Real world preventative drug management of migraine among Spanish neurologists

BACKGROUND: Many different preventatives have showed efficacy in the treatment of migraine. National guidelines differ in their recommendations and patients' characteristics are usually taken into account in their selection. In Spain, real life use of preventive therapies seems to be heterogeneous. We aimed to evaluate differences in clinical practice and adherence to national guidelines among Spanish neurologists. METHODS: Observational descriptive study. A survey was conducted among neurologists ascribed to the Spanish Society of Neurology. Participants were differentiated in accordance with their dedication to headache disorders. We analysed socio-demographic parameters and evaluated 43 questions considering migraine management as well as therapeutic choices regarding migraine sub-types and finally, neurologists' personal perception. RESULTS: One hundred fifty-five neurologists participated from 17 different regions, 43.4% of them female and 53.3% under 40¿years of age. 34.9% confirmed headache disorders as their main interest. The first choice for preventive therapy in chronic migraine among participants was topiramate (57%) followed by amytriptiline (17.9%) and beta-blockers (14.6%). However in episodic migraine, the preferred options were beta-blockers (47.7%), topiramate (21.5%) and amytriptiline (13.4%). Regarding perceived efficacy, topiramate was considered the best option in chronic migraine (42.7%) followed by onabotulinumtoxinA (25.5%) and amitryptiline (22.4%). Where episodic migraine was concerned, surveyed neurologists perceived topiramate (43.7%) and beta-blockers (30.3%) as the best options. When we evaluated the duration of treatment use with a view to adequate therapeutic response, 43.5% of neurologists preferred 3¿months duration and 39.5% were in favour of 6¿months duration in episodic migraine. However, considering the preferred duration of treatment use in chronic migraine, 20.4% recommended 3¿months, 42.1% preferred 6¿months and 12.5% and 22.4% opted for 9 and 12¿months respectively. When considering onabotulinumtoxinA therapy, the number of prior therapeutic failures was zero in 7.2% of neurologists, one in 5.9%, two in 44.1%, three in 30.9% and four or more in 11.9%. Following an initial treatment failure with onabotulinumtoxinA, 49% of subjects decided against a second treatment. The number of OnabotA procedures before considering it as ineffective was two in 18.9% of neurologists, three in 70.8% and four in 10.4%. CONCLUSIONS: The initial management of migraine among Spanish Neurologists is in line with most guidelines, where first choice preventative drugs are concerned. The Management of episodic migraine differed from chronic migraine, both in terms of neurologist preference and in their perceived efficacy

Real-world preventative drug management of Chronic Migraine among Spanish Neurologists

O42 Background: In migraine, the therapeutic preventive drug arsenal is varied. Whenprescribing both Guidelines and patient characteristics are taken intoaccount. In Spain, the use of preventive therapies seems to beheterogeneous.The objective of this study was to evaluate real-life clinical prescribingpractice amongst neurologists in Spain Methods: Observational descriptive study done with a survey by Neurologistsof the Spanish Neurological Society (SEN). Neurologists who participatedwere divided into Headache Specialists or not. The followingdata was collected: socio-demographic data, ; preventive treatmentand choices different migraine sub-types, and their personal perceptionof efficacy and tolerability to different drugs. Results: We analyzed 152 surveys from neurologists around our country.From them: 43.4% were female, 53.3% <40 years, and 34.9% were interestedin headache .In regards to preventive treatment choice; in chronic migraine topiramate(57%) amytriptiline (17.9%) and beta-blockers (14.6%), whereasin episodic migraine the preferred drugs were beta-blockers (47.7%), topiramate (21.5%) and amytriptiline (13.4%).Regarding perceived efficacy, topiramate was considered the bestoption in chronic migraine (42.7%) followed by onabotulinumtoxinA(25.5%) and amitryptiline (22.4%). In episodic migraine, neurologistpreferred topiramate (43.7%) and beta-blockers (30.3%).Regarding the duration of preventive therapy when improvementwas achieved, when treating episodic migraine 43.5% of the surveyedneurologists recommended 3 months and 39.5% preferred 6months. When they treated chronic migraine, 20.4% of neurologistsrecommended 3 months, 42.1% 6 months, 12.5% 9 months and22.4% preferred to maintain treatment during 12 months.When considering onabotulinumtoxinA treatment, the number ofprior therapeutical failures was cero in 7.2% of surveyed, one in5.9%, two in 44.1%, three in 30.9%, and four or more in 11.9%. Theincrease of OnabotulinumtoxinA dose up to 195 UI was consideredby 51% of neurologists after a first ineffective procedure, by 42.2% after two injections, and by 83% after a third infiltration. Surveyedcolleagues admitted to take into account in their decisions mainlypatient comorbidities (70.2%) rather than guidelines (13.9%). Conclusions: Initial management of Migraine among Spanish Neurologists is madewith the preventative drugs which are considered as first choices inmost of the guidelines. Management of episodic migraine differedfrom chronic migraine, both in the order or drugs and the perceptionof the most effective therapy

