Background: The Ohio Cardiovascular and Diabetes Health Collaborative (Cardi-OH) unites the 7 medical schools in Ohio to improve cardiovascular (CV) and diabetes health outcomes and eliminate disparities in Ohio’s Medicaid population. The purpose of the Cardi-OH needs assessment was to identify high priority clinical topics for the dissemination of evidenced-based best practices to providers across the state. Methods: The cross-sectional survey was distributed via REDCap (research electronic data capture) to Cardi-OH members and its external contacts (i.e., people who have engaged with Cardi-OH but are not members) in 2022. Question topics were identified by Cardi-OH members based on perceived gaps in existing content. Results: A total of 88% (n=103) of 117 Cardi-OH members and 8% (n=98) of 1,204 external contacts participated. Of those, 51% (n=53) of Cardi-OH members and 47% (n=46) of external contacts provided direct clinical care. The top items for Cardi-OH members (clinical and non-clinical combined) were: 1) lifestyle prescriptions (n=50, 49%), 2) atypical diabetes (n=38, 37%), 3) COVID-19 and cardiovascular disease (CVD) (n=38, 37%), and 3) mental health and CVD (n=38, 37%). For external contacts, the top topics were: 1) lifestyle prescriptions (n=53, 54.1%), 2) mental health and CVD (n=39, 39.8%), 3) alcohol and CVD (n=27, 27.6%), and 3) CV complications (n=27, 27.6%). Regarding social determinants of health (SDOH), Cardi-OH members prioritized: 1) weight bias and stigma (n=44, 43%), 2) family-focused interventions (n=40, 39%), and 3) adverse childhood experiences (ACEs, n=37, 36%). External contacts selected: 1) family-focused interventions (n=51, 52%), 2) implicit bias (n=43, 43.9%), and 3) ACEs (n=39, 39.8%). Conclusions: Shared prioritized topics included lifestyle, SDOH, and behavioral health; these may be useful to other professional organizations as they consider dissemination priorities. Disclosure E.A.Beverly: None. A.Kinsella: None. L.J.Lammert: None. A.Nevar: None. G.Irwin: None. C.Rollins: None. M.W.Konstan: None. S.D.Bolen: None. S.Koopman gonzalez: Research Support; Bristol Myers Squibb Foundation. K.M.Dungan: Board Member; Elsevier, Consultant; Eli Lilly and Company, Dexcom, Inc., Other Relationship; UpToDate, Research Support; Dexcom, Inc., Abbott, ViaCyte, Inc., Sanofi, Speaker's Bureau; Academy for Continued Healthcare Learning, Cardiometabolic Health Congress, Medscape, Integritas. J.T.Wright: Advisory Panel; Medtronic. K.R.Baughman: None. R.Wexler: None. L.D.Dworkin: None. G.D.Solomon: None. J.F.Lamb: None. Funding Ohio Department of Medicaid’s Medicaid Technical Assistance and Policy Program

Background Cardiovascular risk factor control is challenging, especially in disadvantaged populations. However, few statewide efforts exist to tackle this challenge. Therefore, our objective is to describe the formation of a unique statewide cardiovascular health collaborative so others may learn from this approach. Methodology With funding from the Ohio Department of Medicaid’s Ohio Medicaid Technical Assistance and Policy Program, we used a collective impact model to link the seven medical schools in Ohio, primary care clinics across the state, the Ohio Department of Medicaid, and Ohio’s Medicaid Managed Care Plans in a statewide health improvement collaborative for expanding primary care capacity to improve cardiovascular health in Ohio. Results Initial dissemination activities for primary care teams included a virtual case-based learning series focused on hypertension and social determinants of health, website resources, a monthly newsletter with clinical tips, webinars, and in-person conferences. The collaborative is aligned with a separately funded hypertension quality improvement project for paired implementation. Conclusions The collective impact model is a useful framework for developing a statewide collaborative focused on the dissemination and implementation of evidence-based best practices for cardiovascular health improvement and disparity reduction. Statewide collaboratives bringing payers, clinicians, and academic partners together have the potential to substantially impact cardiovascular health.

