Robbins, Matthew S.

Headache disorders are among the most common and disabling medical conditions worldwide. Pharmacologic acute and preventive treatments are often insufficient and poorly tolerated, and the majority of patients are unable to adhere to their migraine treatments due to these issues. With improvements in our understanding of migraine and cluster headache pathophysiology, neuromodulation devices have been developed as safe and effective acute and preventive treatment options. In this review, we focus on neuromodulation devices that have been studied for migraine and cluster headache, with special attention to those that have gained food and drug administration (FDA) clearance. We will also explore how these devices can be used in patients who might have limited pharmacologic options, including the elderly, children, and pregnant women.

Objectives To describe and analyze Twitter activity associated with American Headache Society (AHS) conferences and evaluate the potential for Twitter to promote education and public outreach. Background Many medical and scientific conferences have adopted Twitter as a method of promoting discussion among attendees as well as increasing visibility. Relatively little is known, however, about the composition of conference Twitter activity, the participants, and the impact on broader Twitter discussions. Methods We analyzed Twitter data from 5 AHS conferences held from 2014 to 2016 using their respective hashtags. Using the Symplur Healthcare Hashtags open social media search platform, we gathered data on numbers of tweets, impressions, participants, and mentions during a 10‐day period surrounding each conference, as well as samples of Twitter accounts participating. Prominent accounts were categorized as individual medical professionals, other individuals, host organizations, health‐related organizations, medical centers, and industry by cross‐checking their Twitter profiles and conference registration lists. Larger samples of accounts participating in the 2016 conferences were also obtained and categorized similarly, with individual person accounts classified by conference registration status. A related prominent hashtag (#migraine) was also identified and Twitter usage before, during, and after each conference was analyzed to evaluate the impact of conference activity on broader Twitter conversations. Results Nineteen thousand nine hundred thirty‐six tweets were generated across the 5 conferences, with 11,531 (58%) created by the Top 10 participating accounts in each conference, which were primarily individual medical professionals and host organizations. Thirty‐two million six hundred eighty‐three thousand impressions were generated across the 5 conferences, with 24,656,000 (75%) coming from the Top 10 participants in each, particularly host organizations and other individuals. An average of 331 accounts participated in each conference. The Top 10 mentioned accounts in each conference (consisting of 21 unique accounts with 14 accounts in the Top 10 across multiple conferences, primarily individual medical professionals) received a total of 15,093 mentions. Among 135 unique accounts participating actively in the two 2016 conferences, 39% were individual medical professionals, 38% other individuals, 16% health‐related organizations (including the 2 host organizations), 4% medical centers, and 2% industry. From these samples, 34 of 70 (49%) and 43 of 66 (65%) individual person accounts participating in the Twitter discussion at each conference were not registered conference attendees, indicating substantial outside participation via Twitter. #migraine usage during conferences showed a significant increase from baseline in number of tweets (6080 in a 10‐day period vs 3721, P < .0001) and participants (2332 vs 1830, P < .0001) but the increase was not significant for impressions (30,155 vs 25,361, P = .240). Conclusions Consistent with the dynamics of Twitter conversations on other topics, AHS conference discussions featured a small group of accounts creating the bulk of content, with individual medical professionals and host organizations generating the largest shares of tweets and mentions while host organizations and other individuals produced the most impressions. Participating accounts were mainly individuals and health‐related organizations, with more non‐attendee participants than expected. Conference Twitter activity correlated with a significant increase in #migraine usage, suggesting a perceptible influence on the discussion of health‐related topics beyond the conference itself.

Objective To evaluate the efficacy and tolerability of single pulse transcranial magnetic stimulation (sTMS) for the preventive treatment of migraine. Background sTMS was originally developed for the acute treatment of migraine with aura. Open label experience has suggested a preventive benefit. The objective of this trial was to evaluate the efficacy and tolerability of sTMS for migraine prevention. Methods The eNeura SpringTMS Post-Market Observational U.S. Study of Migraine (ESPOUSE) Study was a multicenter, prospective, open label, observational study. From December 2014 to March 2016, patients with migraine (n = 263) were consented to complete a 1-month baseline headache diary followed by 3 months of treatment. The treatment protocol consisted of preventive (four pulses twice daily) and acute (three pulses repeated up to three times for each attack) treatment. Patients reported daily headache status, medication use, and device use with a monthly headache diary. The primary endpoint, mean reduction of headache days compared to baseline, was measured over the 28-day period during weeks 9 to 12. The primary endpoint was compared to a statistically-derived placebo estimate (performance goal). Secondary endpoints included: 50% responder rate, acute headache medication consumption, HIT-6, and mean reduction in total headache days from baseline of any intensity. Results Of a total of 263 consented subjects, 229 completed a baseline diary, and 220 were found to be eligible based on the number of headache days. The device was assigned to 217 subjects (Safety Data Set) and 132 were included in the intention to treat Full Analysis Set. For the primary endpoint, there was a −2.75 ± 0.40 mean reduction of headache days from baseline (9.06 days) compared to the performance goal (−0.63 days) ( p < 0.0001). The 50% responder rate of 46% (95% CI 37%, 56%) was also significantly higher ( p < 0.0001) than the performance goal (20%). There was a reduction of −2.93 (5.24) days of acute medication use, headache impact measured by HIT-6, −3.1 (6.4) ( p < 0.0001), and total headache days of any intensity −3.16 days (5.21) compared to the performance goal (−0.63 days) ( p < 0.0001). The most common adverse events were lightheadedness (3.7%), tingling (3.2%), and tinnitus (3.2%). There were no serious adverse events. Conclusions This open label study suggests that sTMS may be an effective, well-tolerated treatment option for migraine prevention. Trial registration number NCT02357381

