Abstract Cerebral amyloid angiopathy is a vascular condition that is characterized amyloid deposits in the vascular system, mainly in cerebral arteries. The main symptoms of this vascular condition include dementia and increased risk for hemorrhagic stroke. The pattern of the intracerebral hemorrhage can be a clue to his condition. It is most commonly seen in the older population and can be genetic in some cases. Cerebral amyloid angiopathy increases the risk of hemorrhage in the brain due to its vasculopathy. This can be a difficult condition to treat especially in cases where patients may also need anti-platelets or anticoagulation for other reasons. Its diagnosis is based mainly on history and imaging, although definitive diagnosis is only with brain tissue specimens. Currently, there are no effective treatments.

Therapeutic monoclonal antibodies against the calcitonin gene‐related peptide (CGRP) receptor or its ligand have changed the landscape of treatment options for migraine. Erenumab is the first and only fully human monoclonal antibody designed to target and block the CGRP receptor. It is approved by the Food and Drug Administration for preventive treatment of migraine in adults. The recommended dose of erenumab is 70 mg monthly, with guidance that some patients may benefit from the 140 mg monthly dose. There is a need for information to guide clinical practice on the comparative efficacy and safety of these two dosing options.

Neuromodulation is a treatment modality that can be used in the abortive and preventive treatment of migraine and other primary headache disorders. The basic concept of neurostimulation is to manipulate peripheral or central pain pathways with either magnetic or electrical impulses. Common neuromodulation techniques include occipital nerve stimulation, which is the oldest technique, and trigeminal nerve stimulation, combined occipital and trigeminal nerve stimulation, sphenopalatine ganglion stimulation, vagus nerve stimulation and transcranial magnetic stimulation, which were introduced soon after. The two newest modalities are remote electrical neuromodulation and caloric vestibular stimulation, the last of which is still in the experimental phases.

Migraine is a common neurologic disorder. This article will discuss a few factors that influence migraine (mostly episodic) and its treatment, such as sleep, obstructive sleep apnea (OSA), obesity, and affective disorders, as well as autoimmune diseases. Practitioners must be aware of these coexisting conditions (comorbidities) as they affect treatment. It is noted in literature that both the quantity (too much or too few hours) and the quality (OSA related) of sleep may worsen migraine frequency. An associated risk factor for OSA, obesity also increases migraine frequency in episodic migraine cases. A bidirectional relationship with migraine along with depression and anxiety is debated in the literature. Retrospective cohort studies are undecided and lack statistical significance, but prospective studies do show promising results on treatment of anxiety and depression as a means of improving migraine control. Finally, we address the topic of autoimmune diseases and migraine. While few studies exist at this time, there are cohort study groups looking into the association between rheumatoid arthritis, hypothyroidism, and antiphospholipid antibody. There is also evidence for the link between migraine and vascular diseases, including coronary and cerebral diseases. We suggest that these comorbid conditions be taken into account and individualized for each patient along with their pharmaceutical regimen. Physicians should seek a multifactorial treatment plan including diet, exercise, and healthy living to reduce migraine frequency.

Background: Multiple studies have identified migraine as a risk factor for stroke. The conclusions have often been contradictory and differ between subpopulations of migraine patients. No studies to date have assessed the risk of readmission for cerebrovascular events up to 1 year after an initial migraine admission. We sought to estimate readmission rates for acute ischemic stroke (AIS), transient ischemic attack (TIA), subarachnoid hemorrhage (SAH) and intracerebral hemorrhage (ICH) after an index admission for migraine, using nationally representative data. Methods: The Nationwide Readmissions Database was designed to analyze readmissions for all payers and the uninsured, with data on >14 million U.S. admissions in 2013. We used International Classification of Diseases, Ninth Revision, Clinical Modification codes to identify index migraine admissions with and without aura or status migrainosus, and readmissions for cerebrovascular events. Cox proportional hazards regression was performed for each outcome with aura and status migrainosus as the main predictors. Models were adjusted for age and vascular risk factors. Results: Out of 12448 index admissions for migraine, 9972 (80.1%) were women, mean age was 45.5±14.8 years, aura was present in 3038 (24.41%) and status migrainosus in 1798 (14.44%). The 30-day readmission rate (per 100,000 index admissions) was 197 for AIS, 86 for TIA, 42 for SAH, and 17 for ICH. In unadjusted models, aura (compared to no aura) was significantly associated with AIS (hazard ratio [HR] 1.53, 95% CI 1.04-2.24) and TIA (2.43, 1.39-4.24), but not ICH (1.86, 0.45-7.79) or SAH (1.84, 0.44-7.75). After adjustment for age and vascular risk factors, aura remained significantly associated with TIA (2.13, 1.22-3.74) but not AIS (1.38, 0.94-2.03). Status migrainosus (compared to no status), in adjusted models, was significantly associated with readmission for SAH (4.83, 1.09-21.42). Conclusions: In this large, nationally representative database, migraine admission with aura was independently associated with TIA readmission, and status migrainosus was independently associated with SAH. Further research would clarify causal relationships underlying these strong associations.