Background: Funded by the Ohio Department of Medicaid, the Ohio Cardiovascular and Diabetes Health Collaborative (Cardi-OH) unites the 7 medical schools in Ohio to improve outcomes and reduce disparities in hypertension and type 2 diabetes (T2D). The purpose of this needs assessment was to identify high priority educational topics for the dissemination of evidenced-based best practices. Methods: Questions surveyed collaborative members’ familiarity with guidelines, educational topics, and barriers to care. Results: A total of 111 out of 123 members completed the needs assessment (90.2% response rate). Half (49.5%, n=55) were familiar with the 2017 ACC/AHA guidelines for hypertension, whereas only 36.9% (n=41) were familiar with the 2020 ADA guidelines. The 3 topics of most interest were: 1) social determinants of health (SDOH, 55.9%, n=62), 2) lifestyle approaches to T2D (40.5%, n=45), and 3) new therapies for T2D (32.4%, n=36). Fifty-nine members (53.2%) provided direct clinical care; the others worked in research and public health. Providers estimated 25% of their T2D patients had A1C values >9.0%. Providers listed the 3 most common patient self-care barriers as: 1) lack of patient motivation (65.5%, n=38), 2) lack of patient education (60.3%, n=35), and 3) limited formularies and prior authorizations (41.4%, n=24). The 3 most common reasons for clinical inertia were: 1) lack of patient education (50.0%, n=29), 2) competing priorities (46.6%, n=27), and 3) lack of patient motivation (44.8%, n=26). Providers felt payers could help them with: 1) transportation (61.0%, n=68), 2) coverage of diabetes self-management education and support (DSMES, 59.4%, n=66), and 3) obtaining glucose monitors (45.9%, n=51). Conclusions: Top priorities for future evidence-based best practices are SDOH, patient engagement, and addressing complexity of care. Payers should prioritize increased coverage for DSMES and simplification of ordering monitoring supplies. Disclosure E. A. Beverly: None. G. D. Solomon: None. M. B. Holliday: None. J. Lewis: None. A. Nevar: None. S. M. Swiatkowski: None. M. W. Konstan: None. S. D. Bolen: None. K. M. Dungan: Advisory Panel; Self; Eli Lilly and Company, Tolerion, Inc., Consultant; Self; Boehringer Ingelheim Pharmaceuticals, Inc., Eli Lilly and Company, Elsevier, Novo Nordisk, Other Relationship; Self; UpToDate, Research Support; Self; Abbott, Sanofi-Aventis, Viacyte, Inc. J. T. Wright: None. A. Caron: None. M. Clemons: None. S. Aldrich renner: None. K. Gawlik: None. M. Sajatovic: Consultant; Self; Alkermes, Janssen Pharmaceuticals, Inc., Otsuka America Pharmaceutical, Inc., Other Relationship; Self; Springer Press, Johns Hopkins University Press, Oxford Press, UpToDate, Research Support; Self; Alkermes, Nuromate, Otsuka America Pharmaceutical, Inc. G. Rao: None. Funding Ohio Medicaid Technical Assistance and Policy Program (G-2021-05-0069)

Migraine is a chronic neurologic disease estimated to affect approximately 50 million Americans. It is associated with a range of symptoms, which contribute to disability and substantial negative impacts on quality of life for many patients. Still, migraine continues to be underdiagnosed, undertreated, and optimising treatment for individual patients has proven difficult. As many migraine patients will be seen first in primary care settings, internists and other primary care providers are ideally positioned to improve diagnosis and migraine management for many patients. In this review, we discuss some of the challenges in diagnosing migraine and suggest strategies to overcome them, summarise the current understanding of migraine pathophysiology and clinical evidence on acute and preventive treatment options, and offer practical approaches to diagnosis and contemporary management of migraine in the primary care setting.Key messagesMigraine is a prevalent disease with substantial impact. Primary care providers are ideally positioned to improve care for migraine patients with streamlined approaches to diagnosis and management.A stepwise diagnostic approach to migraine involves taking a thorough headache history, excluding secondary headache, and identifying primary headache disorder using screening tools or ICHD-3 criteria.The FDA approved seven new migraine therapies from 2018 to 2020 (four monoclonal antibodies, two gepants, one ditan), expanding acute and preventive therapeutic options.

