Cheng, Nan

Abstract Background OnabotulinumtoxinA (BoNT‐A) is an established preventive treatment for chronic migraine but involves 31 to 40 injections per session, often causing discomfort and post‐procedural headaches. Remote electrical neuromodulation (REN) is a noninvasive therapy with efficacy in migraine treatment via conditioned pain modulation but has not been evaluated for procedural pain. This study evaluated REN's effectiveness in reducing acute procedural pain and postprocedural headache associated with BoNT‐A injections. Methods This was an investigator‐initiated single‐center, randomized, single‐blind, sham‐controlled crossover study enrolled 80 adults (aged 22 to 74 years) with chronic migraine undergoing routine BoNT‐A treatment. Each participant received one injection session without a device, followed by sessions using active REN and sham in randomized order. REN was applied to the upper arm 10 min prior to injections and removed after injection completion. Pain intensity was measured using a visual analog scale (0 to 100) at pre‐procedure, intra‐procedure, and post‐procedure time points. The primary outcome was procedural pain intensity, and secondary outcomes included post‐procedural headache incidence and adverse events. Due to clear benefit, the study was terminated early based on predefined stopping criteria. Results Final analysis of 60 participants (mean age 48.0 years; 49/60, 82% female) demonstrated that pre‐procedural pain levels were not significantly different between baseline and the active REN or sham ( p > 0.999 and p = 0.485, respectively). However, during and after BoNT‐A administration, the active REN group reported significantly lower pain scores compared to both the sham and baseline conditions. At intra‐procedure, the REN group experienced a mean pain reduction of 15.0 points ( p < 0.001), and at post‐procedure experienced a 19.1‐point reduction ( p < 0.001). Sham treatment did not result in significant pain reduction compared to baseline ( p > 0.999 for both intra‐procedure and post‐procedure). Additionally, REN lowered the incidence of headache as an adverse event, with only 15% (8/52) of participants experiencing post‐procedural headache compared to 55% (29/53) in the sham group and 39% (23/59) at baseline (odds ratio = 0.28, 95% confidence interval: 0.10 to 0.69, p = 0.008). No additional adverse events were reported. Conclusions REN significantly reduces procedural pain and post‐procedural headache associated with BoNT‐A injections for chronic migraine and may serve as a noninvasive, easily implemented pain management strategy for acute procedural pain. REN represents a promising approach to improving patient comfort during routine migraine treatment as well as reducing post‐procedural headache.

Abstract Objective To examine the effectiveness of treatment strategies for medication‐overuse headache (MOH) in children and adolescents. Background There are no guidelines for the treatment of adult or pediatric patients with MOH. However, research pertaining to MOH in adults is far outpacing research in children and adolescents. Methods A systematic review of evidence on treatment for MOH in children and adolescents was performed via PubMed, Embase, Web of Science, PsycINFO, and Cochrane from database inception to October 2024 for articles with the subject headings and keywords for MOH and pediatric, children, and/or adolescent. Inclusion criteria were: (i) randomized controlled trials and retrospective and prospective observational studies, (ii) children and adolescents aged <18 years with chronic headaches and with medication overuse (MO) or MOH, and (iii) interventions addressing MO or MOH, including pharmacologic and behavioral interventions. At least two independent reviewers screened citations and full‐text articles independently. Results A total of 16 studies (one randomized control trial, six prospective observational studies and nine retrospective observational studies) were identified as meeting final inclusion criteria, resulting in 7978 total participants with a subset of those having MO, MOH or probable MOH. Participants ranged in mean age from 10 to 14.7 years, with 7.1%–46.2% male participants. All the studies recruited patients from an outpatient setting. Interventions used in the studies included withdrawal of the overused acute medication, initiation of preventive medication, patient education, physiotherapy and psychological treatment, and motivational interviewing. Multimodal therapy was studied more than single therapeutic intervention. There was vast heterogeneity across the studies, including study design, diagnostic criteria, intervention type, and outcomes. Conclusion From the data available, there does not seem to be a singular superior treatment approach. Accordingly, the most appropriate treatment modality will need to be tailored to the patient and their caregivers. Further research is required regarding management of MOH in children and adolescents.