OBJECTIVE:-To estimate readmission rates for acute ischemic stroke (AIS), transient ischemic attack (TIA), subarachnoid hemorrhage, and intracerebral hemorrhage after an index admission for migraine, using nationally representative data. METHODS:-The Nationwide Readmissions Database was designed to analyze readmissions for all payers and uninsured, with data on >14 million US admissions in 2013. We used International Classification of Diseases, Ninth Revision, Clinical Modification codes to identify index migraine admissions with and without aura or status migrainosus, and readmissions for cerebrovascular events. Cox proportional hazards regression was performed for each outcome with aura and status migrainosus as main predictors, adjusting for age and vascular risk factors. RESULTS:-Out of 12,448 index admissions for migraine, 9972 (80.1%) were women, mean age was 45.5 ± 14.8 years, aura was present in 3038 (24.41%), and status migrainosus in 1798 (14.44%). The 30-day readmission rate (per 100,000 index admissions) was 154 for ischemic stroke, 86 for TIA, 42 for subarachnoid hemorrhage, and 17 for intracranial hemorrhage. In unadjusted models, aura was significantly associated with TIA (hazard ratio 2.43, 95% CI 1.39-4.24), but not AIS (1.26, 0.73-2.18), intracranial hemorrhage (1.86, 0.45-7.79) or subarachnoid hemorrhage (1.85, 0.44-7.75). When adjusting for age and vascular risk factors, aura remained significantly associated with TIA (2.13, 1.22-3.74). Status, in adjusted models, was significantly associated with subarachnoid hemorrhage readmission (4.83, 1.09-21.42). CONCLUSIONS:-In this large, nationally representative retrospective cohort study, migraine admission with aura was independently associated with TIA readmission, and status migrainosus was independently associated with subarachnoid hemorrhage. Further research would clarify the role of misdiagnosis and causal relationships underlying these strong associations.

Images From Headache Pituitary Apoplexy Presenting as Status Migrainosus Debra Shabas MD, Debra Shabas MD Department of Neurology, Mount Sinai Downtown, New York, NY, USASearch for more papers by this authorHuma U. Sheikh MD, Corresponding Author Huma U. Sheikh MD huma927@gmail.com Department of Neurology, Mount Sinai Downtown, New York, NY, USAAddress all correspondence to H. Sheikh, Brigham and Women's Faulkner Hospital – Neurology, 1153 Centre St Suite 4970, Boston, MA 02130, USA.Search for more papers by this authorRonit Gilad MD, Ronit Gilad MD Department of Neurosurgery, Mount Sinai Downtown, New York, NY, USASearch for more papers by this author Debra Shabas MD, Debra Shabas MD Department of Neurology, Mount Sinai Downtown, New York, NY, USASearch for more papers by this authorHuma U. Sheikh MD, Corresponding Author Huma U. Sheikh MD huma927@gmail.com Department of Neurology, Mount Sinai Downtown, New York, NY, USAAddress all correspondence to H. Sheikh, Brigham and Women's Faulkner Hospital – Neurology, 1153 Centre St Suite 4970, Boston, MA 02130, USA.Search for more papers by this authorRonit Gilad MD, Ronit Gilad MD Department of Neurosurgery, Mount Sinai Downtown, New York, NY, USASearch for more papers by this author First published: 09 February 2017 https://doi.org/10.1111/head.13046Citations: 3 Conflict of Interest: The authors report no relevant conflict of interest. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume57, Issue4April 2017Pages 641-642 RelatedInformation