Letters Health AffairsVol. 38, No. 4: Physicians, Medicare & More Medical Cannabis And Chronic PainGlen D. Solomon and Cynthia Sheppard Solomon AffiliationsWright State University Dayton, OhioPUBLISHED:April 2019Free Accesshttps://doi.org/10.1377/hlthaff.2019.00170AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InRedditEmail ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits TOPICSMedicinal marijuanaKevin Boehnke and coauthors (Feb 2019) report that the chronic pain qualifying condition for medical cannabis use has evidence of efficacy, based on a 2017 report by the National Academies of Sciences, Engineering, and Medicine.1 The studies supporting the use of cannabis for chronic pain mostly investigated neuropathic pain, while in clinical practice, most chronic pain is musculoskeletal. Furthermore, the finding of efficacy in the National Academies report was based largely on studies of nabiximols (a 1:1 delta-9-tetrahydrocannabinol [THC]: cannabidiol [CBD] preparation not available in US), and a small number of studies that used smoked or vaped cannabis obtained from the National Institute for Drug Abuse (7 percent THC content). The report states that “many of the cannabis products that are sold in state-regulated markets bear little resemblance to the products that are available for research.”1(p89) It goes on to say that “while the use of cannabis for the treatment of pain is supported by well-controlled clinical trials…, very little is known about the efficacy, dose, routes of administration, or side effects of commonly used and commercially available cannabis products in the United States.”1(p90)Using terms such as qualifying conditions and medical cannabis, rather than specific diagnoses and reproducible doses and formulations, makes it possible to conclude that medical cannabis is being used for conditions where there is proven efficacy. If instead the data are evaluated based on specific pain diagnoses and the determination of efficacy is limited to cannabis products available to patients, the conclusion will be that the majority of medical cannabis use is for conditions for which there is no evidence of efficacy.NOTE1 National Academies of Sciences, Engineering, and Medicine. The health effects of cannabis and cannabinoids: the current state of evidence and recommendations for research. Washington (DC): National Academies Press; 2017. Google Scholar Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article Metrics History Published online 1 April 2019 Information© 2019 Project HOPE—The People-to-People Health Foundation, Inc.PDF download

Hijab (headscarf) headache is well known among wearers and is a common topic of discussion. It has never previously been reported in the medical literature. Five women described bilateral headache either prompted by or worsened by donning the hijab, or headscarf. The headache always resolved soon after removal of the headscarf. Hijab headache may also be alleviated by minimal modifications in style while allowing women to maintain their moral conviction. It likely represents an extracranial etiology of headache, and recognition may prevent unnecessary evaluation and suffering in hijab wearers.

To the Editors—I read with great interest the article on “Trends in the Ambulatory Management of Headache”1 reporting a decline in clinician counseling for headache. While the paper references three clinical guidelines2–4 suggesting lifestyle modification counseling during headache visits, a review of those guidelines shows no evidence to support lifestyle counseling as having efficacy in reducing migraine or headarche frequency. Review of the headache literature also fails to show scientific evidence that lifestyle modification—changes in diet, sleep, or exercise—have ever been proven to reduce headache frequency. Lifestyle modification counseling may provide value in specific situations. There is evidence that simple advice can be effective as a withdrawal strategy in medication overuse headache.5 Obesity and smoking have been associated with increased severity of headaches, in addition to other myriad medical problems, and should be discouraged. Physicians have limited time with headache patients to take a detailed history, perform an appropriate physical examination, review the diagnosis and treatment options, and explore patient preferences for therapy. Using that limited time for lifestyle modification counseling that provides no clinical benefit offers no value. As a headache specialist for over 30 years, I find that I spend increasing amounts of patient time debunking myths about the value of lifestyle modification. While increased stress, dehydration, lack of sleep, sedentary lifestyle, and poor diet all may contribute to poor health, they have not been scientifically linked to increased migraine frequency. Emphasis on lifestyle modification may detract from non-pharmacologic therapies that have evidence to support their use in headache, such as biofeedback, relaxation therapy, and cognitive-behavioral therapy.2 While I find it discouraging that the use of advanced imaging and referrals have increased for headache patients, I do not believe that the decline in lifestyle modification counseling reflects a lost opportunity to improve the value of healthcare.

