Robertson, Carrie E

Abstract Objectives/Background The intent of this review is to provide practical guidance for trainees considering a headache medicine fellowship and examine key factors that contribute to program selection. Headache medicine continues to gain appeal as a neurologic subspecialty, and the number of headache fellowship programs across the country has paralleled that growth. Residents who develop interest in the field must decide whether to pursue fellowship for more specialized training. Establishing a framework for navigating this process can help trainees better evaluate programs and make informed decisions. Methods This narrative review was conducted as an initiative by the New Investigators and Trainees Special Interest Group of the American Headache Society in collaboration with a group of academic leaders and headache clinicians who participated in headache fellowship and/or the match process. Topics were selected based on themes identified in existing literature on fellowship selection across other disciplines. Headache‐specific information was obtained from a review of literature on headache education and fellowship, along with relevant professional society and program institution websites. This information was supplemented by the authors' perspectives when available evidence was limited. Results Physicians choose headache medicine for various reasons. This career path derives from inspiration through mentorship received during residency, exposure to a diverse patient population during training, and the desire to provide new therapies and procedural interventions. Headache medicine fellowships offer structured and in‐depth training through clinical, educational, professional, and scholarly activities. Programs may vary in size, structure, support, and patient care settings. These factors can help trainees decide whether to pursue fellowship and what to evaluate in different programs. Conclusion This review identifies key factors in pursuing a headache medicine fellowship, allowing trainees to seek programs that support professional interests and career aspirations.

Background Facial synkinesis is characterized by involuntary co-contraction of facial muscles during voluntary movements, impairing both function and aesthetics following facial paralysis. It affects approximately 21% of individuals following Bell's palsy, with symptoms such as involuntary eye closure when smiling. While the pathophysiology remains unclear, therapeutic options range from conservative approaches like botulinum toxin to surgical interventions. A bibliometric analysis offers insights into research trends, key contributors, and knowledge gaps in this field. Materials & Methods A systematic search was conducted in the Scopus database up to July 2024, identifying 100 most-cited articles on facial synkinesis. Articles were categorized as basic science (BSc), clinical (CL), or review articles, with additional data extracted on study focus, journal type, citation metrics, and authorship. Statistical analyses included Pearson's χ2 and Wilcoxon rank sum tests. Results The articles spanned 1952–2020, with the highest publication frequency in 2017. Clinical studies constituted 76%, focusing on conservative treatments (35%), diagnostics (28%), and surgical interventions (19%). Plastic surgery and ENT journals accounted for 76% of publications. The most-cited article, published in neurology (1975), investigated electrophysiologic diagnostics. Citation metrics revealed a mean citation count of 38.3 and a median publication year of 2010. The 50 newer articles demonstrated a trend toward surgical management of synkinesis. Conclusions This bibliometric analysis highlights the evolution of research on facial synkinesis, emphasizing the predominance of clinical studies, focus on conservative treatments and gaps in basic science research. Further research is needed to fill knowledge gaps to improve outcomes for affected patients.

Summary: Facial synkinesis manifests as involuntary muscle movements alongside volitional facial actions and is typically managed with a combination of neuromuscular retraining, botulinum toxin injections, and in some cases, selective neurectomy. Some patients with synkinesis describe persistent neck tightness or pain at the level of the mandibular angle and horizontally towards the midline, similar to the anatomic course of the posterior belly of digastric (PBD) and stylohyoid muscles. There are limited studies exploring the involvement of the PBD and stylohyoid muscles in facial synkinesis and the use of chemodenervation as treatment. Herein, we present 2 patients with facial synkinesis and ipsilateral neck tightness and pain who underwent novel surgical treatment in the form of the standard selective neurectomy procedure along with a myectomy of the PBD and stylohyoid muscles. Following completion of the standard steps of selective neurectomy, the PBD and stylohyoid muscles were carefully dissected and separated from the surrounding structures. Both muscles were divided using bipolar electrocautery. Both patients reported improvement of neck pain and tightness immediately after the intervention and at the 6.5-month follow-up visit. These preliminary results show promise in aiding a subset of patients with synkinesis-related neck pain and tightness.

Abstract Objective To identify and disseminate research priorities for the headache field that should be areas of research focus during the next 10 years. Background Establishing research priorities helps focus and synergize the work of headache investigators, allowing them to reach the most important research goals more efficiently and completely. Methods The Headache Research Priorities organizing and executive committees and working group chairs led a multistakeholder and international group of experts to develop headache research priorities. The research priorities were developed and reviewed by clinicians, scientists, people with headache, representatives from headache organizations, health‐care industry representatives, and the public. Priorities were revised and finalized after receiving feedback from members of the research priorities working groups and after a public comment period. Results Twenty‐five research priorities across eight categories were identified: human models, animal models, pathophysiology, diagnosis and management, treatment, inequities and disparities, research workforce development, and quality of life. The priorities address research models and methods, development and optimization of outcome measures and endpoints, pain and non‐pain symptoms of primary and secondary headaches, investigations into mechanisms underlying headache attacks and chronification of headache disorders, treatment optimization, research workforce recruitment, development, expansion, and support, and inequities and disparities in the headache field. The priorities are focused enough that they help to guide headache research and broad enough that they are widely applicable to multiple headache types and various research methods. Conclusions These research priorities serve as guidance for headache investigators when planning their research studies and as benchmarks by which the headache field can measure its progress over time. These priorities will need updating as research goals are met and new priorities arise.

