Background:Frameless image-guided radiosurgery (IGRS) is an effective and non-invasive method of treating patients who are unresponsive to medical management for trigeminal neuralgia (TN). This study evaluated the use of frameless IGRS to treat patients with medically refractory TN.Methods:We performed a retrospective review of records of 116 patients diagnosed with TN who underwent frameless IGRS using a linear accelerator (LINAC) over 10 years (March 2012-February 2023). All patients had failed medical management for TN. Facial pain was graded using the Barrow Neurological Institute (BNI) scoring system. Each patient received a BNI score before frameless IGRS and following treatment. Failure was defined as a BNI score IV-V at the last follow-up and/or undergoing a salvage procedure following IGRS.Results:All patients had a BNI score of either IV or V before the frameless IGRS. The mean follow-up duration for all 116 patients following IGRS was 44.1 months. Most patients (81 [69.8%]) had not undergone surgery (microvascular decompression [MVD] or rhizotomy) or stereotactic radiosurgery (SRS) for TN before frameless IGRS. A total of 41 (35.3%) patients underwent a salvage procedure (MVD, rhizotomy, or an additional IGRS) following frameless IGRS. The mean duration between the initial frameless IGRS and salvage procedure was 20.1 months. At the last follow-up, a total of 110 (94.8%) patients had a BNI score of I-III. No complications were reported after the frameless IGRS. The BNI score at the last follow-up was lower compared to the initial BNI for patients regardless of prior intervention (P < 0.001). Patients who failed IGRS had a higher BNI score at the last follow-up compared to those who did not fail IGRS (2.8 vs. 2.5, P = 0.05). Patients with pain relief had a shorter follow-up compared to those with pain refractory to SRS (38.0 vs. 55.1, P = 0.005).Conclusion:In this large cohort of patients with medically refractory TN, frameless IGRS resulted in durable pain control in the majority of patients without any toxicity.

Abstract Objective Evaluate neurocognitive change after single low-dose targeted intra-arterial (IA) bevacizumab in patients with brain radiation necrosis. Methods Phase II, single-arm, prospective trial. 10 adults underwent targeted 2.5 mg/kg IA bevacizumab. Neurocognitive indices (Neuropsychological Assessment Battery® and Wechsler Test of Adult Reading) were measured at baseline and 12-months to document performance in 5 domains: Attention, Language, Learning and Memory, Visuospatial, and Executive Function. Clinical indices also quantified. Data (mean ± SD, 95% confidence interval [CI], Cohen’s d) were analyzed using paired t tests. Null hypothesis rejected for p < 0.05. Results At baseline, Numbers-&-Letters Speed T-score (38.2 ± 10.7) indicated decreased processing speed consistent with sub-cortical pattern of illness. All other baseline neurocognitive indices were within normalized means (image). 12-months post-treatment, Numbers-&-Letters Errors T-score increased by 6.0 ± 4.9 [95%CI 1.9,10.1] (t = 3.464, d = 1.225, p = 0.010). List-Learning List-Long-Delayed-Recall T-score increased by 9.0 ± 5.6 [95% CI 4.3,13.7] (t = 4.520, d = 1.598, p = 0.003) and Design-Construction T-score increased by 3.5 ± 4.1 [95%CI 0.04,7.0] (t = 2.391, d = 0.845, p = 0.048). Volume of radiation necrosis decreased by 74.4 ± 14.7% (t = −3.308, d = 1.169, p = 0.013). Headache decreased by 84.4 ± 18.2% (t = −3.495, d = 1.236, p = 0.010). 0/10 died or exhibited AEs attributed to bevacizumab. 2/10 patients experienced radiation necrosis recurrence at months 10 and 11, respectively. Conclusions Single low-dose intra-arterial targeted bevacizumab led to durable neuropsychological performance increase in memory retrieval and visuospatial ability consistent with improvement in sub-cortical function. To our knowledge this is the first prospective report of this novel approach in adults. Clinical improvements mirrored neuropsychologic improvements. Randomized trials are needed comparing targeted low-dose IA bevacizumab to multi-cycle IV bevacizumab at higher doses to determine which is best alternative in brain radiation necrosis.

To evaluate the safety and tolerability of ubrogepant across various demographic and clinical characteristic subgroups.

Purpose of Review Migraine is a common disorder which in many cases can be adequately treated with medications. However, there are some patients who may either not respond to medications or have contraindications to their use. In this review, we will evaluate the available literature on the interventional procedures available to treat patients with episodic migraine. We will review the technical details of performing the procedures, the potential mechanisms of action, and available data on their effectiveness. Recent Findings Recent studies conducted on the subject of interventional procedures including peripheral nerve blocks and onabotulinumtoxinA indicate that some patients with episodic migraine may find benefit from such procedures. Summary In patients with episodic migraine whom traditional treatments have not been effective or are contraindicated, interventional procedures may offer an opportunity to provide additional treatment options.

Chronic migraine is a frequent and debilitating condition affecting 14% of the general population. This prospective observational pilot study investigated whether men with chronic migraine have lower than expected total serum testosterone levels. We identified 14 men ages 26-51 at our Institution who fulfilled the ICHD-3b criteria for chronic migraine and obtained serum total testosterone levels. The mean total testosterone level in our 14 patients was 322 ng/dL (range: 120-542 ng/dL) which is in the lower 5% of the reference range for our laboratory (300-1080 ng/dL). Men with chronic migraine had lower total testosterone levels compared to published agematched normative median values by a median difference of 62 ng/dL (P=0.0494). This finding suggests that hypothalamic regulation is altered in patients with chronic migraine. Further studies are warranted to determine whether testosterone supplementation in men with chronic migraine reduces the number of headaches or the associated symptoms of hypogonadism.

