Current Pain and Headache Reports

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Online ISSN: 1534-3081
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Article
Purpose of Review This narrative review highlights the interventional musculoskeletal techniques that have evolved in recent years. Recent Findings The recent progress in pain medicine technologies presented here represents the ideal treatment of the pain patient which is to provide personalized care. Advances in pain physiology research and pain management technologies support each other concurrently. Summary As new technologies give rise to new perspectives and understanding of pain, new research inspires the development of new technologies
 
Article
Purpose of Review Chronic cluster headache (CH) substantially affects patients’ quality of life, and treatment remains challenging. The current article reviewed controlled studies for new treatment options targeting calcitonin gene–related peptide (CGRP) or its receptors in CH and discussed the current gaps and future directions for the treatment of chronic CH. Recent Findings Two anti-CGRP monoclonal antibodies (i.e., galcanezumab and fremanezumab) completed randomized-control trials for efficacy for the preventive treatment of episodic and chronic CH. Galcanezumab was effective for preventing episodic CH but not chronic CH. Fremanezumab was ineffective in preventing episodic and chronic CH. Studies for other anti-CGRP monoclonal antibodies and CGRP antagonists are still pending for results. Summary There are no randomized controlled trials for CGRP-targeted therapies that showed efficacy for chronic CH prevention. The different responses to galcanezumab between episodic and chronic CH may be due to the study design, i.e., the allowance of concomitant preventive therapies in the chronic CH study but not in the episodic CH study. Another reason for the discrepancies is the different roles and sensitivity of CGRP in chronic CH.
 
Article
Purpose of Review This article reviews PTPS demographics, diagnosis, pathophysiology, surgical and anesthetic techniques, and their role in preventing PTPS along with updated treatment options. Recent Findings Post-thoracotomy pain syndrome (PTPS) can be incapacitating. The neuropathic type pain of PTPS is along the incision site and persists at least 2 months postoperatively. There is a wide reported range of prevalence of PTPS. There are several risk factors that have been identified including surgical technique and younger age. Several surgical and anesthetic techniques have been trialed to reduce pain after thoracotomy. Multimodal pain control is the suggested long-term treatment plan for patients with PTPS. Summary There are several factors that can be modified to reduce pain and incidence of PTPS during the perioperative period and the use of multimodal analgesia is suggested for the treatment of PTPS.
 
Right external carotid artery (ECA) AP and lateral injections demonstrating increased vascularity derived from MMA branches overlying the cerebral convexity in the area of patient’s known cSDH (A, B) and post-embolization angiogram demonstrating Onyx cast of frontal MMA branches (C, D)
Non-contrast CT of the head in a patient with acute or chronic SDH pre- (A) and 2 weeks post-MMA embolization (B), demonstrating decrease in size of collection, mass effect, and acute blood products
Article
Purpose of Review The purpose of this review is to present a brief background on chronic subdural hematomas (cSDH), middle meningeal artery (MMA) embolization, and its role in decreasing recurrence of cSDH. A review of the most up-to-date literature should demonstrate the efficacy of this procedure. Recent Findings The latest data shows that MMA embolization is a safe procedure, with low complication rates and low recurrence rates. While cSDH managed with surgical evacuation can have a recurrence rate upwards of 30%, MMA embolization alone or as an adjunct to surgery decreases recurrence to less than 5% in most studies. MMA embolization can be especially useful in high-risk populations such as the elderly, patients on anti-platelet medication, and those with coagulopathies. It can also be done awake, done without general anesthesia, and is significantly less invasive than traditional surgical techniques. Summary In reviewing the literature on MMA embolization, it is clear that there are numerous retrospective studies and systematic reviews demonstrating its safety and efficacy, and some prospective dual-arm studies that present novel information. The numerous clinical trials that are currently underway should help to further establish MMA embolization as standard of care in the management of cSDH.
 
Article
Purpose of Review Neuropathic pain is a prevalent and burdensome condition. While oral medical therapies are the first-line treatment for refractory neuropathic pain, in some cases, infusion therapy may be employed. This article is a systematic review of recent publications regarding epidemiologic, pathophysiologic, diagnostic, and therapeutic advancements in the treatment of neuropathic pain using intravenous infusion therapy. Special consideration will be given to relevant and practically used agents and available information on outcomes. Recent Findings Individuals with neuropathic pain from various etiologies (e.g. trigeminal neuralgia, post-herpetic neuralgia, diabetic neuropathy) often find short-term relief from infusion therapies. However, it is difficult to generalize the findings of these studies to form a standard treatment regimen. Summary The purpose of this paper is to provide clinicians an up-to-date summary of recent literature regarding several infusion therapies in treating neuropathic pain.
 
Superior hypogastric plexus block. a Lateral fluoroscopic view, needle targeting inferior portion of L5 vertebral body. b Post-contrast AP washout view
Ganglion impar block. a Lateral fluoroscopic view, needle traverses the sacrococcygeal ligament with needle target at anterior surface. b Post-contrast view, showing nonvascular contrast spread
Article
Purpose of Review Chronic abdominal and pelvic visceral pain is an oftentimes difficult to treat pain condition that requires a multidisciplinary approach. This article specifically reviews the interventional treatment options for pain resulting from visceral abdominal and pelvic pain. Recent Findings Sympathetic nerve blocks are the main interventional option for the treatment of chronic abdominal and pelvic visceral pain. Initially, nerve blocks are performed, and subsequently, neurolytic injections (alcohol or phenol) are longer term options. This review describes different techniques for sympathetic blockade. Neuromodulation is a potential option via dorsal column stimulation or dorsal root ganglion stimulation. Finally, intrathecal drug delivery is sometimes appropriate for refractory cases. Summary This paper will review interventional options for the treatment of chronic abdominal and pelvic visceral pain.
 
Thermosensitive acellular extracellular matrix (ECM) hydrogel coupled with adipose mesenchymal stem cell (ADSCs) exosomes for IVD regeneration [38]. Sustained release of ADSC-derived exosomes regulates matrix synthesis and degradation by regulating matrix metalloproteinases (MMPs) and inhibits pyroptosis by mitigating the inflammatory response. Reproduced with permission
Article
Purpose of Review Pain presents a unique challenge due to the complexity of the biological pathways involved in the pain perception, the growing concern regarding the use of opioid analgesics, and the limited availability of optimal treatment options. The use of biomaterials and regenerative medicine in pain management is being actively explored and showing exciting progress in improving the efficacy of conventional pharmacotherapy and as novel non-pharmacological therapy for chronic pain caused by degenerative diseases. In this paper we review current clinical applications, and promising research in the use of biomaterials and regenerative medicine in pain management. Recent Findings Regenerative therapies have been developed to repair damaged tissues in back, joint, and shoulder that lead to chronic and inflammatory pain. Novel regenerative biomaterials have been designed to incorporate biochemical and physical pro-regenerative cues that augment the efficacy of regenerative therapies. New biomaterials improve target localization with improved tunability for controlled drug delivery, and injectable scaffolds enhance the efficacy of regenerative therapies through improving cellular migration. Advanced biomaterial carrier systems have been developed for sustained and targeted delivery of analgesic agents to specific tissues and organs, showing improved treatment efficacy, extended duration of action, and reduced dosage. Targeting endosomal receptors by nanoparticles has shown promising anti-nociception effects. Biomaterial scavengers are designed to remove proinflammatory reactive oxygen species that trigger nociceptors and cause pain hypersensitivity, providing a proactive approach for pain management. Summary Pharmacotherapy remains the method of choice for pain management; however, conventional analgesic agents are associated with adverse effects. The relatively short duration of action when applied as free drug limited their efficacy in postoperative and chronic pain treatment. The application of biomaterials in pain management is a promising strategy to improve the efficacy of current pharmacotherapy through sustained and targeted delivery of analgesic agents. Regenerative medicine strategies target the damaged tissue and provide non-pharmacological alternatives to manage chronic and inflammatory pain. In the future, the successful development of regenerative therapies that completely repair damaged tissues will provide a more optimal alternative for the treatment of chronic pain caused. Future studies will leverage on the increasing understanding of the molecular mechanisms governing pain perception and transmission, injury response and tissue regeneration, and the development of new biomaterials and tissue regenerative methods.
 
