BACKGROUND AND OBJECTIVES:Military sexual trauma (MST) is increasingly recognized in US veterans. MST is associated with psychiatric disease, substance abuse, and pain conditions, including headache. Little is known about the relationship between MST and specific headache disorders. METHODS:This retrospective cross-sectional study analyzed administrative data from the Women Veterans Cohort Study, a sample of post-9/11 US veterans enrolled for Veterans Health Administration care. A positive MST screen in the electronic medical record defined exposure. We extracted demographic and clinical data from administrative coding for migraine and relevant confounders, comparing between subgroups with χ2 tests. Health care utilization variables included designated sites of care and prescribed acute and preventive treatments and were evaluated with multivariable logit, negative binomial (nb), and zero-inflated nb models. RESULTS:Of 846,435 veterans screened for MST, 4.4% of veterans had a positive screen, whereas 9.5% had migraines. Veterans with migraine and a positive MST screen (21.7%) were more often non-White (45.3% vs 38.6%, p < 0.001), and 33 or less years old (55% vs 53%, p < 0.001) than veterans with migraine and a negative MST screen (9.0%). Adjusting for sex, the odds of migraine were greater for veterans with a positive MST screen (OR 1.62, 95% CI 1.57-1.67). Veterans with migraine and a positive MST screen were no more likely to receive triptan medications than veterans with migraine (46.2% vs 45.7%, p = 0.47) although were more likely to be prescribed opioids (36.1% vs 33.4%, p ≤ 0.001), compared with those with migraine and a negative MST screen. After controlling for sex, comorbidities (including chronic pain conditions), treatments, and other health care use, health care utilization was increased among migraine veterans with a positive MST screen, compared with migraine veterans without a positive MST screen for primary care (IRR 1.06, 95% CI 1.04-1.08, p < 0.001) and emergency department care (IRR 1.14, (95% CI 1.07-1.22), whereas neurology visits were not increased (IRR 0.97, 95% CI 0.92-1.02). DISCUSSION:Veterans with a positive MST screen constitute a vulnerable population more likely to have migraine, take opioid medications, and use emergency departments for migraine care.

BACKGROUND AND OBJECTIVES:Refractory migraine (RM) is associated with substantial disability, yet its clinical and health care utilization patterns remain poorly characterized in large, real-world populations. Understanding how preventive treatment progression relates to health care use and patient characteristics may inform earlier identification and care strategies. We sought to evaluate demographic, clinical, and health care utilization patterns in chronic migraine according to the number of preventive medication trials using a large cross-institutional electronic health record (EHR) database. METHODS:We conducted a retrospective observational study using the Epic Cosmos Cross-institutional EHR Database from January 1, 2016, to December 31, 2024. Adults with chronic migraine (International Classification of Diseases, Tenth Edition code G43.7) were included. Preventive medication trials were categorized into 5 classes: antihypertensives, antidepressants, antiseizure agents, calcitonin gene-related peptide-targeted therapies, and onabotulinumtoxinA. We evaluated demographics, comorbidities, and health care utilization metrics, including inpatient or outpatient dihydroergotamine (DHE) infusions, emergency department (ED) visits for headache, MRI brain orders, and patient EHR portal recency (MyChart). Marginal changes were defined as the percentage point change in outcomes between medication classes. Chi-squared tests and analysis of variance were used with significance set at p < 0.05. RESULTS:A total of 1,572,698 patients were identified by our search criteria; 21.2% were prescribed no preventive medications and 2.5% were prescribed all 5 classes, meeting the study's definition of RM. Health care utilization increased significantly with each additional medication class. The greatest marginal increases occurred between zero to 1 classes for MyChart access (43-day decrease), 1 to 2 classes for ED visits (+9.2%), and 4 to 5 classes for DHE administration (+6.1%) and MRI brain orders (+4.9%). Patients prescribed more preventive classes were older, a higher percentage female sex, White race, with public insurance, residence in the Northeast United States, and live in less socially vulnerable areas. Comorbidity burden increased progressively, with 94.6% of refractory patients having at least 1 comorbidity, most commonly anxiety (78.1%), depression (71.5%), hypertension (56.0%), and asthma (36.3%). All differences were statistically significant (p < 0.001). DISCUSSION:Higher health care utilization, greater comorbidity burden, and distinct geographic patterns are observed with increasing numbers of preventive medication trials in chronic migraine. These findings highlight the complexity of RM and underscore the need for earlier identification and more equitable access to comprehensive migraine care.