BackgroundWe studied the efficacy and safety of a second dose of lasmiditan for acute treatment of migraine.MethodsSAMURAI and SPARTAN were double-blind, placebo-controlled Phase 3 studies in which individuals with migraine were randomized to oral lasmiditan 50mg (SPARTAN only), 100mg, 200mg, or placebo. Study drug was to be taken within 4 hours (h) of onset of a migraine attack (moderate or severe pain). A second dose of study drug was provided for rescue (patient not pain-free at 2h and took a second dose 2-24h post-first dose) or recurrence (patient pain-free at 2h, but experienced recurrence of mild, moderate, or severe migraine pain and took a second dose 2-24h after first dose). Randomization to second dose occurred at baseline; patients originally assigned lasmiditan were randomized to the same lasmiditan dose or placebo (2:1 ratio), and those originally assigned placebo received placebo. Data from SAMURAI and SPARTAN were pooled for efficacy and safety assessment of a second dose of lasmiditan.ResultsThe proportion of patients taking a second dose was lower with lasmiditan versus placebo, and decreased with increasing lasmiditan dose; the majority who took a second dose did so for rescue. In patients taking lasmiditan as first dose, outcomes (pain free, most bothersome symptom [MBS] free) at 2h after a second dose for rescue were similar whether the second dose was lasmiditan or placebo (p>0.05 in all cases). In patients taking lasmiditan for first dose, outcomes at 2h after a second dose for recurrence were as follows: lasmiditan pooled versus placebo - pain free, 50% vs 32% (p>0.05); MBS free, 71% vs 41% (p=0.02); pain relief, 77% vs 52% (p=0.03). In patients whose first dose was lasmiditan, the incidence of treatment emergent adverse events (TEAEs) reported after the second dose was similar whether second dose was lasmiditan or placebo.ConclusionsA second dose of lasmiditan showed some evidence of efficacy when taken for headache recurrence. There was no clear benefit of a second dose of lasmiditan for rescue treatment. The incidences of TEAEs were similar whether the second dose was lasmiditan or placebo.

BACKGROUND: Idiopathic intracranial hypertension (IIH) is characterized by increased intracranial pressure. IIH causes significant morbidity marked by incapacitating headaches and visual disturbances. This study investigated the long-term outcomes of venous sinus stenting in a large group of patients with IIH. METHODS: We retrospectively reviewed all patients at our institution who underwent venous sinus stenting for IIH over 6 years (July 1, 2012-June 30, 2018). A particular focus was dedicated to collecting demographic, clinical, radiologic, and outcomes data. All patients had failed medical management. RESULTS: Of the 110 patients evaluated for IIH, 42 underwent venous sinus stenting, with a mean follow-up of 25.6 months (range, 8.7-60.7 months). The mean age was 32 years (range, 15-52 years), 38 (90%) were women, and the mean body mass index was 35.6 kg/m(2) (range, 18.6-47.5 kg/m(2)). Prior to the stenting procedure, all patients had headaches, visual disturbances, and papilledema. Of the 39 patients who had an ophthalmologic evaluation poststenting, 29 (74%) had resolution of their papilledema. Eighteen patients (43%) had complete resolution of their headaches after the stenting procedure, whereas 22 patients (52%) remained under a neurologist's care for chronic migraine and other types of headaches. Two patients underwent a restenting procedure for disease progression, and 1 patient experienced an in-stent thrombosis. CONCLUSIONS: A multidisciplinary approach involving neurosurgeons, ophthalmologists, radiologists, and neurologists is integral in the management of patients with IIH to prevent the complications of papilledema. Venous sinus stenting offers a safe and effective means of treating IIH.

BACKGROUND:Frameless image-guided radiosurgery (IGRS) is a safe and effective noninvasive treatment for trigeminal neuralgia (TN). This study evaluates the use of frameless IGRS to treat patients with refractory TN.METHODS:We reviewed the records of 20 patients diagnosed with TN who underwent frameless IGRS treatments between March 2012 and December 2013. Facial pain was graded using the Barrow Neurological Institute (BNI) scoring system. The initial setup uncertainty from simulation to treatment and the patient intrafraction uncertainty were measured. The median follow-up was 32 months.RESULTS:All patients' pain was BNI Grade IV or V before the frameless IGRS treatment. The mean intrafraction shift was 0.43 mm (0.28-0.76 mm), and the maximum intrafraction shift was 0.95 mm (0.53-1.99 mm). At last follow-up, 8 (40%) patients no longer required medications (BNI 1 or 2), 11 (55%) patients were pain free but required medication (BNI 3), and 1 (5%) patient had no pain relief (BNI 5). Patients who did not have prior surgery had a higher odds ratio for pain relief compared to patients who had prior surgery (14.9, P = 0.0408).CONCLUSIONS:Frameless IGRS provides comparable dosimetric and clinical outcomes to frame-based SRS in a noninvasive fashion for patients with medically refractory TN.

Purpose To provide a review of the diagnostic criteria, pathophysiology, and potential treatments of the complications of migraine as identified by the International Classification of Headache Disorders 3β, with the exception of status migrainosus. Method Migraine with aura may be associated with the onset of rare, but significantly disabling neurological symptoms. This review provides an overview of the associated complications that may arise from migraine with aura. Conclusion The complications of migraine that arise from migraine aura are infrequently encountered in clinical practice; however, they can be severely disabling for patients. As these conditions are encountered, thorough diagnostic evaluation is necessary. In some cases, it may be difficult to find a consistently reliable therapeutic option for these patients; however, as more cases enter the literature, a greater understanding of these conditions and how to treat them may arise.