Article
Purpose of Review We seek to update readers on recent advances in our understanding of sex and gender in episodic migraine with a two part series. In part 1, we examine migraine epidemiology in the context of sex and gender, differences in symptomatology, and the influence of sex hormones on migraine pathophysiology (including CGRP). In part 2, we focus on practical clinical considerations for sex and gender in episodic migraine by addressing menstrual migraine and the controversial topic of hormone-containing therapies. We make note of data applicable to gender minority populations, when available, and summarize knowledge on gender affirming hormone therapy and migraine management in transgender individuals. Finally, we briefly address health disparities, socioeconomic considerations, and research bias. Recent Findings Migraine is known to be more prevalent, frequent, and disabling in women. There are also differences in migraine co-morbidities and symptomatology. For instance, women are likely to experience more migraine associated symptoms such as nausea, photophobia, and phonophobia. Migraine pathophysiology is influenced by sex hormones, e.g., estrogen withdrawal as a known trigger for migraine. Other hormones such as progesterone and testosterone are less well studied. Relationships between CGRP (the target of new acute and preventive migraine treatments) and sex hormones have been established with both animal and human model studies. The natural course of migraine throughout the lifetime suggests a contribution from hormonal changes, from puberty to pregnancy to menopause/post-menopause. Treatment of menstrual migraine and the use of hormone-containing therapies remains controversial. Re-evaluation of the data reveals that stroke risk is an estrogen dose- and aura frequency-dependent phenomenon. There are limited data on episodic migraine in gender minorities. Gender affirming hormone therapy may be associated with a change in migraine and unique risks (including ischemic stroke with high dose estrogen). Summary There are key differences in migraine epidemiology and symptomatology, thought to be driven at least in part by sex hormones which influence migraine pathophysiology and the natural course of migraine throughout the lifetime. More effective and specific treatments for menstrual migraine are needed. A careful examination of the data on estrogen and stroke risk suggests a nuanced approach to the issue of estrogen-containing contraception and hormone replacement therapy is warranted. Our understanding of sex and gender is evolving, with limited but growing research on the relationship between gender affirming therapy and migraine, and treatment considerations for transgender people with migraine.
 
Article
Purpose of Review This review article summaries the epidemiology, etiology, clinical presentations, and latest treatment modalities of meralgia paresthetica, including the latest data about peripheral and spinal cord stimulation therapy. Meralgia paresthetica (MP) causes burning, stinging, or numbness in the anterolateral part of the thigh, usually due to compression of the lateral femoral cutaneous nerve (LFCN). Recent Findings There are emerging data regarding the benefit of interventional pain procedures, including steroid injection and radiofrequency ablation, and other interventions including spinal cord and peripheral nerve stimulation reserved for refractory cases. Summary The strength of evidence for treatment choices in meralgia paraesthetica is weak. Some observational studies are comparing local injection of corticosteroid versus surgical interventions. However, more extensive studies are needed regarding the long-term benefit of peripheral and spinal cord stimulation therapy.
 
Article
Purpose of Review The aim of this review is to aid in decision-making when choosing safe and effective options for preventive migraine medications. Recent Findings In Part 2, we have compiled clinically relevant safety considerations for commonly used migraine prophylactic treatments. Preventive treatment of episodic migraine includes nonspecific and migraine-specific drugs. While medications from several pharmacological classes–such as anticonvulsants, beta-blockers, and antidepressants–have an established efficacy in migraine prevention, they are associated with a number of side effects. The safety of migraine-specific treatments such as anti-CGRP monoclonal antibodies and gepants are also discussed. Summary This review highlights safety concerns of commonly used migraine prophylactic agents and offers suggestions on how to mitigate those risks.
 
Concussion and PTH persistence. Mild traumatic brain injury or concussion is associated with a neuroinflammatory cascade, disruption of ionic homeostasis and metabolic processes, CNS excitability, and the activation of the trigeminovascular system to produce PTH [13]. Concussion is generally transient due to the brain’s restorative process. However, a subset of individuals with concussion and PTH have persistent symptoms. A history of repetitive head and neck injuries and migraine and genetic susceptibilities are risk factors of persistence; however, other health determinants including SDOH may be drivers of long-term functional outcomes and warrant further investigation. Adapted from Monteith TS, Borsook D. Insights and advances in post-traumatic headache: research considerations. Curr Neurol Neurosci Rep. 2014 Feb;14(2):428
Article
Purpose of Review There are notable health disparities and inequities in individuals with traumatic brain injury (TBI) and concussion by race, ethnicity, gender, socioeconomic status, and geography. This review will evaluate these disparities and inequities and assess the social determinants of health that drive outcomes for post-traumatic headache. Interventions for achieving this are also discussed. Recent Findings Significant disparities and inequities exist in TBI and concussion among people of different races, socioeconomic status, and geographic locations. Migraine is a common symptom post-concussion, for which disparities and social determinants of health are also discussed. Overall, multi-level interventions to reduce these disparities and inequities are reviewed for post-traumatic headache but require further investigation. Summary Interventions are needed to reduce disparities and inequities including public health initiatives, improvements in clinical care, diversity/inclusion training, and research efforts. As literature expands, we can form guidance to identify solutions for eliminating disparities in care of diverse populations.
 
Interplay of orofacial disorders and migraine. Extracranial nociceptive and inflammatory inputs from oral and craniofacial structures (V2/V3), including the muscles of mastication, the temporomandibular joint (TMJ), teeth, periodontium, and their associated structures, may influence intracranial input, activating the dural-trigeminovascular system. This may incite or exacerbate a primary headache disorder, such as migraine. Abbreviations: C1 C2 region of the cervical spinal cord, PAG ventrolateral periaqueductal gray, RVM rostral ventromedial medulla, SPG sphenopalatine ganglion, SuS superior salivatory nucleus, TG trigeminal ganglion, TMJ temporomandibular joint, TNC trigeminal nucleus caudalis, VI ophthalmic branch of the trigeminal nerve, V2/3 maxillary and mandibular branches of the trigeminal nerve
Article
Purpose of the Review Migraine and other primary headache disorders can be localized in the face resembling facial or dental pain, indicating the influence of the trigeminovascular system in the structures innervated by the maxillary (V2) and mandibulary (V3) branches of the trigeminal nerve. Disorders of oral and craniofacial structures may influence primary headache disorders. In the current article, we review the potential links of this interplay. Recent Findings This interplay may be related to anatomy, with the trigeminal pathway and the involvement of both peripheral and central mechanisms, and the presence of calcitonin gene–related peptide (CGRP), a key mediator in migraine pathophysiology. CGRP is also involved in the pathophysiology of temporomandibular disorders (TMD) and their comorbidity with migraine and is also implicated in dental and periodontal pathology. Summary Inflammatory and pathological processes of these structures and their trigeminal nociceptive pathways may influence the trigeminovascular system and consequently may exacerbate or even potentially trigger migraine.
 