H eadache is seen in the emergency room (ER) on a daily basis and is a vague symptom, which can be a part of many different types of conditions and diseases. Although most people who come to the ER will have a benign headache, it is important to make sure that dangerous causes of headache are ruled out. There are a number of features that may alert someone to a secondary cause of headache. This article highlights two specific secondary headache syndromes, including carotid dissection and reversible cerebral vasoconstriction syndrome. It also broadly points out other possible causes of secondary headache. The last section focuses on a common primary headache that presents to the ER, migraine and its treatment.

ObjectiveMigraine with aura has been associated with increased risk of ischemic and hemorrhagic stroke. Prior studies have shown a further increase in risk in women using combined hormonal contraceptives (CHCs). This has led to guidelines recommending against use of CHCs in this population. We sought to assess whether the risk of stroke is associated with the dose of estrogen and whether there is evidence of synergism between migraine and CHCs. We also sought to assess whether an interaction effect exists between migraine and CHCs. MethodsWe searched PubMed, the Cochrane Library, and EMBASE from inception through January 2016 for relevant English-language studies of adults, of any design. We included studies that examined exposure to CHCs and reported outcomes of ischemic or hemorrhagic stroke. Data extraction and assessment of study quality were conducted independently by reviewer pairs and quality was assessed with the GRADE and Newcastle Ottawa scales. ResultsOf 2480 records, 15 studies met inclusion criteria and six provided odds ratios for the relevant population. The point estimates for the odds ratios for ischemic stroke in women with migraine who used CHCs with any dose of estrogen ranged from 2.08 to 16.9. Studies were generally small and confidence intervals were wide. No studies reported odds ratios for stroke risk as a function of estrogen dose in women with migraine, largely due to insufficient sample sizes. No interaction effect between migraine and CHCs was seen in the seven studies that assessed this. One study differentiated risk by presence or absence of migraine aura and found an increased risk in the migraine with aura population (OR 6.1; CI 3.1 to 12.1 in migraine with aura vs 1.8; CI 1.1 to 2.9 in the migraine without aura group). Studies generally had high Newcastle Ottawa scores and low GRADE levels of evidence. No studies met all three supplementary quality criteria (assessed migraine subtype, used International Classification of Headache Disorders criteria for diagnosis of migraine, and stratified risk by estrogen dose). ConclusionsThis systematic review shows a lack of good quality studies assessing risk of stroke associated with low dose estrogen use in women with migraine. Further study in this area is needed. The available evidence is consistent with an additive increase in stroke risk with CHC use in women with migraine with aura. Since the absolute risk of stroke is low even in the presence of these risk factors, use of CHCs in women who have migraine with aura should be based on an individualized assessment of harms and benefits.

Dissection refers to a tear in the wall of an artery, with the two main types being intracranial or extracranial. Dissections tend to occur most commonly in the young, sometimes secondary to trauma involving the neck. To confirm a dissection, some type of vessel imaging is necessary, including magnetic resonance angiography (MRA), computed tomography angiography (CTA), or angiography. The most common presentation of a dissection (especially extracranial) is pain, usually head and neck pain along with a Horner's syndrome. Patients may also present with ischemic symptoms, including transient ischemic attack (TIA) or stroke, which may also be a complication of a dissection. Although headache is a common presentation, there is little research into phenotype or long-term outcomes. There are a number of case reports detailing the phenotypes of headaches that may be present in dissection, including a migraine-like or hemicrania-like headache. Dissections are usually treated with some type of anti-platelet or anti-coagulation, although there are only a few randomized controlled trials. In a new acute headache, dissection is an important diagnosis to keep in mind.