Congratulations to all Brazilian headache specialists on the excellent issue entitled The Brazilian Contribution to the Diagnosis and Treatment of Headache Disorders. I read with great interest and much enjoyment the extensive and accurate article on headache research and medical practice in Brazil written by my doctor friends MM Valença, AA da Silva, and CA Bordini. Although it is extremely detailed and accurate, it omitted a fact that many people know and which should have been included. Under international relationships on page 11, it mentions Marcelo Eduardo Bigal and fails to point out that he was awarded the International Headache Society’s Clinical Fellowship and elected to study with Drs. AM Rapoport and FD Sheftell at The New England Center for Headache in Stamford, CT, USA. It was there that he continued his amazingly prolific career as a writer, often being a coauthor on over 10-15 articles per year. It was at that time that we introduced him to RL Lipton, and he continued to work at both the Albert Einstein Medical Center and The New England Center for Headache for several years, becoming one of the most impressive headache specialists of the world at a young age.

Nummular headache (NH) – also known as a "coin-shaped headache" – is a type of primary neuralgia characterized by pain in a rounded or elliptical area of the head.1, 2 First described in 2002, there have been only 250 cases reported in the literature over the past decade. An uncommon disease, the pathophysiology of NH has not yet been clearly identified; specifically, the exact mechanism – either central or peripheral – by which this pain manifests. The localized, sharply delineated borders of the painful area seen in NH suggest a peripherally mediated pain mechanism.1 However, the lack of benefit with localized anesthetic nerve blocks, as well as the topographical involvement of areas supplied by multiple cranial nerves or areas spanning the midline, suggests a centrally mediated mechanism.3 Additionally, patients with NH may either suffer from a remitting and relapsing course (similar to what is observed in cluster headaches), a continuous pattern of pain, or a remitting pattern that evolves into continuous (unremitting) pain. The cluster-like pattern suggests a central pain mechanism, while unremitting pain is consistent with a peripheral pain mechanism. We offer for consideration a possible association between the temporal quality of NH (either continuous or episodic in nature) and the relative response to commonly used medications in the treatment of NH as significant indicators for delineating the possible mechanism behind NH pain. In June 2012, a 47-year-old female presented with symptoms of unremitting headache. She reported initially experiencing these headaches periodically nearly 7 years ago but had a period of relief until the headaches returned 2 years ago. She described the headache as burning with occasional throbbing and localized to the left frontal region of her head. She was able to clearly outline the affected area: perfectly circular and estimated to be about the size of a half-dollar. The headaches were of mild-to-moderate intensity, and the pain associated with the headaches was continuous and somewhat disabling. There was no known history of trauma to the area, and the patient's past medical history was significant only for asthma. She did not identify worsening of the pain during any particular part of the day, nor did she note any change with touch, position, coughing, exertion, or ingestion of certain foods/caffeine. She also denied having any of the following symptoms associated with her headaches: nausea; vomiting; double vision; sensitivity to light, sound, or smell; lacrimation; rhinorrhea; conjunctival injection; or any focal neurological signs. The patient tried Excedrin without relief. Physical exam was benign: the patient exhibited full range of visual fields and acuity, there was no papilledema observed on fundoscopy, extraocular movements were intact, and neurological exam was within normal limits. Pain in the localized region was not reproducible on exam. She was evaluated by a computed tomography scan of the brain, which failed to reveal any cranial or intracranial mass or abnormality. The patient was diagnosed with NHs and placed on a 50 mg dose of indomethacin 3 times daily. Over the next 6 months, the patient exhibited a good response while on indomethacin. During this time, she was transitioned to an extended-release formulation to provide improved control for occasional breakthrough headaches that occurred in the mornings. In January 2013, the patient experienced an episode of extreme upper abdominal pain accompanied with coffee-ground emesis. Following evaluation, she was diagnosed with gastric ulcers secondary to indomethacin use. The medication was discontinued, and she was placed on a proton-pump inhibitor and tramadol