Changes in the number of monthly migraine headache days relative to placebo in clinical trials of galcanezumab (A), erenuamb (B), fremanezumab (C), and eptinezumab (D)
Article
Purpose of Review Monoclonal antibodies against calcitonin gene-related peptide (CGRP) or its receptor have become part of the standard treatment for migraine in clinical practice. The current review focuses on the clinical evidence of CGRP monoclonal antibodies in patients with chronic migraine (CM), including more challenging cases. Recent Findings CGRP monoclonal antibodies were more effective than placebo in reducing the number of monthly migraine days (MMDs), and the change relative to placebo in the treatment group was between − 1.2 and − 2.7 days at 3 months. CGRP monoclonal antibodies resulted in ≥ 50% response in 27.5 to 61.4% of patients, and doubled the odds for having ≥ 50% response. The findings were generally consistent in patients with coexisting medication overuse or with treatment failures to multiple preventive medications, including onabotulinumtoxinA. The results from real-world studies (RWS) were similar to those seen in clinical trials, and the changes from baseline in the number of MMDs and the response rates largely fell within the ranges of those reported in the treatment group in pivotal trials. The therapeutic effects typically started within a few days, and remained steady after regular treatment for up to 1 year. These agents were generally well tolerated, and the discontinuation rates due to adverse events in clinical trials and in many RWS were < 4.5%. Summary CGRP monoclonal antibodies are effective and safe in the treatment of patients with CM, including clinical challenging cases. However, the role of CGRP monoclonal antibodies in a number of conditions, such as cardiovascular or cerebrovascular diseases, pregnancy, and overuse of opioids or barbiturates, needs to be further clarified.
 
Article
Purpose of Review The aim of this review is to aid in choosing safe options when assessing potential risks of acute migraine treatments based on known mechanisms of action and anticipated safety concerns. Recent Findings Part 1 highlights safety issues associated with commonly used medications to treat acute migraine attacks. Strategies to mitigate cardiovascular and gastrointestinal risks of nonsteroidal anti-inflammatory drugs, evaluation of cardiovascular risks of triptan and ergot alkaloids, and precautions with use of antiemetics and the novel drugs gepants and ditans are discussed to help practitioners in clinical decision-making. When available, we included recommendations from professional societies and data from pharmacovigilance systems. Summary While guidelines on efficacy are available, one must also consider the possible risks and adverse effects of a drug when creating treatment plans.
 
PRISMA flow-diagram outlining the study selection process
The combined data for the reported effectiveness of different treatments for acute CH attack abortion. The figure includes results from all 8 included surveys. The data is represented in binary scale (effective, not effective) when possible, or in a scale including partial effectiveness in case of two articles
The combined data for the reported effectiveness of different treatments for acute CH attack abortion. The figure includes results from all 8 included surveys. The data is represented in binary scale (effective, not effective) when possible, or in a scale including partial effectiveness in case of two articles
The hierarchical clustering of self-reported efficacy of the treatments, Spearman correlation with average linkage. Each line consists of: white marker, each indicating the place of a single treatment from a single survey. There are multiple white markers per column, one for each survey which reported on the same treatment. The blue-to-yellow gradient indicates the frequency of both the self-reported effective and self-reported not-effective responses for one treatment from one survey per line. Dark blue indicates frequency of 0%, and bright yellow indicates frequency of 100% of the participants. The columns are organized based on the hierarchical clustering algorithm and both the treatment and frequency columns are placed based on the rank correlation between the columns, as indicated by the dendrogram on the top of the figure. The exact place of the column has no meaning, the place in the dendrogram is the sole indicator for the similarity of any columns as determined by the correlation between the treatments and the frequency data
Article
Purpose of Review The use and efficacy of various substances in the treatment of CH have been studied in several retrospective surveys. The aim of the study is to systematically review published survey studies to evaluate the reported efficacies of both established and unconventional substances in abortive and prophylactic treatment of both episodic and chronic CH, specifically assessing the consistency of the results. Recent Findings No systematic review have been conducted of these studies previously. A systematic literature search with a set of search terms was conducted on PubMed. Retrospective surveys that quantified the self-reported efficacy of two or more CH treatments, published in English during 2000–2020, were included. Several key characteristics and results of the studies were extracted. A total of 994 articles were identified of which 9 were found to be eligible based on the selection criteria. In total, 5419 respondents were included. Oxygen and subcutaneous triptan injections were most reported as effective abortive treatments, while psilocybin and lysergic acid diethylamide were most commonly reported as effective prophylactic treatments. The reported efficacy of most substances was consistent across different studies, and there were marked differences in the reported efficacies of different substances. The reported order of efficacy is generally in agreement with clinical studies. The findings suggest that retrospective surveys can be used to obtain supporting information on the effects of various substances used in the treatment of CH and to form hypotheses about novel treatment methods. The consistently reported efficacy of psilocybin and LSD in prophylactic treatment indicates need for clinical studies.
 
Article
Purpose of Review The authors present data on cardiovascular safety for the new acute and preventive migraine treatments including ditans, gepants, and calcitonin gene-related peptide monoclonal antibodies (CGRP mAbs) alongside older medications like triptans and ergotamines. Recent Findings The authors conclude that there are no cardiovascular safety concerns for lasmiditan, and that it could be used in those with cardiovascular disease. In fact, the literature even suggests that triptans are safer in cardiovascular disease than their contraindications may suggest. At this time, there is insufficient evidence that gepants and CGRP mAbs should be contraindicated in those with cardiovascular disease including stroke or myocardial infarction, though erenumab has now been associated with hypertension. Vasodilation may be an important CGRP-mediated mechanism mid-ischemia especially in patients with small vessel disease; hence, CGRP antagonists should be use with caution in this context. Summary Long-term data is still needed, and prescribers should ensure patients are aware of the limitations of our knowledge at this time, while still offering these effective and well-tolerated treatment options.
 
Article
Purpose of Review Chronic pain in the USA has presented with higher prevalence rates among women, older adults, those unemployed, living in poverty, living in rural environments, and adults with public health insurance. The COVID-19 pandemic has heavily played into the biopsychosocial model of pain. Consequently, greater impacts have affected patients with mood disorders, opioid abuse, and chronic pain. Concurrently, telemedicine has become a popular vehicle during the COVID-19 pandemic in continuing to provide quality patient care. The purpose of this article is to review the benefits and challenges related to the delivery of telemedicine for patients with chronic pain. Recent Findings The benefits of telemedicine have been examined from patient psychosocial and convenience factors as well in relation to medical practice efficiency. Within chronic pain management, one of telemedicine’s most effective utilization is seen via post-injection follow-up and assessment of further necessary interventions. Challenges also exist in this framework, from lack of physical examination and convenient close therapeutic monitoring and drug screening, to technological and resource cost capabilities of older and disadvantaged chronic pain patients, to barriers in establishing patient-provider rapport. During the COVID-19 pandemic, telehealth services were covered at rates comparable to in-person visits. Health insurance coverage and payment were major barriers for implementation of telemedicine prior to the pandemic. It is difficult to predict ongoing coverage and payment of telehealth services, although the benefits in terms of access and patient satisfaction have clearly been demonstrated. Summary While telemedicine has proven to be a very useful tool with a wealth of advantages, the delivery of virtual healthcare for chronic pain poses a set of challenges that will need to be met to ensure the quality and standard of care continue to be upheld.
 