Background Cluster headache (CH), the most common trigeminal autonomic cephalalgia, is an extremely debilitating primary headache disorder that is often not optimally treated. New evidence‐based treatment guidelines for CH will assist clinicians with identifying and choosing among current treatment options. Objectives In this systematic review we appraise the available evidence for the acute and prophylactic treatment of CH, and provide an update of the 2010 American Academy of Neurology (AAN) endorsed systematic review. Methods Medline, PubMed, and EMBASE databases were searched for double‐blind, randomized controlled trials that investigated treatments of CH in adults. Exclusion and inclusion criteria were identical to those utilized in the 2010 AAN systematic review. Results and Recommendations For acute treatment, sumatriptan subcutaneous, zolmitriptan nasal spray, and high flow oxygen remain the treatments with a Level A recommendation. Since the 2010 review, a study of sphenopalatine ganglion stimulation was added to the current guideline and has been administered a Level B recommendation for acute treatment. For prophylactic therapy, previously there were no treatments that were administered a Level A recommendation. For the current guidelines, suboccipital steroid injections have emerged as the only treatment to receive a Level A recommendation with the addition of a second Class I study. Other newly evaluated treatments since the 2010 guidelines have been given a Level B recommendation (negative study: deep brain stimulation), a Level C recommendation (positive study: warfarin; negative studies: cimetidine/chlorpheniramine, candesartan), or a Level U recommendation (frovatriptan). Conclusions This AHS guideline can be utilized for understanding which therapies have superiority to placebo or sham treatment in the management of CH. In clinical practice, these recommendations should be considered in concert with other variables including safety, side effects, patient preferences, clinician experience, cost, and the invasiveness of the intervention. Given the lack of Class I evidence and Level A recommendations, particularly for a number of commonly used preventive therapies, further studies are warranted to demonstrate safety and efficacy for established and emerging therapies.

The sphenopalatine ganglion (SPG) has attracted the interest of practitioners treating head and face pain for over a century because of its anatomical connections and role in the trigemino‐autonomic reflex. In this review, we discuss the anatomy of the SPG, as well as what is known about its role in the pathophysiology of headache disorders, including cluster headache and migraine. We then address various therapies that target the SPG, including intranasal medication delivery, new SPG blocking catheter devices, neurostimulation, chemical neurolysis, and ablation procedures.

Objective To survey neurology residency program directors (PDs) on trainee exposure, supervision, and credentialing in procedures widely utilized in headache medicine. Background Clinic‐based procedures have assumed a prominent role in headache therapy. Headache fellows obtain procedural competence, but reliance on fellowship‐trained neurologists cannot match the population eligible for treatments. The inclusion of educational modules and mechanisms for credentialing trainees pursuing procedural competence in residency curricula at individual programs is not known. Methods A web‐based survey of US neurology residency PDs was designed by the American Headache Society (AHS) procedural special interest section in collaboration with AHS and American Academy of Neurology's Headache and Facial Pain section leadership. The survey addressed exposure, training, and credentialing in: (1) onabotulinumtoxinA (onabotA) injections, (2) extracranial peripheral nerve blocks (PNBs), and (3) trigger point injections (TPIs). Results Fifty‐five PDs (42.6%) completed the survey. Compared to noncompleters, survey completers were more likely to feature headache fellowships at their institutions (38.2% vs 10.8%, P =0.0002). High exposure (onabotA=90.9%, PNBs=80.0%, TPIs=70.9%) usually featured hands‐on patient instruction (66.2%) and lectures (55.7%). Supervised performance rates were high (onabotA=65.5%, PNBs=60.0%, TPIs=52.7%), usually in continuity clinic (60.0%) or headache elective (50.9%). Headache specialists (69.1%) or general neurology (32.7%) faculty most commonly trained residents. Formal credentialing was uncommon (16.4‐18.2%), mostly by documenting supervised procedures (25.5%). Only 27.3% of programs permitted trainees to perform procedures independently. Most PDs felt procedural exposure (80.0‐90.9%) and competence (50.9‐56.4%) by all trainees was important. Conclusions Resident exposure to procedures for headache is high, but credentialing mechanisms, while desired by most PDs, are not generally in place. Implementation of a credentialing process may ensure trainees enter practice with the ability to perform procedures safely and effectively.