BACKGROUND AND OBJECTIVES: Despite the importance of timely access to ambulatory specialty care, data regarding wait times to neurologists are largely lacking. This study examines wait times, and drivers of wait times, for new neurology office visits among commercially insured persons in the United States. METHODS: We conducted a retrospective, repeated cross-sectional study using 2019-2023 data from the Merative MarketScan Commercial Database of approximately 20 million annual US enrollees. Enrollees with a new neurology visit, a primary care or emergency department (ED) visit in the prior 365 days, and continuous enrollment were included. The outcome was wait time in days for a new neurology visit following a primary care or ED visit. Mean (SD) and median (interquartile range [IQR]) wait times were reported by sex, race, neurologic condition, insurance type, and geographic region. Wait times were modeled using generalized estimating equations, clustering within metropolitan statistical areas (MSAs), and adjusted for demographic, insurance, clinical, and geographic variables. RESULTS: Between 2019 and 2023, 114,034 enrollees met our inclusion criteria, the mean age was 42.1 (SD = 16.1), and 65.6% were female. The average wait time for a new neurology visit was 49.7 days (SD = 65.4), and the median wait was 25.0 days (IQR = 9-62). Estimated wait times were shorter for female patients, compared with male patients (-7.0 days; 95% CI -7.8 to -6.2), and for stroke (-8.2 days; 95% CI -9.5 to -6.9), dizziness or vertigo (-7.8 days; 95% CI -10.4 to -5.1), and traumatic brain injury (-6.5 days; 95% CI -8.0 to -5.1) and longer for multiple sclerosis (+4.0 days; 95% CI 2.0-6.1). The Northeast Census region had the longest waits (+4.6 days; 95% CI 3.3-6.0). The proportion of non-Hispanic White race within a MSA was associated with reduced wait times (-0.2 days per MSA percent White; 95% CI -0.2 to -0.1). Enrollees with consumer driven health plans had the shortest wait times (-2.4 days; 95% CI -3.6 to -1.2). Neurologist density/100,000 enrollees was not associated with wait time (0.0 days: 95% CI -0.01 to 0.00). DISCUSSION: Wait times for new neurology appointments vary by sex, neurologic condition, insurance type, and geographic level variables.

INTRODUCTION: In 2018, the JC and AHA introduced a new stroke care certification for Thrombectomy-Capable Stroke Centers, increasing both access and the number of proceduralists performing endovascular thrombectomies(EVT) nationwide. However, dispersing the overall volume for centers located in close proximity may have unclear effects on patient outcome. METHODS: We performed a retrospective cohort study using the 2020 Florida State Inpatient Database. We included adult patients who had a diagnosis of AIS and underwent EVT during the same admission. The primary study outcome was in-hospital death. We used Youden’s Index to define an optimal threshold for number of EVT/year/provider. Based on this cut-point, the cohort was dichotomized into low and high proceduralist volume groups. We fit logistic regression models to mortality in the full cohort, both as univariate analyses and after adjusting for covariates. RESULTS: Amongst 3,143 AIS patients who underwent EVT, 1,907 patients across 59 hospitals and 106 providers met our inclusion criteria. Amongst the 106 providers, the median (interquartile range) number of EVTs performed was 13.5 (7-25). The optimal cut-point was 17 EVT. Demographics and comorbidities were similar between the cohorts. Compared to the low volume cohort, the high volume cohort had a significantly lower rate of in-hospital mortality (low volume: 11.0%vs.high volume 7.2%, p=0.005). After adjusting for potential confounders, high proceduralist volume remained significantly associated with lower odds of in-hospital death(OR: 0.52, 95% CI 0.36 – 0.76, p<0.05). Between the two cohorts, the difference in absolute risk of death was approximately 4.8% (p <0.05). CONCLUSIONS: Our study found that high proceduralist volume, as defined by =18 EVT/year, was associated with reduced in-hospital morality. Further research is necessary to understand the effects of proceduralist experience and benchmarks for technical proficiency with the aim of improving the overall care of AIS patients.