Selection process
Article
Purpose of Review Researchers suggests that patients with COVID-19 develop neuropathic pain within weeks or months following infection and that patients with neuropathic pain and COVID-19 sometimes present with deterioration of neurologic complications and pain exacerbation. The objective of this systematic review is to discuss the case-reports having neuropathic pain during and after COVID-19 infection. Recent Findings Case reports that has described about patients getting neuropathy or neuropathic pain around the disease either immediately or late post COVID were included. The data was extracted and qualitatively synthesised. Literature was searched and 939 articles were found. 12 articles were screened as per the eligibility criteria and finally, 6 case reports on neuropathic pain in Covid-19 were selected from the database and manual search and finalised for analysis. 2 cases of herpes zoster and post herpetic neuralgia, 2 cases of intense burning pain, 1 case of trigeminal neuralgia and 1 of brachial plexopathy included for the review. Summary Covid 19 viral neurogenic invasion is something very newly discovered topic of discussion in the field of research. With the passage of time, more cases will emerge and more data will be available for research. The review is registered in Prospero with no. CRD42021257060.
 
Article
Purpose of Review The purpose of this review is to examine the impact of smoking and its role on the development of chronic pain and provide a critical review of recent literature. Recent Findings Recent studies demonstrate the bidirectional and dependent relationship between smoking and chronic pain. Those who are in pain have a more difficult time in the cessation of smoking as well as an increased sensitivity to pain during abstinence, lower confidence, and higher relapse rates. The fear of pain and the anxiety and depression that abstinence causes results in a grim outcome for long-term cessation. Summary The dependent nature between chronic pain and smoking is affected by numerous variables. Providers should consider a multiprong approach to treating chronic pain and targeting smoking cessation treatment by providing motivational therapy, nicotine replacement, and medication therapies to prevent relapse, and providing those who are more likely to relapse with a higher level of care.
 
Treatment algorithm for painful diabetic neuropathy. *FDA-approved treatment. TENS transcutaneous electrical nerve stimulation, SNRI serotonin-norepinephrine reuptake inhibitors, TCA tricyclic antidepressants, IV intravenous, SCS spinal cord stimulation, DRG-SCS dorsal root ganglion spinal cord stimulation, PNS peripheral nerve stimulation, IDDS intrathecal drug delivery system, IT intrathecal
Article
Purpose of Review Painful diabetic neuropathy (PDN) manifests with pain typically in the distal lower extremities and can be challenging to treat. The authors appraised the literature for evidence on conservative, pharmacological, and neuromodulation treatment options for PDN. Recent Findings Intensive glycemic control with insulin in patients with type 1 diabetes may be associated with lower odds of distal symmetric polyneuropathy compared to patients who receive conventional insulin therapy. First-line pharmacologic therapy for PDN includes gabapentinoids (pregabalin and gabapentin) and duloxetine. Additional pharmacologic modalities that are approved by the Food and Drug Administration (FDA) but are considered second-line agents include tapentadol and 8% capsaicin patch, although studies have revealed modest treatment effects from these modalities. There is level I evidence on the use of dorsal column spinal cord stimulation (SCS) for treatment of PDN, delivering either a 10-kHz waveform or tonic waveform. Summary In summary, this review provides an overview of treatment options for PDN. Furthermore, it provides updates on the level of evidence for SCS therapy in cases of PDN refractory to conventional medical therapy.
 
Strategic planning for migraine
Article
Purpose of Review The goal of this article is to describe migraine advocacy as an essential means to advance the field of headache medicine. Special attention is spent outlining advocacy initiatives and priorities. Recent Findings There is little written about “migraine advocacy” in the literature. However, organizational and expert priorities include advocating for policies that improve systems of care, telemedicine, education, research, and public initiatives that reduce health disparities and the stigma of migraine. Summary This summary includes the latest advocacy efforts to support policies that may improve migraine care, strengthen the field of headache medicine, and eliminate the burden of migraine.
 
Velasquez et al. A AP and B Lateral X-rays showing the epidural paddle placed downward in the in the craniocervical junction and slightly lateralized to the affected side
Article
Background Trigeminal neuralgia (TN) is a chronic neuropathic pain condition affecting one or more divisions of the fifth cranial (trigeminal) nerve. TN is defined by recurrent unilateral electric shock-like pain that is abrupt in both onset and termination. The pain is triggered by innocuous sensory stimuli and is classified as either classic TN, related to vascular compression; secondary TN, due to a tumor along the trigeminal nerve or an underlying disease like multiple sclerosis; or idiopathic TN. Among the various therapies available for TN, carbamazepine remains the first-line treatment. Newer medications have demonstrated efficacy in patients who do not respond to or cannot tolerate carbamazepine. When medical management and neuroablative procedures fail, spinal cord stimulation (SCS) serves as a promising and popular option, with an estimated 34,000 SCS procedures performed annually worldwide. SCS employs the implantation of electrical leads in the epidural space to manage pain. Purpose of Review A review of literature was conducted to explore the use of cervical spinal cord stimulation (SCS) for the treatment of trigeminal neuralgia. Methods A MEDLINE/PubMed search using the search terms “spinal cord stimulation” and “trigeminal neuralgia” was employed to find any case reports and research studies (retrospective studies, double-blinded studies, observational studies) on the topic. No date limiters were used for the search. The initial search resulted in 76 non-duplicate entries from the database. After application of the search criteria, 58 studies were excluded because they were not relevant to the study. A further detailed review of the included articles was conducted by all the reviewers. During this phase of the review, additional 6 studies were excluded. A total of 11 studies were included: 7 case reports and 4 retrospective review studies. Recent Findings In the review, we discuss 7 different case reports on the use of cervical SCS for trigeminal neuralgia and an additional 4 retrospective studies reviewing outcomes and pain relief in patients who underwent treatment. The case reports and retrospective studies reviewed demonstrated that TN patients realized > 50% pain relief following permanent electrode implantation. In all the cases discussed, complications from SCS were rare and/or not reported. Additionally, most of the cases report that patients who had adequate pain relief from SCS were able to wean off, or significantly reduce, oral medications given the vast improvement in pain reduction. Conclusions Cervical spinal cord stimulation (SCS) is a safe and effective procedure for patients with trigeminal neuralgia (TN) who have refractory pain despite the use of medications. In many cases, the procedure provides an adequate level of pain relief with very few complications or side effects. The vast majority of current research on the use of cervical SCS for TN currently consists of case reports and retrospective analysis. In order to further evaluate the efficacy of SCS for treatment, large-scale randomized controlled studies or observational studies need to be conducted to properly evaluate SCS as a treatment modality for trigeminal neuralgia.
 
