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Procedural Headache Medicine in Neurology Residency Training: A Survey of US Program Directors. - Headache
To survey neurology residency program directors (PDs) on trainee exposure, supervision, and credentialing in procedures widely utilized in headache medicine.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.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).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.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.Â© 2015 American Headache Society.
Systematic Review of Preventive and Acute Treatment of Menstrual Migraine. - Headache
The aim of this systematic review is to identify the efficacy of different categories of treatments for menstrual migraines as found in randomized controlled trials or open label studies with similar efficacy endpoints.Menstrual migraine is very common and approximately 50% of women have increased risk of developing migraines related to the menstrual cycle. Attacks of menstrual migraine are usually more debilitating, of longer duration, more prone to recurrence, and less responsive to acute treatment than nonmenstrual migraine attacks.Search for evidence was done in 4 databases that included PubMed, EMBASE, Science Direct, and Web of Science. Eighty-four articles were selected for full text review by 2 separate readers. Thirty-six of the 84 articles were selected for final inclusion. Articles included randomized controlled and open label trials that focused on efficacy of acute and preventative therapies for menstrual migraine. Secondary analyses where excluded because the initial study population was not women with menstrual migraine.After final screening, 11 articles were selected for acute and 25 for preventive treatment of menstrual migraine. These were further subdivided into treatment categories. For acute treatment: triptans, combination therapy, prostaglandin synthesis inhibitor, and ergot alkaloids. For preventive treatment: triptans, combined therapy, oral contraceptives, estrogen, nonsteroidal anti-inflammatory drug, phytoestrogen, gonadotropin-releasing hormone agonist, dopamine agonist, vitamin, mineral, and nonpharmacological therapy were selected. Overall, triptans had strong evidence for treatment in both acute and short term prevention of menstrual migraine.Based on this literature search, of all categories of treatment for menstrual migraine, triptans have the most extensive research with strong evidence for both acute and preventive treatment of menstrual migraine. Further randomized controlled trials should be performed for other therapies to strengthen their use in the care of menstrual migraine patients.Â© 2015 American Headache Society.
Diagnose and adios: practical tips for the ongoing evaluation and care of TAC patients taking indomethacin. - Current pain and headache reports
Paroxysmal hemicrania and hemicrania continua are primary headache disorders characterized by unilateral attacks of severe pain around the orbit with associated autonomic features. They are unique in their absolute response to indomethacin. Diagnosis is made when patients with suspected paroxysmal hemicrania or hemicrania continua have the resolution of headache with therapeutic doses of indomethacin. Once diagnosis is made, limited data exists on the ongoing management of these patients. For patients who do not tolerate indomethacin, or wish to come off medication, there remain few options. This article will discuss the diagnosis of paroxysmal hemicrania and hemicrania continua and the ongoing management of patients on indomethacin, as well as options for patients who do not tolerate or need to come off indomethacin.
Migraine and patent foramen ovale. - Current neurology and neuroscience reports
Migraine is a widespread disorder with a large impact on society. Patent foramen ovale (PFO) is a common occurrence, affecting about 25 % of the population. Observational studies report PFO to be more prevalent in patients with migraine with aura, and patients with migraine with aura have a higher incidence of PFO. The only population-based study does not support this link. It is possible that an association exists between large-sized PFO and migraine. This association may explain how migraine with aura can be triggered. Numerous studies have reported improved migraine with PFO closure, but the only prospective placebo-controlled trial aimed at closure of PFO in patients with migraine with aura did not support this. At this time, evidence does not support the routine detection and closure of PFO in patients with migraine.
Expert consensus recommendations for the performance of peripheral nerve blocks for headaches--a narrative review. - Headache
To describe a standardized methodology for the performance of peripheral nerve blocks (PNBs) in the treatment of headache disorders.PNBs have long been employed in the management of headache disorders, but a wide variety of techniques are utilized in literature reports and clinical practice.The American Headache Society Special Interest Section for PNBs and other Interventional Procedures convened meetings during 2010-2011 featuring formal discussions and agreements about the procedural details for occipital and trigeminal PNBs. A subcommittee then generated a narrative review detailing the methodology.PNB indications may include select primary headache disorders, secondary headache disorders, and cranial neuralgias. Special procedural considerations may be necessary in certain patient populations, including pregnancy, the elderly, anesthetic allergy, prior vasovagal attacks, an open skull defect, antiplatelet/anticoagulant use, and cosmetic concerns. PNBs described include greater occipital, lesser occipital, supratrochlear, supraorbital, and auriculotemporal injections. Technical success of the PNB should result in cutaneous anesthesia. Targeted clinical outcomes depend on the indication, and include relief of an acute headache attack, terminating a headache cycle, and transitioning out of a medication-overuse pattern. Reinjection frequency is variable, depending on the indications and agents used, and the addition of corticosteroids may be most appropriate when treating cluster headache.These recommendations from the American Headache Society Special Interest Section for PNBs and other Interventional Procedures members for PNB methodology in headache disorder treatment are derived from the available literature and expert consensus. With the exception of cluster headache, there is a paucity of evidence, and further research may result in the revision of these recommendations to improve the outcome and safety of these interventions.Â© 2013 American Headache Society.
Tension-type headache and women: do sex hormones influence tension-type headache? - Current pain and headache reports
Most of the world's population has suffered from a tension-type headache (TTH) at some point in their lives. The pathophysiology of this disease is not well understood, but TTH shares many features with migraine, leading to the belief that TTH and migraine may be on different ends of the same disease spectrum. There are many shared triggers between migraine and TTH, menstruation being one of them. Does menses being a trigger for TTH make TTH more like migraine, or does the role of sex hormones in TTH give us insight into the unique pathophysiology of this disease? This article will review TTH, concentrating on the role of sex hormones as a trigger for TTH.
Chronic tension-type headache. - Current pain and headache reports
Tension-type headache is the most common headache type worldwide. Chronic tension-type headache (CTTH) affects 2% to 3% of patients, yet it represents the least talked about subtype of chronic daily headache. There is much debate in the headache community on whether CTTH exists as its own entity or is a milder form of chronic migraine (CM), because there are similarities and differences between the two headache forms. This article reviews CTTH, as well as the current pathophysiology and treatment, and discusses controversial issues in the diagnosis of CTTH and CM.
The role of nerve blocks and botulinum toxin injections in the management of cluster headaches. - Current pain and headache reports
Cluster headache (CH) is a primary headache syndrome that is classified with the trigeminal autonomic cephalalgias. CH treatment involves three steps: acute attack management, transitional therapy, and preventive therapy. Greater occipital nerve block has been shown to be an effective alternative bridge therapy to oral steroids in CH. Botulinum toxin type A has recently been studied as a new preventive treatment for patients with chronic CH, with limited success.
The Sphenopalatine Ganglion: Anatomy, Pathophysiology, and Therapeutic Targeting in Headache. - Headache
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.Â© 2015 American Headache Society.
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