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Peripheral nerve stimulation registry for intractable migraine headache (RELIEF): a real-life perspective on the utility of occipital nerve stimulation for chronic migraine

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  • Kiel Migraine and Headache Center
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Background Migraine is common and ranked as the first cause of disability in people under fifty. Despite significant advances in its pharmacological treatment, it often remains intractable. Neuromodulation is one option considered in the management of those patients.Objective To assess the safety and efficacy of neuromodulation in the treatment of intractable chronic migraine using the Abbott occipital nerve stimulator.Methods Recruitment took place in 18 centres in 6 countries. Patients over the age of 18 who had failed three or more preventative drugs, had at least moderate disability based on MIDAS or HIT-6 score and were implanted with an Abbott neurostimulator were included in the study. Patients were followed up for a maximum of 24 months. Data were collected on adverse events, headache relief, headache days, quality of life, migraine disability, satisfaction and quality of life.ResultsOne hundred twelve patients were included, 79 female and 33 male, with 45 patients reaching the maximum follow-up of 24 months. At 3 months, 33.7% were satisfied or very satisfied with the procedure with 43.0% reporting improved or greatly improved quality of life. 67.5% indicated that they would undergo the procedure again with satisfaction peaking at 9 months when 49.3% were satisfied or very satisfied with the procedure. At 24 months, 46.7% of available patients were satisfied or very satisfied with the procedure—18% of enrolled patients. The adverse events were however frequent with incidences of 37%, 47% and 31% respectively for hardware-, biological and stimulation-related side effects.Conclusion Neuromodulation can be beneficial for selected patients with intractable chronic migraine although frequent complications have been consistently reported across studies. Further research focusing on development of better hardware and technique optimisation and in particular reliable randomised trials with significantly longer follow-ups are warranted in this field.
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ORIGINAL ARTICLE - FUNCTIONAL NEUROSURGERY - PAIN
Peripheral nerve stimulation registry for intractable migraine
headache (RELIEF): a real-life perspective on the utility of occipital
nerve stimulation for chronic migraine
Keyoumars Ashkan
1
&Giannis Sokratous
1
&Hartmut Göbel
2
&Vivek Mehta
3
&Astrid Gendolla
4
&Andrew Dowson
5
&
Theresa Wodehouse
3
&Axel Heinze
2
&Charly Gaul
6
Received: 27 November 2019 /Accepted: 22 April 2020
#Springer-Verlag GmbH Austria, part of Springer Nature 2020
Abstract
Background Migraine is common and ranked as the first cause of disability in people under fifty. Despite significant advances in
its pharmacological treatment, it often remains intractable. Neuromodulation is one option considered in the management of those
patients.
Objective To assess the safety and efficacy of neuromodulation in the treatment of intractable chronic migraine using the Abbott
occipital nerve stimulator.
Methods Recruitment took place in 18 centres in 6 countries. Patients over the age of 18 who had failed three or more
preventative drugs, had at least moderate disability based on MIDAS or HIT-6 score and were implanted with an Abbott
neurostimulator were included in the study. Patients were followed up for a maximum of 24 months. Data were collected on
adverse events, headache relief, headache days, quality of life, migraine disability, satisfaction and quality of life.
Results One hundred twelve patients were included, 79 female and 33 male, with 45 patients reaching the maximum follow-up of
24 months. At 3 months, 33.7% were satisfied or very satisfied with the procedure with 43.0% reporting improved or greatly
improved quality of life. 67.5% indicated that they would undergo the procedure again with satisfaction peaking at 9 months
when 49.3% were satisfied or very satisfied with the procedure. At 24 months, 46.7% of available patients were satisfied or very
satisfied with the procedure18% of enrolled patients. The adverse events were however frequent with incidences of 37%, 47%
and 31% respectively for hardware-, biological and stimulation-related side effects.
Conclusion Neuromodulation can be beneficial for selected patients with intractable chronic migraine although frequent com-
plications have been consistently reported across studies. Further research focusing on development of better hardware and
technique optimisationand in particular reliable randomised trialswith significantly longer follow-ups are warranted in this field.
Keywords Intractable migraine .Neuromodulation .Occipital
nerve stimulation .Quality of life
Background
Migraine is common, with gender adjusted 1-year prevalence
of 35.3% [35],anditisconsideredbytheWorldHealth
Organization as one of the most disabling diseases [13,21,
24,38], ranked as the first cause of disability in people under
the age of fifty [34]. Approximately, 1.32.4% of these cases
will progress to chronic migraine [7,20,30] which is typified
by migraines for 15 days per month, for more than3 months
with a minimum of 8 days per month characterised with mi-
graine headache [1,26].
Despite significant advances in the pharmacological man-
agement of patients with chronic migraine [9], the latter
This article is part of the Topical Collection on Functional Neurosurgery
Pain
*Giannis Sokratous
giannis.sokratous@nhs.net
1
Department of Neurosurgery, Kings College Hospital, London, UK
2
Department of Neurology and Pain Management, Schmerzklinik
Kiel, Kiel, Germany
3
Department of Pain and Anaesthesia, St Bartholomews Hospital,
London, UK
4
Practice for Neurology and Pain Management, Sendlinger Straße,
Essen, Germany
5
Department of Neurology, Kings College Hospital, London, UK
6
Migraine and Headache Clinic, Königstein Klinik,
Königstein, Germany
https://doi.org/10.1007/s00701-020-04372-z
/ Published online: 6 May 2020
Acta Neurochirurgica (2020) 162:3201–3211
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
... Intriguingly, these areas are pivotal in modulating motor-thalamus-brainstem as well as prefrontal-thalamic-cingulate signaling pathways. As a general rule of thumb, high-frequency stimulations, ranging from 5 to 20 Hz, are believed to amplify cortical excitability, interact with diverse neurotransmitter and opioidergic networks, and mold neuronal plasticity [197,198]. The therapeutic potential of rTMS has been officially recognized by the FDA for the management of severe depression and obsessive-compulsive disorders. ...
... Within the last five years, open-label studies have been published on the use of ONS for chronic migraine [195][196][197]. However, the specific parameters of the stimulation and the study endpoints were quite varied between studies. ...
... Similarly, Garcia-Ortega et al. studied 37 refractory CM patients and reported significant pain reduction [196]. However, it is worth noting that up to 20% of patients reported adverse events such as infection, lead migration, and stimulation-related symptoms one year after treatment [197]. ...
Article
Full-text available
This article presents a comprehensive review on migraine, a prevalent neurological disorder characterized by chronic headaches, by focusing on their pathogenesis and treatment advances. By examining molecular markers and leveraging imaging techniques, the research identifies key mechanisms and triggers in migraine pathology, thereby improving our understanding of its patho-physiology. Special emphasis is given to the role of calcitonin gene-related peptide (CGRP) in migraine development. CGRP not only contributes to symptoms but also represents a promising therapeutic target, with inhibitors showing effectiveness in migraine management. The article further explores traditional medical treatments, scrutinizing the mechanisms, benefits, and limitations of commonly prescribed medications. This provides a segue into an analysis of emerging therapeutic strategies and their potential to enhance migraine management. Finally, the paper delves into neuromodulation as an innovative treatment modality. Clinical studies indicating its effectiveness in migraine management are reviewed, and the advantages and limitations of this technique are discussed. In summary, the article aims to enhance the understanding of migraine pathogenesis and present novel therapeutic possibilities that could revolutionize patient care.
... In the past 5 years, there were 4 open-label studies on CM published [48][49][50][51]. Most studies reported continuous ONS except one utilized burst ONS [50], which elicited subthreshold sensory perception and still seemed to reduce pain intensity and headache days. ...
... Using burst ONS, Garcia-Ortega et al. also showed a significant reduction of 10.2 monthly headache days (p = 0.002, one-tailed) in 12 CM patients [50]. The recent multi-center, international open-label RELIEF study recruited 132 intractable CM patients (45 completed 24-month visit) implanted with Abbott ONS and demonstrated headache pain relief, decrease in headache days, and headache disability [51]. The spatial sensory field and quality of the ONS seemed correlated with the clinical effectiveness reported by the patient [52]. ...
... The spatial sensory field and quality of the ONS seemed correlated with the clinical effectiveness reported by the patient [52]. However, there were adverse events of infection, lead migration, and stimulationrelated symptoms in up to 20% of patients after 1 year [51]. Due to these technical issues, new leads with anchors are being developed and will hopefully circumvent the adverse event profile of currently available systems. ...
Article
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Purpose of Review Neuromodulation devices have become an attractive alternative to traditional pharmacotherapy for migraine, especially for patients intolerant to medication or who prefer non-pharmacological options. In the past decades, many studies demonstrated the efficacy of neuromodulation devices in patients with episodic migraine (EM). However, the benefit of these devices on chronic migraine (CM), which is typically more debilitating and refractory than EM, remains not well studied. Recent Findings We reviewed the literature within the last five years on using FDA-cleared and investigational devices for CM. There were eight randomized controlled trials and 15 open-label observational studies on ten neuromodulation devices. Summary Neuromodulation is promising for use in CM, although efficacy varies among devices or individuals. Noninvasive devices are usually considered safe with minimal adverse events. However, stimulation protocol and methodology differ between studies. More well-designed studies adhering to the guideline may facilitate FDA clearance and better insurance coverage.
... [9] It is hard to properly assess the incidence of lead migration in ONS since the studies that report it are heterogeneous, describe few cases, and present extremely variable results [ Table 1]. [2,3,7,11,14,15,[17][18][19][20][21][22]24,[28][29][30]32,34,41] In our review, we identified five randomized clinical trials which reported lead migration. [1,8,23,31,33] ese trials have reported a migration incidence that ranges from 12.9% to 50.9%. ...
... N/A Miller et al. [24] Cohort Cluster headache 1/51 (2.0) N/A Jones et al. [14] Retrospective review Chronic daily headaches and occipital neuralgia 12/21 (57.1) N/A Aibar-Durán et al. [2] Prospective analysis Cluster headache 1/17 (5.9) N/A Ashkan et al. [3] Case series Chronic migraine 2/112 (1.8) N/A Raoul et al. [29] Case series Occipital headaches 6/60 (10.0) N/A Leplus et al. [19] Prospective registry Cluster headache 16 Perhaps, an effective alternative to reduce lead migration associated with fibrosis would be a wireless ONS system that does not require an extension. ...
Article
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Background: Lead migration is a complication associated with occipital nerve stimulation (ONS). We present a rare case in which fibrosis in the stress relief loop caused lead migration in the treatment of occipital neuralgia. Case description: A 30-year-old woman with a 5-year history of refractory occipital neuralgia, who had been under ONS therapy for 2 months, presented with a sudden onset of typical occipital neuralgia pain associated with cervical muscles spasms and myoclonus. A skull radiography showed lead migration. The patient underwent surgery for lead repositioning. During surgery, we identified extensive fibrosis throughout the stress relief loop that produced several constriction points. The fibrosis in the stress relief loop increased tension on the lead during head-and-neck movement, causing progressive migration of the lead. Conclusion: Although lead migration is a common complication of ONS, its association with fibrosis in the stress relief loop has not, to the best of our knowledge, been reported before. Lead migration can directly affect treatment outcome and it is, therefore, important to fully understand the possible mechanisms that can cause it and how to promptly manage them.
... Burst ONS reduces headache days per month and headache frequency and intensity in people with chronic migraine and chronic cluster headache, indicating paresthesias are not required for pain relief [87]. Additionally, ONS is associated with a high rate of adverse events, including 37% with hardware, 47% with biological, and 31% with stimulation-related adverse events [88]. ...
Article
Full-text available
Purpose of Review Neurostimulation treatment options have become more commonly used for chronic pain conditions refractory to these options. In this review, we characterize current neurostimulation therapies for chronic pain conditions and provide an analysis of their effectiveness and clinical adoption. This manuscript will inform clinicians of treatment options for chronic pain. Recent Findings Non-invasive neurostimulation includes transcranial direct current stimulation and repetitive transcranial magnetic stimulation, while more invasive options include spinal cord stimulation (SCS), peripheral nerve stimulation (PNS), dorsal root ganglion stimulation, motor cortex stimulation, and deep brain stimulation. Developments in transcranial direct current stimulation, repetitive transcranial magnetic stimulation, spinal cord stimulation, and peripheral nerve stimulation render these modalities most promising for the alleviating chronic pain. Summary Neurostimulation for chronic pain involves non-invasive and invasive modalities with varying efficacy. Well-designed randomized controlled trials are required to delineate the outcomes of neurostimulatory modalities more precisely.
... Among 2313 patients treated with transcutaneous stimulation of the supraorbital branch of the trigeminal nerve, there were no reports of serious adverse events [17]. A major shortcoming of these studies is that stimulation was limited to only the trigeminal nerve despite the reported efficacy of occipital nerve stimulation [18]. ...
Article
Full-text available
Introduction: Current external peripheral nerve stimulation devices stimulate only one nerve. This prospective, randomized, double-blind, sham-controlled trial assessed efficacy, safety, and tolerability of a novel external combined occipital and trigeminal neurostimulation (eCOT-NS) device as a self-administered home treatment for migraine (Relivion®MG, Neurolief Ltd; Netanya, Israel). Methods: Episodic and chronic migraine subjects (N = 55) were randomized to receive active (n = 27) or sham (n = 28) treatment. Subjects received eCOT-NS devices and performed 60 ± 20-min home treatments within 45 min of migraine episode onset. The primary endpoint was relative (percent) change in mean baseline VAS pain scores 1 h after treatment initiation. Treatment outcomes assessed at 1-, 2-, and 24-h post-treatment initiation were pain reduction and proportion of pain-free subjects and treatment responders, defined as ≥ 50% pain reduction. Categorical pain ratings (none, mild, moderate, and severe pain) were also analyzed. Results: Active stimulation was significantly more effective than sham stimulation for decreasing pain intensity at 1 h (53% vs. 10%), 2 h (52% vs. 17%), and 24 h (71% vs. 34%). Pain-free ratings were greater for the active treatment arm at 1 h (29.2% vs. 16%), 2 h (41.7% vs. 20%), and 24 h (65.2% vs. 40%). The number of subjects with baseline moderate or severe migraine pain who were pain-free at 2 h was significantly greater among active treatment subjects (43% vs. 10.5%). The responder rate was significantly higher among the active treatment group at 1 h (67% vs. 20%), 2 h (66.7% vs. 32%,), and 24 h (78.3% vs. 48%). Overall headache relief was significantly higher in the active treatment group at 1 h (67% vs. 26%) and 2 h (76% vs. 31.6%). Mild adverse events, reported by a minority of subjects, resolved spontaneously. Conclusions: eCOT-NS provides superior clinically meaningful relief and freedom from migraine pain, offering an effective and safe therapy for acute treatment of migraine. Trial registration: ClinicalTrials.gov Identifier NCT03398668.
... Electrical modulation of this common pathway is believed to lead to the desired antinociceptive effect. 13 Key words -Cervicogenic headache -Cluster headache -Migraine -Neuropathic pain of the scalp -Neurostimulation -New daily persistent headache -Tension-type headache Abbreviations and Acronyms ONS: Occipital nerve stimulation SONS: Supraorbital nerve stimulation VAS: Visual analog scale Evidence for long-term headache control using peripheral nerve stimulation has been demonstrated in several institutional studies 2,6,9,11,12,[14][15][16][17][18][19] ; however, data for follow-up longer than only a few years have remained sparse. In the present retrospective study, we assessed the clinical efficacy of ONS and SONS in achieving long-term pain alleviation for various chronic and medically intractable headache disorders at our institution. ...