Article
Purpose of Review Acupuncture is an analgesic technique that has long been utilized in Eastern medicine. In recent times, various acupuncture techniques have been used in integrated pain management approaches in Western medicine. It has even been adopted as an analgesic method in surgical patients. Currently, no review exists regarding various acupuncture techniques used in perioperative pain management and data describing the utility of these techniques. This paper synthesizes the latest literature regarding the role of acupuncture in perioperative pain management. The authors sought to describe various acupuncture modalities used to help manage surgical pain and synthesize the current body of literature to help readers make informed judgements on the topic. Recent Findings Patients undergoing abdominal, spine/neuro, and gynecologic pelvic surgery generally benefit from acupuncture. Out of the various acupuncture techniques, electroacupuncture, transcutaneous electric acupoint stimulation, and traditional total body acupuncture seem to be most promising as adjuncts to multimodal perioperative analgesia. Benefits include improved analgesia and/or reduced narcotic requirements, decrease in PONV, and shorter time to return of bowel function. Summary Acupuncture is a low-risk method that has the potential to enhance perioperative analgesia, decrease opioid requirement, and reduce unwanted side effects of anesthesia, surgery, and opioid administration such as nausea/vomiting. Given the variety of patient populations, various acupuncture techniques, and small patient populations for most current studies; it remains difficult to determine which acupuncture method would most benefit specific patients. Future studies with more robust sample sizes and prospective comparison on acupuncture technique would help better characterize acupuncture’s role in perioperative pain management.
 
Pharmacology of buprenorphine [4]. Used with permission from Springer Nature
Sample guidelines used at our institution, Montefiore Medical Center/Albert Einstein College of Medicine, as of December 2020
Article
Purpose of Review To review the pharmacology of buprenorphine, the evolution of buprenorphine dosing recommendations, and the current literature regarding its recommendations for the perioperative period. Recent Findings There is a consensus that for all surgeries, buprenorphine should be continued throughout the perioperative period. If the surgery is a minimal to mild pain surgery, no dose adjustment is needed. There is no clear consensus regarding moderate to severe pain. With all surgeries, multimodal analgesia should be utilized, with regional anesthesia when possible. Summary Patients taking buprenorphine should continue their buprenorphine perioperatively; whether to decrease or maintain dosing is up for debate. Multimodal analgesia should also be used throughout the perioperative period, and communication between the patient and all provider teams is of the utmost importance to provide adequate analgesia during the perioperative period, as well as to arrange safe analgesia upon discharge.
 
Article
Purpose of Review This narrative review aims to summarize advances in the field of small fiber neuropathy made over the last decade, with emphasis on novel research highlighting the distinctive features of SFN. Recent Findings While the management of SFNs is ideally aimed at treating the underlying cause, most patients will require pain control via multiple, concurrent therapies. Herein, we highlight the most up-to-date information for diagnosis, medication management, interventional management, and novel therapies on the horizon. Summary Despite the prevalence of small fiber neuropathies, there is no clear consensus on guidelines specific for the treatment of SFN. Despite the lack of specific guidelines for SFN treatment, the most recent general neuropathic pain guidelines are based on Cochrane studies and randomized controlled trials (RCTs) which have individually examined therapies used for the more commonly studied SFNs, such as painful diabetic neuropathy and HIV neuropathy. The recommendations from current guidelines are based on variables such as number needed to treat (NNT), safety, ease of use, and effect on quality of life.
 
Article
Purpose of Review Many Americans cope with painful diabetic neuropathy (DN) as a sequela of high rates of diabetes mellitus in the US population. Appropriate management of this complex, debilitating chronic pain condition requires thorough evaluation through a biopsychosocial framework. This review aims to synthesize findings from original research studies and analyze the psychological factors that influence the experience of, and treatments for, DN pain. Recent Findings Existing clinical literature suggests a wide breadth of psychological factors impacting DN pain. One research study detailed the demographic characteristics of DN patients most likely to have significant anxiety or depressive symptoms, and have emotional distress adversely impacting their response to therapies. A retrospective study demonstrated a correlation between patients’ mindfulness-based stress reduction and improvement in DN pain severity. In addtion, a small-scale, randomized controlled pilot study supported cognitive-behavioral therapy as a superior intervention to conventional medical treatments in reducing DN patients’ pain severity and pain interference, even when not accompanied by significant improvement in depressive symptoms. Summary This review of investigations into psychological factors implicated in DN pain suggests that diagnosable mental health conditions as well as discrete, adverse thinking processes both exert significant influences on DN pain. This review further brings attention to the beneficial impact that psychotherapeutic modalities can have on DN pain.
 
Chronic-pain-maintaining reinforcement cycle of non-suicidal self-injury among individuals with childhood trauma
Article
Purpose of Review Individuals with chronic pain are significantly more likely to have experienced overwhelming trauma early and often in key developmental years. There is increasing acknowledgment that childhood trauma disrupts how individuals process and cope with both physical and emotional pain. Emerging studies acknowledge elevated rates of non-suicidal self-injury (NSSI) in chronic pain populations. This review provides a theoretical framework to understand the relationship between NSSI behavior and pain experience in persons with chronic pain and childhood trauma histories. We discuss how NSSI may act to regulate neurobiological (e.g., endogenous opioid systems) and psychological (e.g., heightened negative affect and emotion dysregulation) systems affected by childhood trauma, leading to temporary pain relief and a cycle of negative reinforcement perpetuating NSSI. As these concepts are greatly understudied in pain populations, this review focuses on key areas relevant to chronic pain that may provide a testable, conceptual framework to support hypothesis generation, future empirical investigation, and intervention efforts. Recent Findings See Fig. 1. Summary See Fig. 1.
 
Ultrasound guided greater occipital nerve (GON) block. Panel A: The sonogram of the lateral approach GON block. Panel B: The sonogram of the oblique longitudinal approach GON block. The local anesthetic can be injected into the interfascial space between the semispinalis and obliquus capitis inferior
Article
Purpose of Review This manuscript aims to review the risks and the current treatments for postdural puncture headache (PDPH). Recent Findings PDPH is a relatively frequent complication after neuraxial blocks. It is typically orthostatic in nature, presenting as a positional and dull aching or throbbing headache, with added dysregulation of auditory and/or visual signals. Certain characteristics, such as female sex and young age, may predispose patients to the development of PDPH, as may factors such as previous PDPH, bearing down during the second stage of labor, and the neuraxial technique itself. Long-term complications including chronic headache for years following dural puncture have brought into question of the historical classification of PDPH as a self-limiting headache. So far, the underlying mechanism governing PDPH remains under investigation, while a wide variety of prophylactic and therapeutic measures have been explored with various degree of success. Summary In case of mild PDPH, conservative management involving bed rest and pharmacological management should be used as first-line treatment. Nerve blocks are highly efficient alternatives for PDPH patients who do not respond well to conservative treatment. In case of moderate-to-severe PDPH, epidural blood patch remains the therapy of choice. An interdisciplinary approach to care for patients with PDPH is recommended to achieve optimal outcomes.
 
Article
Purpose of Review To summarise and analyse the current knowledge of CGRP metabolism in childhood and adolescence and its role in childhood and adolescence migraine. Recent Findings Influencing CGRP pathways is nowadays one of the main mechanisms to treat migraine. In adults, several clinical trials with different drug classes have supported this finding. However, only very little is known on these mechanisms in children and adolescents with migraine. Based on a literature search, it can be concluded that substantial parts of the CGRP pathways are already developed and working in the preterm fetus of animals. Newborn animals show high CGRP levels and high density of CGRP positive neurons and nerve fibres. In human studies, increased levels of CGRP were observed in childhood and adolescent migraine patients. Remedies based on influencing CGRP metabolism are also working in that age group. For triptans, this has clearly been shown; for gepants, no data are available, and for CGRP ligand/receptor antibodies, positive evidence is only available from case series. Summary Only very little is known on CGRP metabolism in childhood and adolescence. However, placebo-controlled clinical trials both on CGRP antagonists and on CGRP ligand/receptor antibodies are under way and will show in some years whether these drug classes are efficacious also in children and adolescents.
 