BackgroundThe prevalence and burden of migraine and other severe headaches in the US population as a whole is well documented. Prevalence and treatment patterns in US racial and ethnic minorities, however, have received less attention. We sought to assemble and compare this information as identified in large, nationally representative studies.MethodsWe searched for summary statistics from studies performed in the United States between 1989 and 2014. Included studies had to provide population‐based, nationally or broadly representative information on the prevalence, burden, or treatment of severe or frequent headache or migraine in adult US Blacks, Hispanics, Native Americans, or Asians.ResultsNine studies were included in the review. Prevalence data from the National Health Interview Survey (NHIS) provide the most comprehensive information for major racial and ethnic groups. The average prevalence of severe headache or migraine from 2005 to 2012 NHIS was 17.7% for Native Americans, 15.5% for Whites, 14.5% for Hispanics, 14.45% for Blacks, and 9.2% for Asians. Severe headache or migraine prevalence was higher in females of all races and ethnic groups compared with males and across all included studies. Female to male prevalence ratios from the 2005‐2012 NHIS were 2.1 for Whites, 2.5 for Hispanics, 2.1 for Blacks, and 2.0 for Asians. Among those with chronic migraine (≥15 days of headache per month), prevalence data from the American Migraine Prevalence and Prevention study showed that the prevalence of chronic migraine was highest in Hispanic women (2.26% compared with 1.2% for White females), whereas White males had the lowest prevalence at 0.46%. Data from the National Hospital Ambulatory Care Survey and National Ambulatory Care Survey show that Hispanics make only 89.5 annual ambulatory care visits per 10,000 population at which they receive a diagnosis of migraine, compared with 176.3 for Whites and 133.2 for Blacks. In contrast, visit rates resulting in a diagnosis of nonspecific headache were more comparable across all groups. Only one study obtained information on selected subgroups within Hispanic and Asian populations. This showed that differences among these subgroups, which suggest composite prevalence estimates for broadly defined racial and ethnic groups such as Asians, may conceal meaningful differences in subgroups, such as Vietnamese or Filipinos.ConclusionsIn the United States, migraine prevalence is highest among Native Americans, then Whites, followed closely by Hispanics and Blacks. Asians have the lowest prevalence of severe, frequent headache or migraine of the major racial or ethnic groups. Differences in diagnosis and treatment of headache and migraine may indicate racial and ethnic disparities in access and quality of care for minority patients.

Chronic daily headaches (CDH) is a descriptive term used for patients who experience headaches on at least 15 days or more out of the month; for at least 3 months, irrespective of the underlying headache etiology. It is a syndrome that affects many people, usually with an underlying primary headache disorder, leading to a reduction in quality of life. The two most common underlying primary headaches are migraines and tension-type headaches. The prevalence is about 4%, and research is emerging on risk factors and comorbidities. The first step when approaching a patient with chronic daily headaches is to rule out secondary causes. Once that is done, the goal is to effectively reduce the days of headache through preventive treatment as well as complementary therapies. This also often involves limiting the use of abortive therapy to avoid medication-overuse headaches (MOH). The pathophysiology, although not fully understood, is thought to be related to central sensitization along with "neurogenic inflammation." Chronic daily headaches can be difficult to treat and at times require a tertiary specialized center.

Background Headaches are commonly seen in those patients with human immunodeficiency virus (HIV) and are the most common form of pain reported among HIV patients. There have been relatively few studies attempting to determine the rates and phenotypes of the headaches that occur in patients with HIV. Discussion Patients with HIV are susceptible to a much broader array of secondary headache causes, sometimes with atypical manifestations due to a dampened inflammatory response. The investigation of a headache in the HIV patient should be thorough and focused on making sure that secondary and HIV-specific causes are either ruled out or treated if present. Conclusion An effective treatment plan should incorporate the use of appropriate pharmacological agents along with the integration of non-pharmacological therapies, such as relaxation and lifestyle regulation. When treating for headaches in patients with HIV, it is important to keep in mind comorbidities and other medications, especially combination antiretroviral therapy. For those with complicated headache histories, referral to a specialized headache center may be appropriate.