PrevenBox: Evaluation of concomitant use of preventive medications with OnabotulinumtoxinA in migraine

P114 Background: OnabotulinumtoxinA is an effective, tolerable and safepreventive treatment for chronic migraine (CM). Other than a reduc-tion in headache frequency or disability, in CM the withdrawal ofconcomitant preventive medication indicates treatment effectivenessand quality of life improvement. Objective: To characterize the change in the use of oral preventivemedication after treatment with OnabotulinumtoxinA in patientswith migraine. Methods: This is a multicentre study. We consecutively included pa-tients with migraine (ICHD-3) that were on preventive treatment withOnabotulinumtoxinA. We retrospectively collected demographic data, diagnosis of migraine, frequency and intensity changes, number ofcycle and OnabotulinumtoxinA dose. In addition, we listed the initialand current preventive treatment (number of drugs and group) andthe number and cycle of medications withdrawn. We performed aunivariate and logistic regression analysis. Results: We included 542 patients: 87.6% women, mean age 47.6 ±11.7 years. A 89.3% had chronic migraine and 10.8% had high fre-quency episodic migraine. The mean reduction in frequency aftertreatment was 13.4±8.2 headache days/month. At baseline, a 91.3%took other preventives and during treatment with Onabotulinumtox-inA a 58.6% withdrew at least one drug, 25.8% stopped completelyall oral preventive drugs. Factors associated with withdrawal were:being male, having >50% response in frequency and intensity, thenumber of infiltrations and a shorter chronification period until thefirst OnabotulinumtoxinA administration (p <0.05). The multivariateanalysis showed that a better response in intensity (OR:1.8 [1.4-2.2], p<0.001), a greater number of infiltrations (OR:1.1 [1.0-1.2], p<0.001)and a shorter chronification period (OR:0.994 [0.992-0.997], p<0.001)were predictors of withdrawal. The ROC curve, showed that 6 Onabo-tulinumtoxinA cycles was the cut-off point that better predicted oralpreventive medication withdrawal (p <0.001). Conclusions: Treatment with OnabotulinumtoxinA reduces the use ofother preventive medications for migraine. The highest probability ofwithdrawal occurs after 6 cycles of treatment

Evaluation of the Impact of the COVID-19 Lockdown in the Clinical Course of Migraine

Objective: Previous studies have demonstrated that emotional stress, changes in lifestyle habits and infections can worsen the clinical course of migraine. We hypothesize that changes in habits and medical care during coronavirus disease 2019 (COVID-19) lockdown might have worsened the clinical course of migraine. Design: Retrospective survey study collecting online responses from migraine patients followed-up by neurologists at three tertiary hospitals between June and July 2020. Methods: We used a web-based survey that included demographic data, clinical variables related with any headache (frequency) and migraine (subjective worsening, frequency, and intensity), lockdown, and symptoms of post-traumatic stress. Results: The response rate of the survey was 239/324 (73.8%). The final analysis included 222 subjects. Among them, 201/222 (90.5%) were women, aged 42.5 ± 12.0 (mean±SD). Subjective improvement of migraine during lockdown was reported in 31/222 participants (14.0%), while worsening in 105/222 (47.3%) and was associated with changes in migraine triggers such as stress related to going outdoors and intake of specific foods or drinks. Intensity of attacks increased in 67/222 patients (30.2%), and it was associated with the subjective worsening, female sex, recent insomnia, and use of acute medication during a headache. An increase in monthly days with any headache was observed in 105/222 patients (47.3%) and was related to symptoms of post-traumatic stress, older age and living with five or more people. Conclusions: Approximately half the migraine patients reported worsening of their usual pain during the lockdown. Worse clinical course in migraine patients was related to changes in triggers and the emotional impact of the lockdown. © 2021 The Author(s) 2021. Published by Oxford University Press on behalf of the American Academy of Pain Medicine

Cómo y cuándo derivar un paciente con cefalea secundaria y otros tipos de dolores craneofaciales desde Urgencias y Atención Primaria: recomendaciones del Grupo de Estudio de Cefaleas de la Sociedad Española de Neurología