Article
Purpose of Review The purpose of this review was to summarize current reports regarding emotional problems in children and adolescents with primary headaches. Emotional problems include those related to personality, psychiatric, and neurodevelopmental disorders. Recent Findings Alexithymia-like characteristics and internalized personality characteristics are considered to worsen primary headaches. Comorbid psychiatric traits such as depression and anxiety have been observed. When neurodevelopmental disorders coexist, it is necessary to pay attention not only to emotional problems but also to the side effects of concomitant drug and history of abuse. There are few reports with strong evidence for the pharmacological treatment of headaches accompanied by emotional problems. Summary Understanding emotional problems at an initial consultation and examining the application of psychotherapy could help improve the outcome of headaches in children and adolescents.
 
Characteristics of vulnerable and underserved populations
Article
Purpose of Review This review will briefly summarize recent literature published on headache disparities in underserved and vulnerable populations. It will also report the personal observations of headache medicine providers working with underserved and vulnerable populations in the USA, specifically in an urban practice dedicated to patients in a safety net program and a rural practice dedicated to Native American patients. Recent Findings Headache disorders are recognized as one of the most prevalent neurological conditions. People with headache and migraine encounter several barriers to obtaining appropriate care, which are magnified in vulnerable and underserved populations. Research has shown disparities in headache and migraine diagnosis, prevalence rates, treatment, and outcomes based on race, socioeconomic status, and geography. Summary Continued research regarding disparities in headache medicine is required. Strategies to address the identified challenges, including structural competence and the underrepresented in medicine pipeline, are reviewed.
 
Article
Although the number of SARS-CoV-2 new cases may be declining due to the implementation of the vaccine in the USA, there is a rising cohort of people with long-term effects from the virus. These long-term effects include loss of taste, heart palpitations, and chronic pain syndromes. In this commentary, we assess the current literature to appraise the knowledge of long-term COVID-19 effects related to long-term pain syndromes including testicular pain, headache, chronic pain, and chest pain.
 
Article
Purpose of Review The purpose of the review is to evaluate the current evidence on techniques for sacroiliac joint (SIJ) injections using landmark, ultrasound, fluoroscopy, and computed tomography (CT) guidance. Methods A literature search was performed to find all relevant retrospective, prospective, and randomized controlled (RCT) studies where SIJ injections were performed under ultrasound, fluoroscopy, and CT guidance. Recent Findings A total of eight studies were identified with suitable data for inclusion. There were two RCTs, four prospective, and two retrospective studies included. Case reports or case series were excluded. A total of 420 patients were enrolled across all eight studies. CT guidance provided the most accurate needle placement in the SIJ injections followed by fluoroscopy, which was more accurate than ultrasound. Landmark-guided injections were not accurate. Summary Accurate needle placement in SIJ confirms SIJ-mediated pain and injection of corticosteroids leads to improvement in pain and/or disability outcome measures regardless of guidance technique. Diagnostic CT-guided SIJ injections should be performed prior to consideration of SIJ fusion.
 
Illustrative case of cerebral amyloid angiopathy-related inflammation. An 80-year-old woman with a history of hypertension, hyperlipidemia, and multiple transient ischemic attacks presented with 1 day of acute onset, progressive right hemicranial headache, nausea, and vomiting. Examination revealed an elderly woman with normal vital signs, severe inattention, left homonymous hemianopsia, and left hemispatial neglect. Brain MRI revealed small scattered hypointensities on axial gradient echo sequences (A) as well as prominent regions of confluent hyperintensity on axial FLAIR sequences in the right temporal and bilateral occipital white matter (B). She was treated with intravenous corticosteroids with clinical resolution over a few days and radiographic improvement on axial FLAIR sequences after 3 months (C)
Article
Purpose of Review To critically evaluate the recent literature on cognitive impairment and headache. Recent Findings Neurocognitive symptoms are prevalent, debilitating, and occur often with both primary and secondary headache disorders. Summary This is a “narrative review of the current literature in PubMed on cognitive function and headache.” Migraine is associated with cognitive impairment years before a migraine diagnosis. In young and middle-aged adults, migraine is associated with deficits in attention, executive function, processing speed, and memory. It is unlikely that migraine is associated with dementia. Although methodologically difficult to assess, there does not seem to be an association between tension-type headache and cognitive dysfunction. In early to midlife, cluster headache seems to be associated with executive dysfunction. Several secondary headache syndromes relevant to clinicians managing headache disorders are associated with poorer cognitive performance or distinctive cognitive patterns, including those attributed to chronic cerebral or systemic vascular disorders, trauma, and derangements of intracranial pressure and volume, including frontotemporal brain sagging syndrome.
 
Scematic of scalp innervation
Article
Purpose of Review Postcraniotomy headache (PCH) is a highly underappreciated and very common adverse event following craniotomy. Recent Findings Analgetic medication with opioids often interferes with neurologic evaluation in the acute phase of recovery and should be kept to a minimal, in general, in the treatment of chronic pain as well. We provide an update on the latest evidence for the management of acute and chronic PCH. Summary Especially in the neurosurgical setting, enhanced recovery after surgery protocols need to include a special focus on pain control. Patients at risk of developing chronic pain must be identified and treated as early as possible.
 
PRISMA diagram. Flow chart of study selection
Risk of bias assessment for randomized controlled trials. Green indicates “low risk for bias”, yellow indicates “unclear risk for bias”, and red indicates “high risk for bias”
Article
Purpose of Review Painful diabetic neuropathy (PDN) is a prevalent and debilitating condition, characterized by severe burning, tingling, and lancinating pain usually located in the distal lower extremities. In addition to manifesting with severe pain, PDN may also be associated with poor quality of life and sleep, mood disorders, burns, falls, and social withdrawal. The authors appraised the current body of literature for evidence on neuromodulation interventions for PDN. Recent Findings In patients with refractory PDN unresponsive to conventional medical management (glucose optimization and oral analgesic medications), there is level I evidence supporting the use of 10-kHz and tonic dorsal column spinal cord stimulation (SCS). Included studies reported significant associations between 10-kHz and tonic dorsal column SCS and superior analgesic outcomes, physical functioning, and patient satisfaction. Current level of evidence remains limited for other modalities of neuromodulation for PDN including burst SCS (level II-3), dorsal root ganglion SCS (level III), and peripheral nerve stimulation (level II-3). Some studies reported improvements in neurological physical examination, sensory testing, and/or reflex testing in patients undergoing 10-kHz SCS for treatment of PDN. Summary In summary, the purpose of this review is to equip provider with important updates on the use of neuromodulation interventions for the treatment of PDN that is refractory to conventional medical therapy, with current level I evidence supporting use of 10-kHz and tonic SCS for PDN.
 