BACKGROUND AND OBJECTIVES:Ischemic stroke following cardiac intervention is a serious complication. However, there are limited data comparing stroke risk and severity among patients undergoing different types of cardiac interventions. We examined the incidence of ischemic stroke among patients undergoing cardiac interventions and identified variables associated with risk and severity of ischemic stroke. METHODS:We included cardiac intervention hospitalizations for adults within the United States from 2016 to 2021 in the National Inpatient Sample. We constructed a cross-sectional cohort of cardiac intervention hospitalizations comprising all hospitalizations within a Centers for Medicare & Medicaid Services-defined "Cardiac Surgery" Diagnosis-Related Group. The exposure was category of cardiac intervention, and primary outcome was ischemic stroke in any coding position. After survey weighting, we examined the frequency and factors associated with ischemic stroke, stroke severity, and inpatient mortality. A secondary analysis was performed in a subset of patients with documented NIH Stroke Scale (NIHSS). RESULTS:After survey weighting, among 6,083,899 cardiac intervention hospitalizations (mean age: 67.8 years, 34.5% female), ischemic stroke was diagnosed in 75,280 (1.24%). A higher risk of stroke was associated with female sex (vs male, adjusted odds ratio [OR] 1.25, 95% CI 1.20-1.29), age 75 or older (vs 18-54, OR 1.33, 95% CI 1.23-1.42), and non-Hispanic Black ethnicity (vs White, OR 1.32, 95% CI 1.24-1.39). Compared with percutaneous interventions, open cardiac surgery was associated with higher incidence of stroke (adjusted OR 2.47, 95% CI 2.39-2.55) and the strokes were significantly more severe (NIHSS median: 5 vs 3, mean 8.7 vs 5.6, respectively, p < 0.001). Among patients undergoing a cardiac intervention, the rate of ischemic stroke increased from 1.10% in 2016 to 1.33% in 2021 (p < 0.001) and ischemic stroke increased the risk of in-hospital death 5-fold (OR 5.07, 95% CI 4.77-5.39). DISCUSSION:Ischemic stroke during hospitalizations for cardiac interventions in the United States varies by type of intervention and shows an increasing trend from 2016 to 2021. Cardiac intervention patients sustaining an ischemic stroke are 5 times as likely to have in-hospital death as those without stroke. Further research is needed to identify high-risk populations that could benefit from specific postoperative monitoring strategies and/or specific therapeutic interventions.

Background Behavioral interventions for people with headache (HA) diseases have demonstrated clinical efficacy. Despite strong empirical support and endorsement by professional practice organizations, behavioral interventions are not widely accessible to HA patients. Clinic-based behavioral treatments remain inaccessible to many. The objectives of this study are to conduct a pilot randomized controlled trial and to determine the feasibility of the implementation of a cognitive behavioral therapy protocol for HA (CBT-HA) delivered via telehealth (TENACITY) compared to enhanced HA usual treatment (EHUT). Methods/design TENACITY is a single-blinded, randomized, controlled, pilot trial with a single intervention arm and an EHUT control arm analyzed as intention-to-treat. This multi-site study had a 31-day run-in/screening period to confirm chronic migraine and an approximately 12-week CBT-HA treatment period. Follow-up assessments were conducted at 3- and 6-month post-treatment initiation. Analysis plan The primary outcome will be analyzed as the change in self-reported number of HA days from the 30-day baseline run-in period before treatment to the number of self-reported days at 3 months post-treatment using a generalized mixed effects model. Secondary outcomes at 3- and 6-month post-treatment will be analyzed in addition. Trial Registration IRP 20-002, TENACITY: Telemedicine-based cognitive therapy for migraine NCT04613362

Background Cognitive behavioral therapy for headache (CBT-HA) improves headache-related outcomes, but accessibility barriers limit its use. This pilot study evaluated the feasibility, acceptability and clinical signal of an interactive voice response (IVR)-delivered CBT-HA intervention for veterans with post-traumatic headache (PTH). Methods A single-arm pilot trial was conducted with 18 veterans diagnosed with PTH. Participants completed a 10-week IVR-CBT-HA program. Outcomes were assessed at baseline, immediately post-treatment and one-month follow-up. Primary outcomes included changes in headache days, interference, disability, feasibility and acceptability. Results Fifteen participants completed the study. Headache frequency, headache-related disability, depressive symptoms, anxious symptoms, sleep quality and headache catastrophizing were not statistically significant. Self-efficacy significantly improved from baseline to post-treatment ( F 2,12 = 8.71, p = 0.001), and remained stable at follow-up. Participants reported high satisfaction with the intervention (27.73/32, SD = 5.66) but low system usability (mean = 20.83/100, SD = 15.72). Study therapists rated the intervention as highly acceptable (acceptability of intervention: mean = 4.83/5, SD = 0.37) and feasible (feasibility of intervention measure: mean = 4.92/5, SD = 0.28). Interactive CBT for headache and relaxation training (i.e. iCHART) resulted in an approximately 33% cost savings compared to traditional CBT-HA. Conclusions Asynchronous, IVR-delivered CBT-HA was feasible, acceptable and cost-effective for veterans with PTH. Although headache reductions were not statistically significant, self-efficacy improvements suggest long-term benefits. Future research should explore technology refinements and larger randomized trials. Trial Registration ClinicalTrials.gov: NCT05093556 (registered 26 October 2021)