Introducción: . Cuando se sospecha que estamos ante una cefalea secundaria y se deriva un paciente a Urgencias o a la consulta de Neurología es importante saber qué exploraciones complementarias son oportunas hacer en cada caso, además de saber posteriormente cuál es el circuito adecuado que ha de seguir el paciente.Por este motivo, el Grupo de Estudio de Cefaleas de la Sociedad Espanola ˜ de Neurología (GECSEN) ha decidido crear unas recomendaciones consensuadas que establezcan un protocolo de derivación de pacientes con cefalea y/o neuralgias craneofaciales. Desarrollo: Se ha contactado con neurólogos jóvenes con interés y experiencia en cefalea y con la Junta Directiva del GECSEN han desarrollado este documento que, por razones prácticas, se ha dividido en 2 artículos. El primero centrado en las cefaleas primarias y neuralgias craneofaciales, y este centrado en las cefaleas secundarias y otros dolores craneofaciales. El enfoque es práctico, con tablas que resumen los criterios de derivación con exploraciones complementarias y otros especialistas a los que derivar, para que sea útil y facilite su uso en nuestra práctica asistencial diaria. Conclusiones: Esperamos ofrecer una guía y herramientas para mejorar la toma de decisiones ante un paciente con cefalea valorando exploraciones a priorizar y que circuitos seguir para así evitarla duplicación de consultas y retrasos en el diagnóstico y en el tratamiento. © 2017 Publicado por Elsevier Espana, ˜ S.L.U. en nombre de Sociedad Espanola ˜ de Neurolog´ıa. Este es un art´ıculo Open Access bajo la licencia CC BY-NC-ND (http://creativecommons.org/ licenses/by-nc-nd/4.0/)

Headache attributed to SARS-CoV-2 infection, vaccination and the impact on primary headache disorders of the COVID-19 pandemic: a comprehensive review.

ObjectiveThe objective is to summarize the knowledge on the epidemiology, pathophysiology and management of secondary headache attributed to SARS-CoV-2 infection and vaccination; as well as to delineate their impact on primary headache disorders.MethodsThis is a narrative review of the literature regarding primary and secondary headache disorders in the setting of COVID-19 pandemic. We conducted a literature search in 2022 on PubMed, with the keywords “COVID 19” or “vaccine” and “headache” to assess the appropriateness of all published articles for their inclusion in the review.ResultsHeadache is a common and sometimes difficult-to-treat symptom of both the acute and post-acute phase of SARS-CoV-2 infection. Different pathophysiological mechanisms may be involved, with the trigeminovascular system as a plausible target. Specific evidence-based effective therapeutic options are lacking at present. Headache attributed to SARS-CoV-2 vaccinations is also common, its pathophysiology being unclear. People with primary headache disorders experience headache in the acute phase of COVID-19 and after vaccination more commonly than the general population. Pandemic measures, forcing lifestyle changes, seemed to have had a positive impact on migraine, and changes in headache care (telemedicine) have been effectively introduced.ConclusionsThe ongoing COVID-19 pandemic is a global challenge, having an impact on the development of secondary headaches, both in people with or without primary headaches. This has created opportunities to better understand and treat headache and to potentiate strategies to manage patients and ensure care.Paroxysmal Cerebral Disorder

BRIVA-LIFE–A multicenter retrospective study of the long-term use of brivaracetam in clinical practice

Objectives: Evaluate long-term effectiveness and tolerability of brivaracetam in clinical practice in patients with focal epilepsy. Materials and Methods: This was a multicenter retrospective study. Patients aged =16 years were started on brivaracetam from November 2016 to June 2017 and followed over 1 year. Data were obtained from medical records at 3, 6 and 12 months after treatment initiation for evaluation of safety- and seizure-related outcomes. Results: A total of 575 patients were included in analyses; most had been treated with =4 lifetime antiepileptic drugs. Target dosage was achieved by 30.6% of patients on the first day. Analysis of primary variables at 12 months revealed that mean reduction in seizure frequency was 36.0%, 39.7% of patients were =50% responders and 17.5% were seizure-free. Seizure-freedom was achieved by 37.5% of patients aged =65 years. Incidence of adverse events (AEs) and psychiatric AEs (PAEs) was 39.8% and 14.3%, respectively, and discontinuation due to these was 8.9% and 3.7%, respectively. Somnolence, irritability, and dizziness were the most frequently reported AEs. At baseline, 228 (39.7%) patients were being treated with levetiracetam; most switched to brivaracetam (dose ratio 1:10-15). Among those who switched because of PAEs (n = 53), 9 (17%) reported PAEs on brivaracetam, and 3 (5.7%) discontinued because of PAEs. Tolerability was not highly affected among patients with learning disability or psychiatric comorbidity. Conclusions: In a large population of patients with predominantly drug-resistant epilepsy, brivaracetam was effective and well-tolerated; no unexpected AEs occurred over 1 year, and the incidence of PAEs was lower compared with levetiracetam

¿Se interesan los residentes de Neurología en la cefalea?

