

Dr. Tesha Monteith talks with Dr. Lars Edvinsson who is a leading expert in the field of cerebral circulation and migraines. In this episode, they discuss CGRP and the role of sex hormones as part of our November Headache Series. This podcast is sponsored by argenx. Visit www.vyvgarthcp.com for more information.

Stocks surged for a second straight day, with the major indices now more than 5% above their 2022 lows, and Jim Cramer is taking a closer look at what drove the averages higher. First, Biohaven closed its deal with Pfizer yesterday, selling its CGRP franchise to Pfizer for $11.6b, and Cramer is talking to Biohaven CEO Vlad Coric about the transaction and its pipeline of bipolar disorder and epilepsy treatments. Then, after a massive two-day rally, could this market rally keep running or is it due to run out of steam? Cramer's going Off The Charts to find out. Plus, Cramer's exclusive with Suntory Holdings CEO Tak Niinami.

Dr. Kevin Weber @KwebMD (Ohio State University Wexner Medical School) takes the pain out of headache management!  Have the confidence to prescribe new CGRP-antagonists and ditans for migraine prevention and acute relief.  We also dive deep into when to order imaging and alternatives like infusions and devices.  Claim free CME for this episode at curbsiders.vcuhealth.org! Episodes | Subscribe | Spotify | Swag! | Top Picks | Mailing List | thecurbsiders@gmail.com | Free CME! Show Segments Intro, disclaimer, guest bio Guest one-liner, Picks of the Week Case from Kashlak Definitions Imaging for headaches Labs Headache types Acute Migraine Treatment Ditans Anti-cgrp medications Prophylactic Migraine Treatment CGRP antagonists Devices Take home points Outro Credits Producer, writer, and show notes: Isabel Valdez PA-C Infographic: Edison Jyang Cover Art: Chris Chiu MD Hosts: Matthew Watto MD, FACP; Paul Williams MD, FACP; Chris Chiu MD    Reviewer: Molly Heublein MD Showrunner: Matthew Watto MD, FACP Technical Production: PodPaste Guest: Dr. Kevin Weber Sponsor: Better Help Go to betterhelp.com/curb to get 10% off your first month.  Sponsor: Birch Living Birch is giving $200 off all mattresses and 2 free eco-rest pillows at birchliving.com/curb Sponsor: Indeed Sign up at indeed.com/internalmedicine now and get $75 credit toward your first sponsored job. Sponsor: Locumstory Visit locumstory.com to learn more about locums.  The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit.