Pejic, Jelena

Abstract Objective The goal of this study was to synthesize the evidence on how “status migrainosus” is defined in research studies in comparison to established International Classification of Headache Disorders (ICHD) criteria. Background Current ICHD‐3 criteria define status migrainosus as a headache attack occurring in a patient with a history of migraine with or without aura that is typical of previous attacks except for its duration (>72 h) and severity (debilitating). Despite the ICHD criteria, there are varying inclusion criteria noted in studies enrolling patients with status migrainosus. With this diagnostic uncertainty, there remains difficulty in studying this patient population. Methods This systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta‐Analysis guidelines. Ovid MEDLINE, Ovid EMBASE, All Evidence‐Based Medicine Reviews, the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov , and the World Health Organization International Clinical Trials Registry Platform were searched with the end search date of August 29, 2025. We included studies that were original research focused on status migrainosus, published in English after January 1, 1988, and also included diagnostic criteria to define this condition. The abstracts and full texts were screened by independent reviewers, with a third independent reviewer remaining available to settle disputes. There were 45 studies that underwent full text review, with 19 of these studies included. Data extraction was conducted recording the criteria used to define status migrainosus, headache characteristics, and goals of each study. Results We identified four common domains among studies of status migrainosus, including use of ICHD criteria, headache duration, symptom severity, and treatment response. Reference to ICHD criteria was variable, with only 68% (13/19) of studies specifying an edition of ICHD criteria applied in recruiting or studying patients with status migrainosus. The majority of studies (16/19; 84%) used a headache duration greater than 72 h to define status migrainosus. The use of symptom severity with “debilitating” or “severe” was present in 63% (12/19) of studies and depended on the edition of ICHD criteria that was referenced. Treatment response was rarely used as a condition in defining status migrainosus, with only 15% (3/19) of studies utilizing this stipulation in diagnostic criteria. Conclusion The results of this systematic review show inconsistent application of ICHD criteria in research studies focusing on status migrainosus. These inconsistencies lead to ambiguity in how status migrainosus is defined in the research setting and limit the ability to replicate or compare studies. Guidelines outlining best practices for research of status migrainosus are necessary. For prospective studies, consistent utilization of ICHD criteria is necessary, with potential need to revise these criteria to better reflect the clinical realities of this entity. For retrospective studies, implementation of a standardized International Classification of Diseases code for status migrainosus would be of benefit to improve diagnostic clarity because the current codes are lengthy, cumbersome, and unclear.

Objectives: Tobacco use is a known modifiable risk factor for postoperative complications and revision surgery after anterior cruciate ligament reconstruction (ACLR). Prior studies focus on “tobacco” as a broad categorization of traditional cigarette smoking, smokeless tobacco, and other forms of nicotine use. It is unclear if differences in the type of nicotine used lead to similar adverse outcomes after ACLR. Thus, the purpose of this study was to (1) assess the incidence of postoperative complications among ACLR patients who use smokeless tobacco, and (2) compare these outcomes with those of patients who do not use tobacco and those who smoke cigarettes. Methods: A retrospective cohort study utilizing a large insurance database was conducted. Patients undergoing primary ACLR without concomitant knee procedures with a minimum 2-year follow-up were included. Smokeless tobacco only users, cigarette only users, and non-tobacco users were matched based on demographic variables and comorbidities. Postoperative complications within 90 days of surgery and subsequent knee surgery within 2 years were compared among groups. Multivariable logistic regressions were employed to control for confounding variables. Results: After applying exclusion criteria, there were 241,194 ALCR patients eligible for analysis. Of these, there were 898 (0.37%) patients that used smokeless tobacco only, 22,062 (9.1%) patients that exclusively used cigarettes, and 207,462 (86%) patients that did not use any tobacco products. Compared to non-users, smokeless tobacco users demonstrated increased risk of emergency department (ED) utilization (20.4% vs 8.7%, OR: 6.29; 95% CI: 3.70-10.9, p<0.001), pneumonia (1.2% vs 0.5%, OR: 3.36; 95% CI: 1.41-7.90, p=0.005), and acute kidney injury (AKI) (1.2% vs 0.1%, OR:12.7; 95% CI: 3.77-52.8, p<0.001) within 90 days of surgery. Additionally, smokeless tobacco users had a markedly increased risk of subsequent ACLR (13.5% vs 3.2%, OR: 4.75; 95% CI: 3.60-6.26, p<0.001) and meniscus surgery (12.9% vs 4.9%, OR: 2.89; 95% CI: 2.23-3.73, p<0.001) within 2 years compared to controls. When compared to cigarette smokers, smokeless tobacco users showed increased risk of ED visits (20.6% vs 19.3%, OR: 1.55; 95% CI: 1.25-1.90, p<0.001), pneumonia (1.2% vs 0.6%, OR: 3.25; 95% CI: 1.33-7.78, p=0.008), and AKI (1.3% vs 0.3%, OR: 7.63; 95% CI: 2.72-22.5, p<0.001) within 90 days. They also demonstrated a significantly increased risk of subsequent ACLR (13.4% vs 4.1%, OR: 4.81; 95% CI: 3.58-6.47, p<0.001) and meniscus surgery (12.8% vs 5.5%, OR: 2.45; 95% CI: 2.45-4.26, p<0.001) within 2 years when compared to cigarette smokers. Conclusions: Smokeless tobacco use was associated with increased risk of medical complications, ED utilization, and subsequent procedures compared to non-user controls and traditional smokers. These findings highlight the importance of considering specific forms of tobacco use in preoperative screening for patients undergoing ACLR.

Background: Tobacco use is a known modifiable risk factor for postoperative complications and revision surgery after anterior cruciate ligament reconstruction (ACLR). Previous studies focus on tobacco as a broad categorization of traditional smoking, smokeless tobacco, and other forms of nicotine use. It is unclear if differences in the type of nicotine used lead to similar adverse outcomes after ACLR. Purposes: To (1) assess the incidence of postoperative complications among ACLR patients who use smokeless tobacco and (2) compare these outcomes with those of patients who do not use tobacco and those who smoke tobacco. Study Design: Cohort study; Level of evidence, 3. Methods: A retrospective cohort study utilizing the PearlDiver database was conducted. Patients undergoing primary ACLR with a minimum 2-year follow-up were included. Smokeless tobacco users (n = 898), cigarette smokers (n= 22,062), and non–tobacco users (n= 207,462) were matched based on patient variables and comorbidities. Postoperative complications within 90 days of surgery and subsequent knee surgery within 2 years were compared among groups. Multivariable logistic regressions were used to control for confounding variables. Results: Compared with nonusers, smokeless tobacco users demonstrated an increased risk of pneumonia (odds ratio [OR], 3.36; 95% CI, 1.41-7.90), acute kidney injury (OR, 12.7; 95% CI, 3.77-52.8), and emergency department (ED) utilization (OR, 6.29; 95% CI, 3.70-10.9) within 90 days of the ACLR. Additionally, smokeless tobacco users had an increased risk of ACLR (OR, 4.75; 95% CI, 3.60-6.26) and meniscal surgery (OR, 2.89; 95% CI, 2.23-3.73) within 2 years. When compared with cigarette smokers, smokeless tobacco users showed an increased risk of pneumonia (OR, 3.25; 95% CI, 1.33-7.78), acute kidney injury (OR, 7.63; 95% CI, 2.72-22.5), and ED visits (OR, 1.55; 95% CI, 1.26-1.90) within 90 days and subsequent ACLR (OR, 4.81; 95% CI, 3.58-6.47) and meniscal surgery (OR, 3.23; 95% CI, 2.45-4.26) within 2 years. Conclusion: Smokeless tobacco use was associated with an increased risk of medical complications, ED utilization, and subsequent procedures compared with nonuser controls and traditional smokers. These findings highlight the importance of considering specific forms of tobacco use in preoperative screening for patients undergoing ACLR.