Resumen: Introducción: Los años de residencia son la base fundamental para el ejercicio posterior de cualquier especialidad médica. El objetivo de nuestro estudio es evaluar la situación actual, grado de implicación y calidad percibida en la formación como neurólogos de los residentes, específicamente en el área de cefaleas. Métodos: Desde el Grupo de Estudio de Cefaleas de la Sociedad Española de Neurología (GECSEN) se diseñó una encuesta autoadministrada que fue enviada vía e-mail a todos socios los residentes de Neurología (mayo de 2015). Resultados: Completaron la encuesta 53 residentes (53/426: 12,4%; R1: 6%; R2: 25,5%; R3: 23,5% y R4: 45% de 13 comunidades autónomas). Las áreas que más les interesan son por orden: vascular, cefalea y epilepsia. El 85% considera que el área de cefalea está infravalorada. Más de la mitad (52,8%) no rotan en consultas específicas de cefaleas y solo el 35,8% terminan su formación con dominio de la técnica de bloqueos anestésicos e infiltración de toxina. El 81,1% considera que la investigación es escasa o nula. El 69,8% nunca ha realizado un póster/comunicación, el 79,3% no ha publicado y solo un 15% colabora en proyectos de investigación en esta área. El 40% considera que no ha recibido una formación adecuada. Conclusiones: La cefalea está entre las enfermedades que más interesan a nuestros residentes, sin embargo, consideramos que hay que mejorar su formación tanto en el ámbito asistencial como investigador, así como la visión que tienen de ella. Aumentar los cursos, crear páginas web formativas, involucrarles en investigación y considerar obligatoria la rotación en una unidad especializada son algunos de los objetivos fundamentales que planteamos desde el GECSEN. Abstract: Introduction: The years of residency are the pillars of the subsequent practice in every medical specialty. The aim of our study is to evaluate the current situation, degree of involvement, main interests, and perceived quality of the training received by Spanish residents of neurology, specifically in the area of headache. Methods: A self-administered survey was designed by the Headache Study Group of the Spanish Society of Neurology (GECSEN) and was sent via e-mail to all residents who were members of the Society as of May 2015. Results: Fifty-three residents completed the survey (N  =  426, 12.4%): 6% were first year residents, 25.5% second year, 23.5% third year, and 45% fourth year residents, all from 13 different Spanish autonomous communities. The areas of greatest interest are, in this order: Vascular neurology, headache, and epilepsy. Of them, 85% believe that the area of headache is undervalued. More than half of residents (52.8%) do not rotate in specific Headache Units and only 35.8% complete their training dominating anaesthetic block and toxin infiltration techniques. Of them, 81.1% believe that research is scarce or absent; 69.8% have never made a poster/presentation, 79.3% have not published and only 15% collaborate on research projects in this area. Lastly, 40% believe that they have not received adequate training. Conclusions: Headache is among the areas that interest our residents the most; however, we believe that we must improve their training both at a patient healthcare level and as researchers. Thus, increasing the number of available courses, creating educational web pages, involving residents in research, and making a rotation in a specialised unit mandatory are among the fundamental objectives of the GECSEN. Palabras clave: Residentes, Neurología, Cefalea, Investigación, Formación, Docencia, Keywords: Residents, Neurology, Headache, Research, Training, Teachin

Are neurology residents interested in headache?