Article
Objective: To provide long-term data on clinically meaningful pain alleviation in drug-refractory headache disorders with occipital and supraorbital nerve stimulation (ONS; SONS). Methods: Retrospective review of 96 patients suffering from migraine, cervicogenic headache, cluster headache, neuropathic pain of the scalp, tension-type headache and new daily persistent headache, who underwent ONS (61.5%), SONS (11.5%), or a combined ONS + SONS (27.1%) trial implantation and definitive implantation between 2007 and 2017. Changes in pain perception over time were followed using the visual analog scale (VAS). Results: The cohort consisted of 60.4% females and 39.6% males with a mean age of 46.9±11.5 years and pain duration of 14±14.1 years. 65 (67.7%) were treatment-responders to a trial (at least 30% amelioration of average or maximum VAS pain and/or number of headache days) lasting 22.5±8.8 days, with a reduction of their average VAS pain to 37±24.4% of baseline (vs. 99.1±24.1% of baseline for non-responders; p<0.01). Out of 56 implanted patients with long-term follow-up of up to 10 years, 32 (57.1%) reported a ≥50% reduction of their average VAS pain. Four patients (6.5%) requested hardware explantation. Stage II complications included 1 infection (1.6%) and 6 electrode dislocations (9.7%). Study limitations included the retrospective nature, lack of controls receiving placebo intervention and as such randomization. Conclusions: After careful patient selection, based on a positive response to a trial of ONS / SONS, clinically meaningful long-term benefit can be achieved in 57.1% of the patients with various chronic headache conditions.
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Background: Combined peripheral occipital and trigeminal neurostimulation is clinically proven to alleviate migraine symptoms, however, it was previously possible only via high-risk surgical procedures. Neuromodulation using currently available peripheral nerve stimulation devices stimulates only one nerve. The objective of this prospective, randomized, double-blind, sham-controlled trial was to evaluate the efficacy, safety and tolerability of a novel external concurrent occipital and trigeminal neurostimulation (eCOT-NS) device designed as a self-administered home treatment for migraine (Relivion® MG, Neurolief, Ltd; Netanya, Israel). Methods: Episodic and chronic migraine subjects (N=55) were randomized to receive active (n=27) or sham (n=28) treatment. Each subject received an eCOT-NS device and performed a 60 ±20-minute treatment at home within 45 minutes of migraine episode onset. The primary endpoint was the change in mean baseline pain intensity based on VAS pain scores 1 hour after treatment initiation, defined as relative (percent) change. Treatment outcomes assessed at 1, 2 and 24 hours post-treatment initiation were pain-reduction, and proportion of pain-free subjects and treatment responders, defined as ≥50% pain reduction. Categorical pain ratings (none, mild, moderate, and severe pain) were also analyzed. Results: Active stimulation was significantly more effective than sham stimulation for decreasing pain intensity at 1 hour (53% vs.10%), 2 hours (52% vs. 17%) and 24-hours (71% vs. 34%). Pain-free ratings were greater for the active treatment arm at 1 hour (29.2% vs. 16%), 2 hours (41.7% vs. 20%) and 24 hours (65.2% vs. 40%). Subjects with moderate or severe migraine baseline pain who were pain-free at 2 hours was significantly greater among subjects receiving active treatment (43% vs. 10.5%). The responder rate was significantly higher among the active treatment group at 1 hour (67% vs. 20%), 2 hours (66.7% vs. 32%,) and 24 hours (78.3% vs. 48%). Overall headache-relief was significantly higher in the active treatment group at 1 hour (67% vs. 26%) and 2 hours (76% vs. 31.6%). Mild adverse events, reported by a minority of subjects, resolved spontaneously. Conclusions: eCOT-NS provides superior clinically meaningful relief and freedom of migraine pain compared to sham, offering a highly effective and safe non-pharmacological treatment for acute migraine. Trial registration: ClinicalTrials.gov Identifier NCT03398668.