for pain. The patient was seen in a follow-up appointment a few months later following resolution of her gastrointestinal issues. During the interim, she utilized the low-dose tramadol for management of her headaches. She reported that it provided some control of the headaches. There was no change in the quality or severity of the headaches during this time. She was placed on gabapentin and titrated up to 1800 mg daily. Over the next 3 months, the patient reported a dramatic clinical response to gabapentin. She utilized tramadol as needed for any breakthrough headaches initially but cut down use considerably as gabapentin provided improved control. In November 2013, a 49-year-old female presented with symptoms of unremitting headache. Initially, she began experiencing these headaches intermittently 8 years ago but reported almost daily head pain for the past 5 years. She described the headaches as a severe sharp constant pain localized to a 5 × 2 cm egg-shaped area in the right parietal region of her head. There was no known history of trauma to the area, and the patient's past medical history was significant only for well-controlled rheumatoid arthritis. She did not note any worsening of the pain with light touch but did identify that pain was improved when applying pressure on her scalp. She also noted experiencing some nausea/vomiting as well as sensitivity to light/sound and a tightness in her neck with her headaches. She otherwise denied symptoms of lacrimation, rhinorrhea, conjunctival injection, or any focal neurological signs. The patient had tried topiramate, NSAIDs, triptans, and opiates without relief. In the past, the patient had been treated with indomethacin 150 mg daily and initially had some improvement; however, her headaches returned once again within 2 months of treatment. Physical exam was benign: the patient exhibited full range of visual fields and acuity, there was no papilledema observed on fundoscopy, extraocular movements were intact, and neurological exam was within normal limits. Pain in the localized region was not reproducible on exam. She was evaluated by an MRI scan of the brain, which failed to reveal any cranial or intracranial mass or abnormality. The patient was diagnosed with NHs and placed on gabapentin and titrated to 1200 mg daily. Over the next 2 weeks, the patient reported a dramatic clinical response to gabapentin, with complete relief of her head pain. NH were first characterized by Pareja et al in 2002.1 According to the Appendix of the International Classification of Headaches Disorders, 2nd edition,2 NH is defined as a primary neuralgia unrelated to an underlying disorder or malignancy in which pain is characteristically localized to a single round, oval, or elliptical area typically 2-6 cm in diameter on the head surface.1, 2 The chronic pain is either continuous or episodic with spontaneous remissions lasting weeks to months.1, 2 More than two-thirds of patients suffer from the continuous type of NH.3 The pain typically associated with NH is of a pressure-like or stabbing quality and of mild-to-moderate intensity.4 Most cases of NH are usually localized to the right parietal region (53.7%), although cases of left-sided frontal (11.7%), temporal (13.0%), and occipital (19.6%) headaches have been documented.3, 5 The pain does not radiate or change shape/size and is typically unifocal – although cases of bifocal and even multifocal headaches have been reported.4-6 On exam, patients may demonstrate touch-evoked paresthesias or even thinness of the skin in the painful area.4, 5 There is no definitive diagnostic tool in making the assessment of NH. It is important for the clinician to perform a full work-up so as to rule out any other intrinsic disease process that may be responsible for this localized pain. A majority of those suffering from NH are females in their mid-40s and -50s.3 Patients rarely experience any accompanying symptoms, and there have not been any precipitating factors identified in studies to date.5 Studies thus far have identified response among patients to treatment with NSAIDS – including indomethacin7-9 – as well as with gabapentin,6, 10-12 botulinum toxin,13, 14 carbamazepine,3, 15 tricyclic antidepressants,9 and neurotropin.16 Recent studies utilizing transcutaneous electrical nerve stimulation have also been reported to be effective.17 Of all these, gabapentin has been the most widely utilized, although none have yet been identified as achieving complete resolution of the headaches. The pathophysiology behind NHs remains controversial; it is widely believed that the localized, sharply delineated borders of the painful area seen in NH suggests a peripherally mediated pain mechanism.1, 7 Even multifocal cases of NH – in which each symptomatic area has been observed to maintain all the same characteristics – helps to reinforce the argument for a peripherally mediated pain