Introduction: The years of residency are the pillars of the subsequent practice in every medical specialty. The aim of our study is to evaluate the current situation, degree of involvement, main interests, and perceived quality of the training received by Spanish residents of neurology, specifically in the area of headache. Methods: A self-administered survey was designed by the Headache Study Group of the Spanish Society of Neurology (GECSEN) and was sent via e-mail to all residents who were members of the Society as of May 2015. Results: Fifty-three residents completed the survey (n = 426, 12.4%): 6% were first year residents, 25.5% second year, 23.5% third year, and 45% fourth year residents, all from 13 different Spanish autonomous communities. The areas of greatest interest are, in this order: Vascular neurology, headache, and epilepsy. Of them, 85% believe that the area of headache is undervalued. More than half of residents (52.8%) do not rotate in specific Headache Units and only 35.8% complete their training dominating anaesthetic block and toxin infiltration techniques. Of them, 81.1% believe that research is scarce or absent; 69.8% have never made a poster/presentation, 79.3% have not published and only 15% collaborate on research projects in this area. Lastly, 40% believe that they have not received adequate training. Conclusions: Headache is among the areas that interest our residents the most; however, we believe that we must improve their training both at a patient healthcare level and as researchers. Thus, increasing the number of available courses, creating educational web pages, involving residents in research, and making a rotation in a specialised unit mandatory are among the fundamental objectives of the GECSEN. Resumen: Introducción: Los años de residencia son la base fundamental para el ejercicio posterior de cualquier especialidad médica. El objetivo de nuestro estudio es evaluar la situación actual, grado de implicación y calidad percibida en la formación como neurólogos de los residentes, específicamente en el área de cefaleas. Métodos: Desde el Grupo de Estudio de Cefaleas de la Sociedad Española de Neurología (GECSEN) se diseñó una encuesta autoadministrada que fue enviada vía e-mail a todos socios los residentes de Neurología (mayo de 2015). Resultados: Completaron la encuesta 53 residentes (53/426: 12,4%; R1: 6%; R2: 25,5%; R3: 23,5% y R4: 45% de 13 comunidades autónomas). Las áreas que más les interesan son por orden: vascular, cefalea y epilepsia. El 85% considera que el área de cefalea está infravalorada. Más de la mitad (52,8%) no rotan en consultas específicas de cefaleas y solo el 35,8% terminan su formación con dominio de la técnica de bloqueos anestésicos e infiltración de toxina. El 81,1% considera que la investigación es escasa o nula. El 69,8% nunca ha realizado un póster/comunicación, el 79,3% no ha publicado y solo un 15% colabora en proyectos de investigación en esta área. El 40% considera que no ha recibido una formación adecuada. Conclusiones: La cefalea está entre las enfermedades que más interesan a nuestros residentes, sin embargo, consideramos que hay que mejorar su formación tanto en el ámbito asistencial como investigador, así como la visión que tienen de ella. Aumentar los cursos, crear páginas web formativas, involucrarles en investigación y considerar obligatoria la rotación en una unidad especializada son algunos de los objetivos fundamentales que planteamos desde el GECSEN. Keywords: Residents, Neurology, Headache, Research, Training, Teaching, Palabras clave: Residentes, Neurología, Cefalea, Investigación, Formación, Docenci

Cómo y cuándo derivar un paciente con cefalea secundaria y otros tipos de dolores craneofaciales desde Urgencias y Atención Primaria: recomendaciones del Grupo de Estudio de Cefaleas de la Sociedad Española de Neurología

Introducción: . Cuando se sospecha que estamos ante una cefalea secundaria y se deriva un paciente a Urgencias o a la consulta de Neurología es importante saber qué exploraciones complementarias son oportunas hacer en cada caso, además de saber posteriormente cuál es el circuito adecuado que ha de seguir el paciente.Por este motivo, el Grupo de Estudio de Cefaleas de la Sociedad Espanola ˜ de Neurología (GECSEN) ha decidido crear unas recomendaciones consensuadas que establezcan un protocolo de derivación de pacientes con cefalea y/o neuralgias craneofaciales. Desarrollo: Se ha contactado con neurólogos jóvenes con interés y experiencia en cefalea y con la Junta Directiva del GECSEN han desarrollado este documento que, por razones prácticas, se ha dividido en 2 artículos. El primero centrado en las cefaleas primarias y neuralgias craneofaciales, y este centrado en las cefaleas secundarias y otros dolores craneofaciales. El enfoque es práctico, con tablas que resumen los criterios de derivación con exploraciones complementarias y otros especialistas a los que derivar, para que sea útil y facilite su uso en nuestra práctica asistencial diaria. Conclusiones: Esperamos ofrecer una guía y herramientas para mejorar la toma de decisiones ante un paciente con cefalea valorando exploraciones a priorizar y que circuitos seguir para así evitarla duplicación de consultas y retrasos en el diagnóstico y en el tratamiento. © 2017 Publicado por Elsevier Espana, ˜ S.L.U. en nombre de Sociedad Espanola ˜ de Neurolog´ıa. Este es un art´ıculo Open Access bajo la licencia CC BY-NC-ND (http://creativecommons.org/ licenses/by-nc-nd/4.0/)