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Headaches are one of the most common medical complaints worldwide, and treatment is often made difficult because of misclassification. Peripheral nerve stimulation has emerged as a novel treatment for the treatment of intractable headaches in recent years. While high-quality evidence does exist regarding its use, efficacy is generally limited to specific nerves and headache types. While much research remains to bring this technology to the mainstream, clinicians are increasingly able to provide safe yet efficacious pain control.
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Functional neurosurgery involves the surgical management of a wide range of neurological diseases with the aim of treating conditions such as movement disorders, spasticity, epilepsy and intractable pain. Functional neurosurgery began with ablative surgical techniques involving destruction of neural structures responsible for the aberrant neural pathways/networks causing pathology. In more recent years there has been a move away from the creation of permanent destructive lesions towards modulation of the neural networks utilizing neuromodulation. Neuromodulation therapies include invasive (e.g. deep brain stimulators, cortical stimulators, vagal nerve stimulators and spinal cord stimulators) and non-invasive (e.g. transcranial magnetic stimulation) approaches that involve the application of electrical stimulation to drive or inhibit neural function within a circuit. Most implantable neuromodulation systems include three primary components: stimulating electrode(s) with contacts at the tip through which electricity is delivered, an implantable pulse generator (IPG) that serves as a signal generator/battery pack, and the extension cable(s) to subcutaneously connect the electrode(s) to the IPG. In this article we primarily focus on the current role of neuromodulation in treating movement disorders, epilepsy and pain, and also consider emerging and evolving applications.
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Background Comparable data on the global and country-specific burden of neurological disorders and their trends are crucial for health-care planning and resource allocation. The Global Burden of Diseases, Injuries, and Risk Factors (GBD) Study provides such information but does not routinely aggregate results that are of interest to clinicians specialising in neurological conditions. In this systematic analysis, we quantified the global disease burden due to neurological disorders in 2015 and its relationship with country development level. Methods We estimated global and country-specific prevalence, mortality, disability-adjusted life-years (DALYs), years of life lost (YLLs), and years lived with disability (YLDs) for various neurological disorders that in the GBD classification have been previously spread across multiple disease groupings. The more inclusive grouping of neurological disorders included stroke, meningitis, encephalitis, tetanus, Alzheimer's disease and other dementias, Parkinson's disease, epilepsy, multiple sclerosis, motor neuron disease, migraine, tension-type headache, medication overuse headache, brain and nervous system cancers, and a residual category of other neurological disorders. We also analysed results based on the Socio-demographic Index (SDI), a compound measure of income per capita, education, and fertility, to identify patterns associated with development and how countries fare against expected outcomes relative to their level of development. Findings Neurological disorders ranked as the leading cause group of DALYs in 2015 (250·7 [95% uncertainty interval (UI) 229·1 to 274·7] million, comprising 10·2% of global DALYs) and the second-leading cause group of deaths (9·4 [9·1 to 9·7] million], comprising 16·8% of global deaths). The most prevalent neurological disorders were tension-type headache (1505·9 [UI 1337·3 to 1681·6 million cases]), migraine (958·8 [872·1 to 1055·6] million), medication overuse headache (58·5 [50·8 to 67·4 million]), and Alzheimer's disease and other dementias (46·0 [40·2 to 52·7 million]). Between 1990 and 2015, the number of deaths from neurological disorders increased by 36·7%, and the number of DALYs by 7·4%. These increases occurred despite decreases in age-standardised rates of death and DALYs of 26·1% and 29·7%, respectively; stroke and communicable neurological disorders were responsible for most of these decreases. Communicable neurological disorders were the largest cause of DALYs in countries with low SDI. Stroke rates were highest at middle levels of SDI and lowest at the highest SDI. Most of the changes in DALY rates of neurological disorders with development were driven by changes in YLLs. Interpretation Neurological disorders are an important cause of disability and death worldwide. Globally, the burden of neurological disorders has increased substantially over the past 25 years because of expanding population numbers and ageing, despite substantial decreases in mortality rates from stroke and communicable neurological disorders. The number of patients who will need care by clinicians with expertise in neurological conditions will continue to grow in coming decades. Policy makers and health-care providers should be aware of these trends to provide adequate services.