origin.5 Some studies have even suggested that this peripheral pain associated with NH may specifically be a neuropathy of a terminal branch of a cutaneous scalp nerve and a focal, nociceptive-type pain stemming from epicranial tissues.1, 7 Despite this evidence, many continue to argue for a centrally mediated mechanism of pain. Although dissidents to this concept claim that the pattern of pain associated with NH is not consistent with what would be expected if the pain were centrally mediated (ie, wider distributions of pain without distinct borders), proponents for the argument identify that this cannot be completely ruled out. Schwartz et al specifically identifies that the lack of benefit with localized anesthetic nerve blocks observed in a majority of cases of NH as well as the topographical involvement of areas supplied by multiple cranial nerves or areas spanning the midline still allow for a centrally mediated argument.3 He also acknowledges that cases in which a therapeutic response to centrally acting agents, such as indomethacin, is observed also supports such an argument.3 A report published in 2010 makes a strong case for a centrally mediated mechanism, and their argument is entirely based on the response to a particular treatment.7 Baldacci et al described a patient suffering from NHs with episodic periods of exacerbations lasting hours. The patient had been treated with several medications – including gabapentin – without any relief. He was transitioned to indomethacin, and his headaches significantly improved. Baldacci et al theorized that this case of unilateral, indomethacin-responsive NH provides support for a centrally mediated pain mechanism – as the pain associated with most other unilateral, indomethacin-responsive headaches, the trigeminal autonomic cephalalgias, are thought to be of a central origin.7 We propose for consideration a possible association between the temporal pattern of NHs and a patient's response to a specific therapy as a possible means of delineating the pathophysiology behind this unique disease process. Our first patient initially experienced periods of remissions; she was treated with indomethacin, which provided improvement in her pain. As her head pain evolved into a non-remitting headache, she had an excellent response to gabapentin. Our second patient also initially had periods of remission and had some response to indomethacin. After her head pain evolved from episodic to chronic/continuous, she also responded well to gabapentin. We hypothesize that headaches of a non-episodic/continuous nature are reflective of a peripherally mediated pain mechanism (as has been largely described in the literature) and may be less responsive to indomethacin, whereas headaches of a cluster-like/episodic nature are more consistent with a centrally mediated mechanism and therefore are more likely to be responsive to indomethacin. Our hope is that this case series stimulates studies on exploring this potential relationship.

We offer for consideration a possible association between hypermobility syndrome seen in Ehlers–Danlos syndrome and risk of potential development of idiopathic intracranial hypertension – mediated primarily through the effects of insulin‐like growth factor‐1.

Migraine is a common chronic headache disorder affecting more than 10% of persons in Western populations. The clinical management of migraine is notable for the variability of diagnostic testing, therapeutic interventions and cost. Standards of care and clinical guidelines for migraine have recently been published or are currently under development. For these reasons, migraine is an ideal disease for a disease management programme. This article outlines the key concepts in developing a disease management programme for migraine which include: setting appropriate goals of migraine disease management; identifying patients for enrolment; providing critical components of care; instituting appropriate referral guidelines; and using continuous quality improvement methods to reach desired goals. Appropriate goals of migraine disease management should focus on decreasing migraine frequency and/or severity and improving quality of life for individuals who experience migraine. Additional goals may include reducing: overall cost to the organisation; pharmacy costs for migraine therapies; and emergency department and urgent care patient visits. Methods for identifying patients for enrolment in a migraine disease management programme include screening patients in various clinical settings, reviewing pharmacy records or self-enrolment. Key components of care include diagnostic and treatment algorithms, instruments to monitor quality of life, and education programmes for practitioners and patients. The final step in designing a disease management approach to migraine is to ensure that the process is continuously undergoing analysis and improvement.