Article
Purpose of Review This review provides an update on sex differences in chronic migraine (CM), with a focus on clinical characteristics, pathophysiology, and treatments. Recent Findings Approximately 6.8–7.8% of all migraineurs have CM, with an estimated prevalence of 1.4–2.2% in the general population. The economic burden caused by CM, including medical costs and lost working ability, is threefold higher than that caused by episodic migraine (EM). Notably, the prevalence of migraine is affected by age and sex. Female migraineurs with CM experience higher levels of headache-related disability, including longer headache duration, higher frequency of attacks, and more severely impacted efficiency at work. Sex hormones, including estrogen, testosterone, and progesterone, contribute to the sexually dimorphic characteristics and prevalence of migraine in men and women. Recent neuroimaging studies have indicated that migraine may have a greater impact and cause greater dysfunction in the organization of resting-state functional networks in women. Accumulating evidence suggests that topiramate, Onabotulinumtoxin A and calcitonin gene-related peptide (CGRP) monoclonal antibodies are effective as the preventative treatments for CM. Summary Recent evidence highlights a divergence in the characteristics of CM between male and female populations. The data comparing the treatment response for CM regarding sex are lacking.
 
Article
Purpose of Review Migraine is and continues to be a significant medical issue in older adults. Migraine can have different characteristics in older adults and specific diagnostic and treatment considerations need to be applied when managing headache and migraine in this population, which is increasing in both size and diversity. Contrary to widely held beliefs, migraine may not improve in older women following menopause and can have new onset in older age. The purpose of this review is to give an update on the diagnosis and treatment of episodic migraine in older adults. Recent Findings As the population ages, migraine in older adults will become a more significant public health issue. Migraine in older adults can present with different clinical symptoms than in a younger population and is primarily a diagnosis of exclusion in older adults. Migraine treatment considerations for older adults should include comorbidities and medication interactions. Recent findings suggest there are medications that should be avoided when treating seniors with migraine. Summary The purpose of this review is to give an update on the most important aspects regarding the diagnosis and treatment of headache and migraine in older adults. In addition, recommendations will be made concerning medications that need careful consideration when prescribing to seniors.
 
Article
Purpose of Review While most women with migraine improve during pregnancy, a subset may remain unchanged or even become more severe. Given the limited evidence for the use of prescription medications during pregnancy, many look to other treatment modalities. We seek to review complementary and integrative medicine, procedural interventions, and neurostimulation to empower women with safe and effective treatment options during pregnancy. Recent Findings Migraine treatment during pregnancy remains controversial. While evidence is limited, prospective and retrospective reviews, as well as clinical experience support the use of nutraceuticals, procedural interventions, and neurostimulation during pregnancy when the appropriate risks and benefits are weighed. Summary Empowering patients with information on complementary and integrative medicine, as well as non-systemic and interventional treatments, may help to reduce anxiety and headache burden during pregnancy. Various nutraceuticals have shown promise for the preventive management of migraine. Non-systemic interventions such as trigger point injections and peripheral and sphenopalatine nerve blocks offer effective treatment options with minimal side-effects. Options for neurostimulation have expanded in recent years and may offer safe and effective non-pharmacologic options for the management of migraine. It is imperative that providers do not minimize migraine during pregnancy and become aware of the treatment modalities available to help guide women through this experience.
 
Article
Purpose of Review This paper will examine the efficacy and safety of occipital nerve stimulation as a non-pharmacological alternative treatment for migraine. Recent Findings Migraine is characterized as a primary headache disorder with possible premonitory and aura phases, both of which vary greatly in symptomatology. The most common treatments for chronic migraine are pharmacological and are aimed at both acute relief (e.g., nonsteroidal anti-inflammatory drugs, triptans, and ergots) and prophylaxis (e.g., propranolol, valproic acid, and topiramate). For patients with medically refractory migraine, acute relief medication overuse can increase the risk of developing more severe and more frequent migraine attacks. Occipital nerve stimulation is a non-pharmacological alternative treatment for chronic migraine, which could eliminate the risk of adverse effects from acute relief medication overuse. Neurostimulation is thought to prevent pain by blocking signal transduction from small nociceptive fibers with non-painful signaling in larger adjacent fibers. Summary Existing data from clinical trials support the overall safety and efficacy of occipital nerve stimulation for the treatment of chronic migraine. However, few large controlled, double-blinded studies have been conducted, due to both practical and ethical concerns. Currently, occipital nerve stimulation is available as an off-label use of neurostimulation for pain prevention but is not approved by the FDA specifically for the treatment of chronic migraine.
 
Article
Purpose of Review Breast surgery is common and may result in significant acute as well as chronic pain. A wide range of pharmacologic interventions is available including opioids, non-steroidal anti-inflammatory drugs (NSAIDs), N-methyl-d-aspartate (NMDA) receptor antagonists, anticonvulsants, and other non-opioids with analgesic properties. We present a review of the evidence for these pharmacologic interventions. A literature search of the MEDLINE database was performed via PubMed with combined terms related to breast surgery, anesthesia, and analgesia. Articles were limited to randomized controlled trial (RCT) design, adult patients undergoing elective surgery on the breast (not including biopsy), and pharmacologic interventions only. Article titles and abstracts were screened, and risk of bias assessments were performed. Recent Findings The search strategy initially captured 7254 articles of which 60 articles met the full inclusion criteria. Articles were organized according to intervention: 6 opioid agonists, 14 NSAIDs and acetaminophen, 4 alpha-2 agonists, 7 NMDA receptor antagonists, 6 local anesthetics, 7 steroids, 15 anticonvulsants (one of which also discussed an NMDA antagonist), 1 antiarrhythmic, and 2 serotonin reuptake inhibitors (one of which also studied an anticonvulsant). Summary A wide variety of medications is effective for perioperative breast analgesia, but results vary by agent and dose. The most efficacious are likely NSAIDs and anticonvulsants. Some agents may also decrease the incidence of chronic postoperative pain, including flurbiprofen, gabapentin, venlafaxine, and memantine. While many individual agents are well studied, optimal combinations of analgesic medications remain unclear.
 
Article
Purpose of Review Studies on event-related evoked potentials have indicated that altered cortical processing of sensory stimuli is associated with migraine. However, the results depend on the experimental method and patients. Electrophysiology of resting state cortical activity has revealed compelling results regarding the pathophysiology of migraine. This review summarized the available information related to patients with episodic and chronic migraine to determine whether certain features can be used as signatures for migraine. Recent Findings A recent study examined differences in resting state functional connectivity among the pain-related regions and revealed that beta connectivity was attenuated in migraine and that altered connectivity in the anterior cingulate cortex was linked to migraine chronification. These findings suggested that chronification leads to neuroplasticity in the pain areas of higher-level processing rather than in areas involved in basic sensory discrimination (i.e., primary and secondary somatosensory areas). Another study discovered that the betweenness centrality of delta band in right precuneus was significantly lower in those with longer history of migraine. Electroencephalogram may also predict the treatment outcomes in patients with chronic migraine that those with lower pre-treatment occipital alpha power tend to show greater reduction in headache frequency. Summary Studies on resting state activity have yielded convincing findings regarding aberrant oscillatory power and functional connectivity in relation to migraine, thus contributing to identifying brain signatures for migraine. The role of such assessment in precision medicine should be further investigated.
 