Background and Objectives Migraine is a prevalent neurological condition and is associated with an increased risk of myocardial infarction (MI) and ischemic stroke. However, the cardiovascular risks or benefits of specific migraine preventive medications remain unknow. The objective of this study is to compare the risk of major adverse cardiovascular events (MACE) among patients with migraine disorder initiating lisinopril/candesartan or anti-calcitonin gene-related peptide (aCGRP) treatments versus topiramate. Methods Two target trials were emulated comparing patients who were prescribed lisinopril/candesartan or aCGRP treatment to those receiving topiramate for migraine prevention within the U.S. Department of Veterans Affairs between June 1, 2018 and September 30, 2024. Outcome was MACE including MI, ischemic stroke, intracerebral and subarachnoid hemorrhage (ICH/SAH) and all-cause mortality. Five-year cumulative incidences, risk differences, risk ratios and overall hazard ratios (HRs) were estimated. Results Among 48,610 person-trials initiating lisinopril/candesartan (mean [SD] age, 52.3 [12.3] years; 18.9% women) and 25,635 initiating aCGRP treatment (mean [SD] age, 47.2 [12.2] years; 39.4% women), lisinopril/candesartan was associated with an increased risk of MACE (HR 1.21; 95%CI, 1.10-1.34), particularly MI (HR 1.28; 95%CI, 1.03-1.59). The MI risk was greater in patients without documented cardiovascular indications (HR 2.75; 95%CI, 2.01-3.77), patients aged <40 years (HR 3.18; 95%CI, 1.63-6.20), or with baseline systolic blood pressure (SBP) <130 mm Hg (HR 1.86; 95%CI, 1.44-2.39). aCGRP use was associated with a reduced risk of MI (HR 0.80; 95% CI, 0.62-1.02) and was not associated with ischemic stroke (HR 1.11; 95% CI, 0.84-1.49) or ICH/SAH (HR 0.95; 95% CI, 0.65-1.38). Discussion Lisinopril/candesartan may increase the risk of MACE or MI in patients with migraine disorder, particularly in those with minimal atherosclerotic risks. aCGRP treatment appears safe regarding cardiovascular events and potentially protective against MI. Future research is needed to confirm these findings before clinical recommendations can be made. ### Competing Interest Statement A. de Havenon has received research funding from NIH/NINDS (UG3NS130228, R01NS130189, R21NS138995), consultant fees from Integra and Novo Nordisk, royalty fees from UpToDate, and has equity in TitinKM and Certus. No other disclosures were reported. ### Funding Statement This study was funded by the U.S. Department of Veterans Affairs Headache Centers of Excellence Special Purpose Medical Service funding (SP80DPE.1). ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: This study was approved by the VA Connecticut Healthcare System Research & Development Committee and granted a waiver of informed consent (IRBNet# 1784787). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes The data used for this study are available with an approved study protocol by the Department of Veterans Affairs. The data are not publicly available due to regulations and ethics agreements.

To determine impact of a physician assistant-led care-coordination intervention on visit costs, no-show and follow-up rates for a TeleNeurology practice.

BACKGROUND While issues related to lesbian, gay, bisexual, and transgender (LGBT) health are increasingly incorporated into medical training, there remains limited guidance and opportunities for continuing medical education in LGBT health. It is unclear how participation in LGBT-specific training is distributed across physician specialties and practice regions. Additionally, national data assessing cultural competency training for physicians are scarce and do not delineate LGBT-specific training or training completed prior to, during, or after graduate medical education. METHODS Using data from the 2016 National Culturally and Linguistically Appropriate Services Physician Survey, this study evaluated patterns of post-residency cultural competency training, as well as associations between LGBT-specific training and provider perceptions of patient care outcomes. RESULTS Provider specialty, practice region, and receiving cultural competency training as a trainee were associated with post-residency LGBT-specific training. Surgical providers (odds ratio [OR]: 0.42; confidence interval [CI] 0.25–0.73; p = .002) and those practicing in the South (OR: 0.49; CI: 0.26–0.92; p = .025) had lower odds of completing LGBT-specific cultural competency training while in independent practice. Post-residency LGBT-specific training was associated with provider agreement that cultural competency training improves the quality of care (OR: 2.76; CI: 1.44–5.28; p = .002), patient satisfaction (OR: 2.55; CI: 1.32–4.93; p = .005), and patient comprehension (OR: 2.03; CI: 1.05–3.90; p = .034). CONCLUSIONS Our findings provide disaggregated analyses that nuance the assessment of cultural competency interventions and support a broader effort to increase attention to LGBT health in continuing medical education.