OBJECTIVE: Evaluating efficacy and tolerability of triptans in basilar and hemiplegic migraines. BACKGROUND: Basilar migraine (BM) is a migraine sub-type with symptoms thought to originate from the brainstem and/or from simultaneous bihemispheric activation. Hemiplegic migraine (HM) is another migraine sub-type involving episodes of unilateral weakness in the setting of headache. Although triptans have been a mainstay in abortive treatment of migraine headaches, the FDA mandates that package labeling state that triptans are contraindicated in BM and HM. Triptans are 5-HT1B/D agonists which inhibit vasoactive peptide release by trigeminal nerves, and cause vasoconstriction of dilated cerebral arteries. A proposed mechanism for BM is basilar artery vasoconstriction, which has not been demonstrated in angiographic studies. HM carries a theoretically elevated risk of stroke compared to migraine with aura, which has not been well elucidated. Despite this lack of data, patients with BM and HM have been excluded from triptan clinical trials. In clinical practice, physicians at times prescribe triptans in patients meeting criteria for or have features consistent with BM and HM. DESIGN/METHODS: A retrospective chart review was conducted at two tertiary care institutions via electronic searchable databases from 2007-2013. Searchable terms included basilar migraine, vertigo, dysarthria, diplopia, hemiplegia/hemiparesis, facial droop, weakness, confusion, altered consciousness, confusion, ataxia, and aphasia, as well as all triptans. RESULTS: The study included thirty-nine patients. Thirty-six were included in the BM subtype, three in HM. No side effects of stroke or myocardial infarction were reported. Five patients reported adverse effects, including GI upset, rash, neck dystonia, nightmares, and flushing. CONCLUSIONS: In this retrospective study, triptans were used effectively with no subsequent vascular events for the abortive treatment of migraines with basilar and hemiplegic features. This data also suggests that beta blockers, tricyclic anti-depressants, anti-convulsants, and Botox injections have some efficacy in the treatment of migraines with basilar type and hemiplegic features. Disclosure: Dr. Krel has nothing to disclose. Dr. Mathew has nothing to disclose. Dr. Spinner has received personal compensation for activities with Merz Pharma and Allergan Inc. as speaker bureau member. Dr. Joshi has nothing to disclose.

Reversible cerebral vasoconstriction syndrome (RCVS) is a clinico-radiological syndrome characterized by recurrent thunderclap headache, with or without neurologic symptoms, and reversible vasoconstriction of cerebral arteries. RCVS affects patients in various racial and ethnic groups and in all age groups, although most commonly in the fourth decade of life. Many conditions and exposures have been linked to RCVS, including vasoactive drugs and the peripartum period. Disturbance of the cerebral vascular tone is thought to contribute to the disease’s pathophysiology. RCVS generally follows a monophasic course. Associated strokes and cerebral hemorrhages are not uncommon. In this review we will attempt to provide a comprehensive overview of RCVS, with emphasis on the controversies in the field and the newest findings in the reported literature.

Background Four ongoing US public health surveillance studies gather information relevant to the prevalence, impact, and treatment of headache and migraine: the National Health Interview Survey, the National Health and Nutrition Examination Survey, the National Ambulatory Care Survey, and the National Hospital Ambulatory Medical Care Survey. The American Migraine Prevalence and Prevention (AMPP) study is a privately funded study that provides comparative US population-based estimates of the prevalence and burden of migraine and chronic migraine. Objective To gather in one place and compare the most current available estimates of the US adult prevalence of headache and migraine, and the number of affected people overall and in various subgroups, and to provide estimates of headache burden and treatment patterns by examining migraine and headache as a reason for ambulatory care and emergency department (ED) visits in the United States. Methods We reviewed published analyses from available epidemiological studies identified through searches of PubMed and the National Center for Health Statistics. We aimed to identify information about migraine and headache burden, and treatment in national surveys conducted over the last decade. For each source, we selected the best available and most current estimate of migraine or headache prevalence, and selected associated measures of disability, health care use, and treatment patterns. Results Compared with a slightly higher proportion of 22.7% in the National Health and Nutrition Examination Survey, 16.6% of adults 18 or older reported having migraine or other severe headaches in the last 3 months in the 2011 National Health Interview Survey. In contrast, the AMPP study found an overall prevalence of migraine of 11.7% and probable migraine of 4.5%, for a total of 16.2%. Data from National Ambulatory Medical Care Survey/National Hospital Ambulatory Medical Care Survey showed that head pain was the fifth leading cause of ED visits overall in the US and accounted for 1.2% of outpatient visits. The burden of headache was highest in females 18-44, where the 3-month prevalence of migraine or severe headache was 26.1% and head pain was the third leading cause of ED visits. The prevalence and burden of headache was substantial even in the least affected subgroup of males 75 or older, where 4.6% reported experiencing severe headache or migraine in the previous 3 months. Triptans accounted for almost 80% of antimigraine analgesics prescribed at office visits in 2009, nearly half of which were for sumatriptan. Migraine is associated with increased risk for other physical and psychiatric comorbidities, and this risk increases with headache frequency. Conclusion This report provides the most current available estimates of the prevalence, impact, and treatment patterns of migraine or severe headache in the United States. Migraine and other severe headaches are a common and major public health problem, particularly among reproductive-aged women. Data about prevalence and disability from the major government-funded surveillance studies are generally consistent with results of studies such as the American Migraine Studies 1 and 2, and the AMPP study.

