Faculty Bibliography

OBJECTIVE:To report two cases of hemicrania continua (HC) in a mother and daughter. BACKGROUND:HC is a rare primary headache disorder belonging to the family of trigeminal autonomic cephalalgias (TACs). Unlike migraine, familial cases of TACs are rare, and we know relatively little of their inheritance pattern and genetic mechanisms. METHODS:We present a mother and daughter with HC. We compare the similarities and differences between this family and the first report of familial HC and discuss the implications for future studies. RESULTS:Both the mother and daughter presented with a constant, side-locked headache of moderate intensity, with episodic exacerbations of more severe pain that are associated with ipsilateral cranial autonomic activation. After negative workup, both patients were started on indomethacin and achieved absolute response at different doses, confirming HC. CONCLUSIONS:Our report further corroborates other reports of familial TACs that TACs are primary headaches possibly attributable to genetic factors, albeit detailed mechanisms remain elusive. Nevertheless, whether clinical presentation and treatment responses would be substantially different between sporadic and familial HCs remain unclear.

OBJECTIVE:We sought to investigate the patient experience of telemedicine for headache care during the coronavirus disease 2019 (COVID-19) pandemic. BACKGROUND:The use of telemedicine has rapidly expanded and evolved since the beginning of the COVID-19 pandemic. Telemedicine eliminates the physical and geographic barriers to health care, preserves personal protective equipment, and prevents the spread of COVID-19 by allowing encounters to happen in a socially distanced way. However, few studies have assessed the patient perspective of telemedicine for headache care. METHODS:The American Migraine Foundation (AMF) designed a standardized electronic questionnaire to assess the patient experience of telemedicine for headache care between March and September 2020 to help inform future quality improvement as part of its patient advocacy initiative. The date parameters were identified as the emergence of severe acute respiratory syndrome coronavirus 2 disease and the declaration of a national emergency in the United States. The questionnaire was distributed electronically to more than 100,000 members of the AMF community through social media platforms and the AMF email database. RESULTS:A total of 1172 patients responded to our electronic questionnaire, with 1098 complete responses. The majority, 1081/1153 (93.8%) patients, had a previous headache diagnosis prior to the telemedicine encounter. A total of 648/1127 (57.5%) patients reported that they had used telemedicine for headache care during the study period. Among those who participated in telehealth visits, 553/647 (85.5%) patients used it for follow-up visits; 94/647 (14.5%) patients used it for new patient visits. During the telemedicine encounters, 282/645 (43.7%) patients were evaluated by headache specialists, 222/645 (34.4%) patients by general neurologists, 198/645 (30.7%) patients by primary care providers, 73/645 (11.3%) patients by headache nurse practitioners, and 21/645 (3.2%) patients by headache nurses. Only 47/633 (7.4%) patients received a new headache diagnosis from telemedicine evaluation, whereas the other 586/633 (92.6%) patients did not have a change in their diagnoses. During these visits, a new treatment was prescribed for 358/636 (52.3%) patients, whereas 278/636 (43.7%) patients did not have changes made to their treatment plan. The number (%) of patients who rated the telemedicine headache care experience as "very good," "good," "fair," "poor," and "other" were 396/638 (62.1%), 132/638 (20.7%), 67/638 (10.5%), 23/638 (3.6%), and 20/638 (3.1%), respectively. Detailed reasons for "other" are listed in the manuscript. Most patients, 573/638 (89.8%), indicated that they would prefer to continue to use telemedicine for their headache care, 45/638 (7.1%) patients would not, and 20/638 (3.1%) patients were unsure. CONCLUSIONS:Our study evaluating the patient perspective demonstrated that telemedicine facilitated headache care for many patients during the COVID-19 pandemic, resulting in high patient satisfaction rates, and a desire to continue to use telemedicine for future headache care among those who completed the online survey.

Objective: Recurrence of migraine pain and associated symptoms often causes dissatisfaction with acute treatment. Rimegepant is a small molecule calcitonin generelated peptide receptor antagonist with efficacy in migraine; its half-life may provide sustained benefits in acute treatment. The objective of this analysis was to assess the clinical benefits of rimegepant versus placebo through 24 and 48 h postdose.
Method(s): Three double-blind, randomized, placebo-controlled, multicenter trials (Studies 301, 302, 303) were conducted in adults with migraine. Subjects randomized to rimegepant 75 mg tablet (301 & 302), 75 mg ODT (303), or placebo treated a single moderate-severe migraine attack. Endpoints were pain freedom, pain relief, freedom from functional disability, freedom from the most bothersome symptom (MBS), and use of rescue medication.
Result(s): In total, 3507 subjects were evaluated (rimegepant n=1749, placebo n=1758). In pooled results, rimegepant was superior to placebo on sustained pain freedom and pain relief through 24 and 48 h postdose. In Study 303, rimegepant was significantly superior to placebo for sustained freedom from functional disability and the MBS 2-24 and 2-48 h postdose (p<=.0018 for each). Rimegepant was well-tolerated; no individual AEs were reported in >2% of subjects.
Conclusion(s): Rimegepant 75 mg significantly outperformed placebo on a range of endpoints through 48 h postdose. Few rimegepant-treated subjects used rescue medication; tolerability was similar to placebo

Objective: Rimegepant is a small molecule calcitonin gene-related peptide receptor antagonist with demonstrated efficacy in the acute treatment of migraine. Acute treatment is still required by the majority of patients using preventive migraine medication since preventive therapy rarely eliminates all attacks. This analysis was conducted to compare the efficacy of rimegepant with placebo in subjects taking preventive medication.
Method(s): Three double-blind, randomized, placebo-controlled, multicenter trials of identical design (Studies 301, 302, 303) were conducted in adults >=18 years of age with >=1-year history of ICHD 3-beta migraine. Subjects were randomized to rimegepant 75 mg tablet (301 & 302), 75 mg ODT (303), or placebo and instructed to treat a single migraine attack of moderate to severe pain intensity. Subjects receiving preventive migraine medication were eligible if they were on a stable dose regimen for >=3 months prescreening. The coprimary endpoints were pain freedom and freedom from the most bothersome symptom (MBS) at 2 hours.
Result(s): Of 3507 subjects evaluated for efficacy (rimegepant n=1749, placebo n=1758), 547 (15.6%) were using preventive medication (rimegepant n=272, placebo n=275). Pooled 2-hour pain-free rates (95%CIs) for rimegepant and placebo were 20.6% (15.8, 25.4) vs 10.2% (6.6, 13.8); for MBS-free, they were 37.1% (31.4, 42.9) for rimegepant and 20.4% (15.6, 25.1) for placebo. Results from the individual studies were consistent with the pooled results. Rimegepant was well-tolerated, and no individual AEs were reported in >2% of subjects.
Conclusion(s): Among subjects taking concurrent preventive medications in 3 Phase 3 clinical trials, rimegepant was effective for the acute treatment of migraine; tolerability was similar to placebo

OBJECTIVES/OBJECTIVE:To provide a unique perspective on geriatric headache and a number of novel treatment options that are not well known outside of the headache literature. DESIGN/METHODS:Review of the most current and relevant headache literature for practitioners specializing in geriatric care. RESULTS:Evaluation and management of headache disorders in older adults requires an understanding of the underlying pathophysiology and how it relates to age-related physiological changes. To treat headache disorders in general, the appropriate diagnosis must first be established, and treatment of headaches in elderly adults poses unique challenges, including potential polypharmacy, medical comorbidities, and physiological changes associated with aging. CONCLUSION/CONCLUSIONS:The purpose of this review is to provide a guide to and perspective on the challenges inherent in treating headaches in older adults.