Background: Dynamic facial reanimation is the gold standard treatment for a paralyzed face. The use of the cross-face nerve graft (CFNG) in combination with the masseteric nerve to innervate the free gracilis muscle has been reported to provide both spontaneity and strong neural input. We report a case series of dual innervation, using a novel method where the branch to masseter is coapted to the side of the CFNG. Methods: Eight patients received free gracilis muscle transfer using the new dual innervation method between September 2014 and December 2017. The CFNG, which was performed nine months prior, was sutured in an end-to-end fashion to the obturator nerve. A nerve graft was coapted to the ipsilateral masseteric nerve and then sutured in an end-to-side fashion to the CFNG proximal to its coaptation to the obturator nerve. Results: All patients recovered smile function with and without teeth clenching around the same time period. Smiles without teeth clenching appeared later in two of eight patients and earlier in one of eight patients, being noted at an average of 8.25 months of follow-up versus 7.6 months. The estimate of true attainment is limited by the spacing of follow-up dates. Average follow-up time was 36.07 months (range: 10–71.5). FACE-Gram software smile analysis with and without biting demonstrated similar excursion on average (7.64 mm versus 8.6 mm respectively, P = 0.93), both of which are significantly improved from preoperation. Conclusion: This novel method of a dual-innervated free gracilis muscle transfer offers a viable technique that achieves a symmetric, strong, and emotional smile.

Abstract Objectives/Background Treatment of migraine in the setting of either renal or hepatic disease can be daunting for clinicians. Not only does the method of metabolism have to be considered, but also the method of elimination/excretion of the parent drug and any active or toxic metabolites. Furthermore, it is difficult to think about liver or kidney disease in isolation, as liver disease can sometimes contribute to impaired renal function and renal disease can sometimes impair hepatic metabolism, through the cytochrome P450 system. Methods A detailed search for terms related to liver disease, renal disease, and migraine management was performed in PubMed, Ovid Medline, Embase, and the Cochrane Library.For each medication, product labels were retrieved and reviewed using the US FDA website, with additional review of IBM Micromedex, LiverTox, and the Renal Drug Handbook. Results This manuscript provides an overview of migraine drug metabolism and how it can be affected by liver and renal impairment. It reviews the standard terminology recommended by the US Food and Drug Administration for the different stages of hepatic and renal failure. The available evidence regarding the use of abortive and preventative medicines in the setting of organ failure is discussed in detail, including more recent therapies such as lasmiditan, gepants, and calcitonin gene‐related peptide antibodies. Conclusions For acute therapy, the use of NSAIDS should be limited, as these carry risk for both severe hepatic and renal disease. Triptans can be selectively used, often with dose guideline adjustments. Ubrogepant may be used in severe hepatic disease with dose adjustment and lasmiditan can be used in end stage renal disease. Though non‐medicine strategies may be the most reasonable initial approach, many preventative medications can be used in the setting of hepatic and renal disease, often with dose adjustment. This review provides tables of guidelines, including reduced dosing recommendations, for the use of abortive and preventative migraine medications in hepatic and renal failure.

Abstract OBJECTIVE Using individual pharmacogenomic phenotypes to investigate the factors affecting the efficacy and tolerability of verapamil for migraine prevention. BACKGROUND Verapamil has a wide range of dosing in headache disorders without reliable tools to predict the optimal doses for an individual. METHODS This is a retrospective chart review examining adults with existing pharmacogenomic reports at Mayo Clinic who had used verapamil for migraine. Effects of six cytochrome P450 phenotypes on the minimum effective and maximum tolerable verapamil doses for migraine prevention were assessed. RESULTS The mean minimum effective and maximum tolerable doses for the 33 patients in final analysis were 178.2(20–320) mg and 227.9(20–480) mg. A variety of CYP2C9, CYP2D6, and CYP3A5 phenotypes were found, without significant association with the verapamil doses after adjusting for age, sex, body mass index, and smoking status. CONCLUSIONS We demonstrated a wide range of effective and tolerable verapamil doses used for migraine in a cohort with various pharmacogenomic phenotypes.

Abstract Objective To provide an overview of the current available literature on peripheral nerve blocks for the management of migraine and other headache disorders in adults. Background Peripheral nerve blocks have been commonly performed in the headache practice for migraine, cluster headache, occipital neuralgia, and other headache disorders, despite a paucity of evidence supporting their use historically. In the past decade, there has been an effort to explore the efficacy and safety of peripheral nerve blocks for the management of headache, with the greatest interest centered around greater occipital blocks. Design We performed a search in PubMed using key words including “occipital nerve blocks,” “peripheral nerve blocks,” “occipital nerve,” “migraine,” “cluster headache,” and “neuralgia.” We reviewed the randomized controlled trials (RCTs), observational studies, and case series, and summarized the anatomy, techniques, and the evidence for the use of peripheral nerve blocks in different headache disorders, with particular focus on available RCTs. Case reports were included for a detail review of adverse events. Results Of 12 RCTs examining the use of greater occipital nerve blocks for migraine, all but one demonstrate efficacy with reduction in headache frequency, intensity, and/or duration compared to placebo. Studies have not demonstrated a difference in clinical outcomes with the use of corticosteroids for nerve blocks compared to blocks with local anesthetic in the treatment of migraine. There are two RCTs supporting the use of greater occipital blockade for cluster headache, both showing benefit of suboccipitally injected corticosteroid. One RCT suggests benefit of greater occipital nerve blocks for cervicogenic headache. Observational studies and case series/reports show that greater occipital nerve block may be effective in prolonged migraine aura, status migrainosus, post‐dural puncture headache, and occipital neuralgia. Overall, peripheral nerve blocks are well tolerated. Serious side effects are rare but have been reported, including acute cerebellar syndrome and infection. Conclusions Peripheral nerve blocks, especially occipital nerve blocks, are a viable treatment option for migraine and may be helpful in cluster headache as a transitional therapy or rescue therapy. Additional prospective studies are needed to investigate the efficacy and safety of occipital nerve blocks for long‐term migraine prevention, as well as for other headache disorders, such as occipital neuralgia.