Migraine is a widespread primary headache disorder which requires a broad and an inclusive approach. This requires the use of appropriate pharmacological agents along with the integration of non-pharmacological therapies. There are 2 main categories of medication that are utilized for the treatment of migraine. Acute medications aim to relieve the pain and other symptoms associated with individual attacks and halt progression. Preventive therapies are used to reduce attack frequency, severity, and duration. There are a variety of medications available for both acute and preventive therapies. Some of them are specific for migraine while others are nonspecific headache or pain medications. Specific acute treatment for migraine includes triptans and ergots, which by definition are effective in migraine but not other non-headache pain disorders. Nonsteroidal anti-inflammatory drugs, neuroleptics/antiemetics, barbiturates, antihistamines, and opioids are some of the nonspecific medications that can be utilized for acute treatment. Preventive options for the treatment include beta-blockers, calcium channel blockers, antidepressants, and antiepileptic medications. With preventive and acute therapy, many patients are able to find relief from the debilitating effects of migraine.

Introduction: The short duration of symptoms and multitude of non-vascular mimics make diagnosis of transient ischemic attack (TIA) subjective and challenging. Physician practice may influence whether a patient receives the diagnosis of TIA. Pathophysiology is the same for TIA and ischemic stroke (IS). Therefore, the proportion of TIA versus IS diagnoses should be the same across demographic and clinical strata and theoretically should not vary between physicians. Hypothesis: The TIA-IS ratio, defined as the proportion of TIA among all TIA and IS cases, varies between medicine and neurology services and between board-certified vascular and other neurologists. Methods: TIA and IS cases were identified using primary ICD9 discharge codes at Montefiore Medical Center from January 2009 through June 2011. Each TIA diagnosis was confirmed by chart review, excluding cases with acute IS on brain imaging, duration >24 hours or a clearly non-vascular syndrome. The TIA-IS ratio was assessed based on the primary ICD9 code and again on the diagnosis by chart review for discharges from the neurology versus the medicine service and also individually for each board-certified neurologist with more than 25 IS or TIA discharges during the study period. Mantel-Hantsel chi-square was used for univariate statistical comparison between groups. Results: There were 659 cases of TIA and 1927 cases of IS by primary ICD9 discharge code, for an overall TIA-IS ratio of 25.5 %. The ratio was higher for discharges from medicine (28.6%) than neurology services (23.8%, p=0.009). The ratio was higher for 12 non-vascular neurologists (27.0%, range 17.9-44.4%, 904 cases), than 5 vascular neurologists (20.0%, range 18.7-23.0, 715 cases, p=0.001). Chart review reduced the overall TIA-IS ratio to 16.3% and the difference between medicine and neurology discharges became non-significant but non-vascular neurologists still had a higher TIA-IS ratio (20.7%) than vascular neurologists (14.4%, p=0.001). Conclusions: The TIA-IS ratio is different on medicine and neurology services and varies widely among board-certified neurologists, with vascular neurologists less likely to assign the diagnosis of TIA than other neurologists even after excluding obvious non-TIA cases. The ABCD2 score, assessing patients’ symptoms and vascular risk factors, is promoted as a criterion for admission; however, these data suggest that physician training and perspective affect the diagnosis, and thus assessment of future stroke risk, as well.