Brain MRI findings of tuberous sclerosis complex. A Sagittal view of mixed nodular and cystic subependymal giant cell astrocytoma in lateral ventricle causing asymmetric enlargement of ventricle. B Axial view of scattered cortical and subcortical FLAIR hyperintensities consistent with cortical tubers
Article
Purpose of Review Tuberous sclerosis complex (TSC) and neurofibromatosis (NF) are neurocutaneous disorders often encountered by neurologists in clinical practice. This article aims to familiarize adult and pediatric neurologists with common features of these disorders and headache specific evaluation and management. Recent Findings Non-malignant intracranial tumors in TSC include cortical tubers (glioneuronal hamartomas), subependymal nodules or subependymal giant-cell astrocytomas (SEGA). Headache disorders in TSC are largely secondary and can cause headaches due to increased intracranial pressure, mass effect, obstructive hydrocephalus, or hemorrhage. Neurosurgical intervention is typically required for management of large SEGAs; however, in patients with increased surgical risk, newer treatment modalities may be offered such as neoadjuvant therapy with an mTOR inhibitor (mTORi). Newer studies indicate headache disorders are more prevalent in neurofibromatosis type 1 (NF1). Primary headache disorders can include migraine and tension-type headache, while secondary headache disorders can be due to associated neoplasms such as optic pathway gliomas or brainstem gliomas, or less commonly vasculopathies such as moyamoya syndrome. Selumetinib is an oral, small molecule mitogen-activated protein kinase (MEK) agent with antineoplastic activity which is in ongoing trials for treatment of NF1-associated pediatric low-grade gliomas. Summary NF1 stands out as having a higher association with primary headache disorders such as migraine. This association may be related to effects of mutation of the neurofibromin gene on pathways involved in pain and migraine genesis, however, warrants future study. Care should be taken when formulating a headache treatment plan to address comorbidities and avoid medications that may be contraindicated.
 
An overview of the observational and case-control studies concerning vitamins and minerals levels with migraine
An overview of the clinical trials about vitamins, minerals, and migraine
(continued)
Article
Purpose of Review The lifetime prevalence of headaches is 96%. Approximately 11% of the adult population worldwide has a migraine headache. Migraine is a complex disorder that is more than a simple headache. So far, many underlying mechanisms, i.e. inflammatory, vascular, neurogenic have been hypothesized. In recent years evidences proposed that an energy deficit due to changes in mitochondrial function contributes to migraine pathophysiology as an upstream disorder. Recent insights suggested that the coexistence of sensory-stimuli surplus and energy-reserve shortage activate the trigeminovascular system. Some nutrients are considered as essential elements in mitochondrial bioenergetics and some others are known as natural immuno-modulatory components. Also, evidence showed their beneficial effect in headache prophylaxis and treatment. In present study, we aimed to review the available data in this field. Recent Findings Vitamin B group, magnesium, and Coenzyme Q10 (CoQ10) are well-known for their function in mitochondrial energy metabolism. On the other hand, studies support their beneficial role in controlling migraine headache symptoms. For instance, daily intake of 400-milligram riboflavin for 3 months resulted in more than 50% reduction in migraine attacks in more than half of the consumers. According to recent evidence, vitamin D and Omega-3 which are considered as famous immune-modulatory compounds are also reported to be effective in migraine prophylaxis. For example, every 22% reduction in migraine headache occurrence was reported for every 5 ng/ml rise in serum vitamin D. Summary Supplementation with vitamin B group, CoQ10, magnesium, vitamin D and Omega-3 could be considered as an effective, less costly strategy in headache/migraine prophylaxis.
 
Article
Purpose of Review To describe the most recent findings related to lifestyle behaviors and migraine. Recent Findings An individualized conceptualization of how lifestyle factors impact migraine activity has increased our understanding of the role of behavioral interventions for episodic migraine. Healthy diets of several types have been associated with migraine attack reduction, whereas disruptions in diet like skipping meals are associated with migraine attack onset. Both aerobic activity and lower intensity yoga interventions show promise for migraine prevention. Sleep disruption has been associated with migraine day and may have a bi-directional relationship. Both increases and decreases in stress have been associated with migraine activity. Summary Evidence is converging around the principle that highly unusual disruptions in daily routine are particularly associated with migraine attack onset and that a consistent healthy lifestyle is a key feature of effective behavioral migraine prevention strategies.
 
Article
Purpose of Review The aim of this review is to discuss the use of tramadol in the perioperative period. There is no doubt that tramadol has revolutionized pain treatment, making it important to understand the pharmacokinetics and pharmacodynamics in order to provide patients with the safest and most effective analgesia. Recent Findings Tramadol is a centrally acting synthetic analgesic with a multimode of action used to help treat moderate to severe pain. Pharmacologically, the unique opioid acts as a serotonin-norepinephrine reuptake inhibitor, while its metabolite, O-desmethyltramadol, acts on the μ-opioid receptor. The analgesic strength of tramadol is about one-tenth that of morphine, making it a relatively safe analgesic. Potential side effects of tramadol include nausea, vomiting, constipation, pruritus, and respiratory depression; however, the severity of these symptoms is minimal compared to traditional opioids. Summary Although some of the perioperative uses of tramadol may be rare, it is a pain management option to consider when alternatives have proved ineffective.
 
Article
Purpose of Review This work aimed to review the epidemiology, clinical criteria, and primary and secondary diagnoses of pediatric thunderclap headache and to compare to adult thunderclap headache. Recent Findings Thunderclap headache among children aged 6–18 years are rare; this headache presented in 0.08% of the patients admitted to a pediatric emergency department in a tertiary pediatric center. In that recent single-center study, thunderclap was a headache of grade 10 on the pain scale and conferred a benign course. Contrary to adults, in children, most thunderclap headaches are due to either a primary thunderclap headache or another type of primary headache. A number of case reports have attributed pediatric thunderclap to reversible vasoconstriction syndrome and bleeding due to intracranial aneurysm. However, 3-year data from a pediatric emergency department of one center did not find these reasons to be causes of secondary thunderclap headache. This may be due to the rarity of these diagnoses in children compared to adults. Four of the 19 patients with thunderclap headache reported in that single study had secondary thunderclap; the causes were infection in three and malignant hypertension in one. All the patients had a benign course. Summary Although urgent imaging and lumbar puncture are required in the workup of pediatric thunderclap, severe causes are very rare. More research is needed to investigate pediatric thunderclap headache.
 
Schematic representation of afferent projections of the vagus nerve. AP, area postrema; PAG, periaqueductal gray; PB, parabrachial nucleus; DRN, dorsal raphe nucleus; LC, locus coeruleus; NTS, nucleus tractus solitaries; SuS, superior salivatory nucleus (preganglionic parasympathetic neurons); TCC, trigeminocervical complex (trigeminal nucleus caudalis and its cervical extension to C1 and C2)
Article
Purpose of Review Historically, therapies for migraine have generally involved pharmacological treatments using non-selective or selective analgesics and preventive treatments. However, for many patients these treatments are not effective, while others prefer to use non-pharmacological-based therapies. To fill this need, over the last 15 years, neuromodulatory devices have entered the market for migraine treatment. Here, we will review the most recent findings for the use of these devices in the treatment of migraine. Recent Findings Non-invasive vagus nerve stimulation and spring-pulse transcranial magnetic stimulation are both cleared for the treatment of migraine, supported by preclinical studies that validate efficacy and mechanism of action, and complemented with clinical trial data. Other options also authorized for use include transcutaneous supraorbital nerve stimulation and remote electrical neuromodulation. Summary Various options are available to treat migraine using authorized neuromodulatory devices. These data support their efficacy in the treatment of episodic migraine, although further studies are necessary to elucidate their mechanism of action and to provide rigor to clinical trial data.
 
Top-cited authors
Adam m Kaye
  • University of the Pacific
Richard Lipton
  • Albert Einstein College of Medicine
Omar Viswanath
  • LSU Shreveport
Ivan Urits
Dawn C Buse
  • Albert Einstein College of Medicine