Faculty Bibliography

OBJECTIVES: To analyze triptan coverage by insurers to examine (1) possible disparities in coverage for different formulations (oral, intranasal, etc) and (2) quantity limits and stepped care requirements to obtain triptans. BACKGROUND: Triptans are FDA approved migraine abortive medications. Patients frequently state that they have difficulty accessing triptans prescribed to them. METHODS: We searched the 2015 drug formularies of commercial and government health insurers providing coverage in NY State. We created a spreadsheet with all of the commercially available triptans and included information about covered formulations, tier numbers and quantity limits for each drug. We then calculated the number of listed plans that cover or do not cover each triptan or triptan formulation, the total number of medications not covered by an insurance provided across all of its plans, as well as the percentage of plans offered by individual companies and across all companies that covered each drug. We also calculated the number and proportion of plans that imposed quantity limits or step therapy for each drug. RESULTS: Of the 100 formularies searched, generic sumatriptan (all formulations), naratriptan, and zolmitriptan tablets were covered by all plans, and rizatriptan tablets and ODTs were covered by 98% of plans. Brand triptans were less likely to be covered: 4/36 Medicaid plans covered brand triptans. Commercial insurers were more likely to cover brand triptans. All plans imposed quantity limits on 1+ triptan formulations, with >80% imposing quantity limits on 14/19 formulations studied. Almost all plans used tiers for cost allocation for different medications. Generic triptans were almost always in Tier 1. Brand triptans were most commonly in Tier 3. Approximately 40% of brand triptans required step therapy, compared with 11% of generic triptans. CONCLUSIONS: There are substantial variations in coverage and quantity limits and a high degree of complexity in triptan coverage for both government and commercial plans.

This article consists of a Letter to the Editor regarding Post-traumatic headache: the use of the sport concussion assessment tool (SCAT-3) as a predictor of post-concussion recovery, recently published in The Journal of Headache and Pain, along with a response from the original authors.

PurposeThe inhomogeneity of flip angle distribution is a major challenge impeding the application of high-field MRI. We report a method combining spatially selective excitation using generalized spatial encoding magnetic fields (SAGS) with radiofrequency (RF) shimming to achieve homogeneous excitation. This method can be an alternative approach to address the challenge of B1+ inhomogeneity using nonlinear gradients. MethodsWe proposed a two-step algorithm that jointly optimizes the combination of nonlinear spatial encoding magnetic fields and the combination of multiple RF transmitter coils and then optimizes the locations, RF amplitudes, and phases of the spokes. ResultsOur results show that jointly designed SAGS and RF shimming can provide a more homogeneous flip angle distribution than using SAGS or RF shimming alone. Compared with RF shimming alone, our approach can reduce the relative standard deviation of flip angle by 56% and 52% using phantom and human head data, respectively. ConclusionThe jointly designed SAGS and RF shimming method can be used to achieve homogeneous flip angle distributions when fully parallel RF transmission is not available. Magn Reson Med 78:577-587, 2017. (c) 2016 International Society for Magnetic Resonance in Medicine

PURPOSE OF REVIEW: Post-traumatic headache (PTH) is a common headache type after traumatic brain injury (TBI). There are no FDA approved medications for PTH, and it is unknown how medications can affect the brain's ability to recover from TBI. Thus, we sought to examine the biopsychosocial factors that influence PTH and the non-pharmacologic treatments studied for headache treatment. We also sought to determine if there is literature examining whether the non-pharmacologic treatments influence the biopsychosocial factors. The non-pharmacologic treatments assessed included cognitive behavioral therapy (CBT), biofeedback, progressive muscle relaxation therapy (PMR), acupuncture, and physical therapy (PT). RECENT FINDINGS: Factors associated with prognosis in PTH may include the following: severity of TBI, stress, post-traumatic stress disorder, other psychiatric comorbidities, sociocultural and psychosocial factors, litigation, base rate misattribution, expectation as etiology, and chronic pain. There are few high quality studies on the non-pharmacologic treatments for PTH. Thermal and EMG biofeedback appear to have been examined the most followed by CBT. Studies did not have secondary outcomes examining the psychosocial factors related to PTH. Most of the behavioral studies involved a multi-modality intervention limiting the ability to assess the individual non-pharmacologic interventions we sought to study. There were very few randomized clinical trials evaluating the efficacy of non-pharmacologic interventions. Therefore, future research, which considers the noted biopsychosocial factors, is needed in the field to determine if these interventions reduce PTH.