To review current evidence on epigenetic mechanisms in migraine, offering insights into diagnosis, disease classification, and future therapeutic management. Recent research has focused on three primary epigenetic mechanisms: DNA methylation, non-coding RNAs, and histone modifications. Altered methylation patterns have been identified in CALCA and RAMP1, both critical components of the CGRP signaling pathway. Furthermore, recent research on non-coding RNA data has enabled the development of composite risk scores to distinguish endophenotypes and support clinical diagnosis. Lastly, the therapeutic efficacy of valproic acid may be mediated via its endogenous histone deacetylase-inhibiting effect and chromatin remodeling. As our understanding of epigenetic modulation in migraine expands, these molecular insights can be integrated with genomic profiles to advance precision medicine, adding value to the interaction between genetic and environmental factors.
Diet is frequently cited among the lifestyle interventions important to managing migraine disease, but existing evidence informing dietary recommendations is hindered by limited and heterogeneous dietary study designs and results. Here, we review recent literature on migraine and diet with attention toward study designs needed to better inform dietary recommendations for migraine. Numerous recent observational studies agree that dietary intake of individuals with migraine is slightly different than their counterparts without migraine, and the disparity appears to be greater with more severe symptoms. The cross-sectional nature of the data prevents determination of causality. Meanwhile, mechanistic evidence is mounting that the relationship between dietary intake and migraine is bidirectional, yet little has been observed about the direct influence of migraine on dietary intake. Increasingly rigorous controlled dietary feeding studies demonstrate the ability of dietary modifications to impact migraine outcomes, and the strongest evidence exists for diets that diverge substantially from typical eating patterns. The implications of long-term dietary intake on migraine prognosis are also not yet known due to lack of prospective data. Multidimensional evidence supports the existence of a bidirectional relationship between diet and migraine, but data are lacking on how this interplay actually impacts dietary intake and what it means for dietary recommendations. Future research needs include: expanded study designs to better elucidate how migraine influences diet, clinical trials evaluating interventions that support healthy eating behaviors in the presence of migraine symptoms, and prospective cohorts with longitudinal assessments of migraine and dietary intake, to provide data on the reduction of risk for migraine, its exacerbation and co-morbid diet-related chronic diseases.
This review summarizes current approaches to pain assessment and pharmacologic therapy in the intensive care unit (ICU) and evaluates the expanding role of regional anesthesia (RA). Contemporary ICU analgesia emphasizes systematic pain assessment and multimodal therapy while avoiding unnecessary deep sedation. RA provides targeted, opioid-sparing analgesia for localized pain but is limited by coagulopathy, infection, altered anatomy, and practical considerations. Fascial-plane blocks may provide useful alternatives in selected patients. Thoracic epidural and paravertebral techniques remain options for selected patients but may cause hypotension and clinically significant bleeding. Ultrasound-guided techniques, including erector spinae, serratus anterior, parasternal, rectus sheath, and transversus abdominis plane blocks, expand analgesic options. Continuous catheter techniques may extend analgesia when prolonged pain is anticipated. However, evidence in heterogeneous ICU populations remains limited, and much of the current evidence is derived from perioperative or trauma populations rather than general medical ICU cohorts. Further ICU-specific comparative trials are needed to define patient selection and clinically meaningful outcomes.
Essential tremor (ET) is the most prevalent movement disorder worldwide. There are limited current pharmacological therapies, and their side effects often preclude adequate doses. Surgical therapies, such as Deep Brain Stimulation (DBS) and Focused Ultrasound (FUS), are reserved for patients with tremor that debilitates activities of daily living (ADLs). Peripheral nerve stimulation (PNS), including transcutaneous afferent patterned stimulation (TAPS) and transcutaneous peripheral nerve stimulation (TPNS), has emerged as a promising non-invasive neuromodulatory approach for many patients with intermediate symptoms. A systematic review and meta-analysis following PRISMA 2020 guidelines was conducted, with searches across PubMed, Scopus, Cochrane, and Web of Science. Studies enrolling patients with ET assessing TAPS and TPNS were included. Primary outcomes were tremor severity (TETRAS performance scale, total TETRAS) and tremor amplitude. Secondary outcomes included functional disability (BF-ADL, TETRAS-mADL) and safety. Nineteen studies (2,541 patients) were included. Sham-controlled analyses showed statistically significant improvement in TETRAS performance scale scores (MD = − 1.00; p = 0.002; I2 = 0
This is a narrative review to summarize current evidence on use of therapies targeting calcitonin gene-related peptide (CGRP) for children and adolescents with headache disorders. The CGRP-targeting therapies have been used in adults for prevention of migraine since 2018. There is one randomized controlled trial (RCT) published on fremanezumab in children age 6–17 years old which showed favorable outcome as a preventive treatment for episodic migraine. Several real-world evidence (RWE) studies report on use of CGRP-targeting therapies in patients younger than 18 years old. Several clinical trials are pending for other CGRP-targeting therapies. There is a small number of RWE studies and one RCT study that shows that CGRP-targeting therapies have potential to be beneficial and safe to use in children and adolescents with headache disorders. Future clinical trials, once completed, will further shed light on efficacy and safety of CGRP-targeting therapies.