Objective: To assess the impact of a comprehensive migraine disease management program, as measured by humanistic outcomes measures, conducted in a managed care setting. Design: A prospective comparative study comprised of an intervention and a control group to evaluate the impact of the disease management initiative. Setting: Independent Practice Association (IPA)-type managed care organization. Study participants and main outcomes measures: Study participants resided in adjacent regions (intervention region included Minneapolis, MN, USA and the usual care region included St Paul, MN, USA and adjacent areas in MN, USA) separated by natural geographic barriers. Eligible patients were identified through a review of the Medica plan’s administrative claims database and were asked to complete the Migraine Therapy Assessment Questionnaire (MTAQ), a tool to assess the presence of migraine management issues. Responders (patients completing the MTAQ) who reported ≥2 migraine care risk indicators in the intervention region received the disease management intervention, while all responders in the control region received usual care. Responders in both regions with ≥2 migraine care risk indicators were also asked to complete the Migraine Disability Assessment (MIDAS) questionnaire and the 12-item Short Form Health Survey (SF-12) at baseline. All participants were asked to complete the same instruments at the end of the program as they did at baseline. Interventions: Disease management intervention activities included patient and physician education, as well as a patient feedback report containing migraine care risk indicators, which was sent to the treating physicians. All patients were encouraged to contact their physicians if they reported two or more migraine management issues. Results: A total of 2232 patients with migraine were enrolled in the study (1373 from the intervention region and 859 in the control region). Compared with patients in the control region, patients in the intervention region reported, as measured by MTAQ, significant improvement in migraine symptom relief, more knowledge about potential migraine triggers, a decrease in economic burden, and more satisfaction with migraine treatment. In addition, the change in MIDAS scores from baseline showed a greater shift towards decreasing disability in the intervention group compared with the control group. However, no statistically significant improvement was detected in terms of health status as measured by SF-12. Of the participants in the intervention region who completed the program evaluation survey, 40% indicated that they called or visited their physicians regarding their migraine survey results if it was recommended. For those contacting their physicians, 76% had their medications changed and 75% noted an improvement in relief due to a change in medication. Conclusions: Considering the significant toll of migraine on patients, employers, and the healthcare system, healthcare plans should consider implementing migraine disease management programs to improve migraine care.

There have been associations demonstrated between migraine and ischemic stroke and heart disease. Additionally, headache patients have increased cardiovascular risk factors. This article reviews available data supporting these concerns and answers the following questions: 1) Does the association between migraine and cardiovascular disease warrant cardiovascular screening tests in migraine sufferers? There is enough observational data to conclude that migraine with aura is a risk factor for cardiovascular disease. With the available data, we cannot recommend any additional cardiovascular screening tests for migraine patients. 2) Are there specific risk modification approaches for headache patients? As there is no data to suggest that migraine is a modifiable risk factor, no additional cardiovascular interventions beyond the standard practice of treating modifiable risk factors are suggested for migraine sufferers. 3) What is the appropriate screening for patients who may be candidates for triptans or tricyclic antidepressants? We support screening headache patients by obtaining a history of prior cardiovascular disease and traditional cardiovascular disease risk factors. We have found no data to suggest that any non-invasive cardiovascular screening test will identify a population of migraine sufferers at high risk for cardiovascular events following triptan use. Due to the increased risk of cardiovascular toxicity, ECGs should be considered prior to initiating tricyclic antidepressants in patients with preexisting cardiovascular disease.