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The International Classification of Headache Disorders, second edition (ICHD-II) was the result of 4 years' work by a large number of headache experts from different parts of the world. This article summarizes the main new features of ICHD-II, compared with the original International Headache Society classification: better definition of migraine with aura, inclusion of chronic migraine, inclusion of a number of new primary headaches (SUNCT, hypnic headache, benign thunderclap headache, new daily-persistent headache, hemicrania continua), better definition of the secondary headaches, introduction of medication-overuse headache and of headache attributed to psychiatric disorder. An appendix defines a number of entities for research purposes. The new classification has already been translated into many of the world's major languages and many more are in the pipeline. It is enormously important that headache experts support and encourage the use of the new classification in order to develop a common knowledge base, and that they research ways of further improving it.
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Background: Recent evidence shows that multidisciplinary treatment is effective in chronic pain syndromes, especially in headache disorders. Aim: The aim of this review is to summarize current knowledge on integrative care concepts in headache patients regarding the optimal and necessary treatment parts, optimal duration and setting. Methods: We present a narrative review reporting current literature and personal experience. Results and conclusion: Based on current knowledge, multidisciplinary treatment programs appear to be reasonable and efficient in headache disorders. Sufficient controlled studies regarding the need for individual parts of the integrative care approach are missing as yet. Recommendations are therefore at least partly based on personal experiences. It seems to be unambiguous that patients should be referred to a specialized headache center offering such a program instead of being sent sequentially to various medical specialists. The extent and kind of required therapy (e.g. personal consultation versus group sessions) is not known yet. All patients should learn relaxation training, although it is unclear yet which training is the best for which patient. Physiotherapy with guidance on more activity and individual exercises should be used in all patients. Some patients might benefit from cognitive behavioral therapy. However, therapies often depend more on country-specific health care systems than on clinical needs or scientific data.
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The management of patients with migraine is often unsatisfactory because available acute and preventive therapies are either ineffective or poorly tolerated. The acute treatment of migraine attacks has been limited to the use of analgesics, combinations of analgesics with caffeine, ergotamines, and the triptans. Successful new approaches for the treatment of acute migraine target calcitonin gene-related peptide (CGRP) and serotonin (5-hydroxytryptamine, 5-HT1F) receptors. Other approaches targeting the transient receptor potential vanilloid (TRPV1) receptor, glutamate, GABAA receptors, or a combination of 5-HT1B/1D receptors and neuronal nitric oxide synthesis have been investigated but have not been successful in clinical trials thus far. In migraine prevention, the most promising new approaches are humanised antibodies against CGRP or the CGRP receptor. Non-invasive and invasive neuromodulation approaches also show promise as both acute and preventive therapies, although further studies are needed to define appropriate candidates for these therapies and optimum protocols for their use.
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Because of the epidemiological transition, the global burden of illness has changed. Several factors have contributed to this change, including improvements in maternal and child health, increasing age of populations, and newly recognized disorders of the nervous system. It is now evident that neurologic disorders have emerged as priority health problems worldwide. This is reflected in the Global Burden of Disease Study, jointly published by the World Health Organization and other groups. The proportionate share of the total global burden of disease resulting from neuropsychiatric disorders is projected to rise to 14.7% by 2020. Although neurologic and psychiatric disorders comprise only 1.4% of all deaths, they account for a remarkable 28% of all years of life lived with a disability. This study provides compelling evidence that one cannot assess the neurologic health status of a population by examining mortality statistics alone. Health ministries worldwide must prioritize neurologic disorders, and neurologists must be prepared to provide care for increased numbers of people individually and in population groups.