Elizabeth K. Seng

Background: Migraine ranks among the leading causes of disability worldwide. Comorbid depressive symptoms are highly prevalent in patients with migraine and are associated with worsened pain severity, greater migraine-related disability, and poorer migraine prognosis. Despite this burdensome comorbidity, the treatment of these co-occurring disorders has rarely been studied. While mindfulness-based cognitive therapy (MBCT) shows promise for addressing both migraine-related disability and depressive symptoms, its traditional format—8 weekly 2-hour sessions in person—creates substantial access barriers, particularly for patients who experience frequent debilitating migraine and mood symptoms. Objective: The objective of the Treatment for Migraine and Mood (TEAM-M) trial is to evaluate the feasibility of an abbreviated MBCT intervention (MBCT-Brief) delivered via telephone or videoconferencing in adults with migraine and elevated depressive symptoms. Methods: TEAM-M is a 3-site trial with a goal sample size of 145 adults with episodic migraine and elevated depressive symptoms randomized to MBCT-Brief telephone, MBCT-Brief videoconferencing, or enhanced usual care (EUC). To be eligible, participants must meet the criteria for migraine as defined by the International Classification of Headache Disorders 3rd edition, have ≥1 year of migraine history, and have mild to moderate depressive symptoms (scores 5‐19 on the Patient Health Questionnaire-9). Results: Our primary outcomes include treatment feasibility, acceptability, and fidelity. Our secondary outcomes include headache disability, migraine-specific quality of life, and depressive symptoms. This trial was funded in May 2021. We began recruitment in November 2023 and completed enrollment in January 2026. As of May 2026, we have randomized 145 participants, of which 104 have completed the intervention and provided data for our primary outcomes. Data analysis is currently in progress, and primary outcome results are expected to be submitted for publication in spring 2027. Conclusions: The TEAM-M trial addresses a gap in clinical care by evaluating an abbreviated version of MBCT that has scalability and accessibility advantages over full-length MBCT and the potential to address both migraine and depressive symptoms. By reducing the time commitment while maintaining the core MBCT components, MBCT-Brief can potentially address significant access barriers that often prevent patients from receiving evidence-based health care for comorbid physical and mental health symptoms. The remote delivery model offers enhanced scalability. This trial will also yield information about potential differences in telephone versus videoconferencing delivery, which will inform optimal integration into existing primary care and mental health clinic workflows, allowing for improved access to specialized care for mental health and migraine across diverse health care settings.

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. 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. 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). 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: Rimegepant improves both headache pain and physical function in clinical studies for the acute treatment of migraine. It is not clear whether rimegepant has direct effects on physical function or if improvements in function are an indirect treatment effect mediated through reductions in headache pain. The objective of this study was to estimate the extent to which rimegepant-mediated reductions in headache pain intensity contribute to improvements in physical functioning during a migraine attack. Methods: Data were pooled from four placebo-controlled trials of rimegepant 75 mg for acute treatment of migraine. Participants rated current headache pain and functional disability on four-point scales prior to dosing and from 15 min to 48 h post-dose. A cross-sectional mediation model including variables for pain, function, and treatment (rimegepant or placebo) was run separately at each timepoint. Based on results of cross-sectional modeling, a longitudinal pseudo-steady-state mediation model was constructed to estimate relationships between variables using all available data during the period when all processes in the model were considered to have achieved and maintained equilibrium. The pseudo-steady-state model assumed relationships between variables were the same at all timepoints. Results: Across all studies and treatment groups, participants ( N = 3975) were mostly female (75.2–89.2%) and mean age was 40.0 to 41.9 years. Cross-sectional models ( N = 3441–3834 across timepoints) indicated that the period represented by measurements at 3, 4, 6, and 8 h can be considered a pseudo-steady-state period for a mediation model representing inter-relationships among headache pain, function, and treatment. The pseudo-steady-state model ( N = 3281) incorporated all available data from 3, 4, 6, and 8 h post-dose and estimated that 76.1% of the effect of treatment on function is mediated indirectly via improvements in headache pain, with 23.9% representing a direct effect (representing all other effects/mediators not included in the model). Conclusion: The effect of rimegepant on functioning was largely mediated through reductions in headache pain intensity during the migraine attack. Approximately one-quarter of the improvement in functioning was mediated through factors other than pain intensity.

BACKGROUND Migraine ranks among the leading causes of disability worldwide. Comorbid depressive symptoms are highly prevalent in patients with migraine and are associated with worsened pain severity, greater migraine-related disability, and poorer migraine prognosis. Despite this burdensome comorbidity, the treatment of these co-occurring disorders has rarely been studied. While Mindfulness-Based Cognitive Therapy (MBCT) shows promise for addressing both migraine-related disability and depressive symptoms, its traditional format—8 weekly, 2-hour in-person sessions—creates substantial access barriers, particularly for patients who experience frequent debilitating migraine and mood symptoms. OBJECTIVE The objective of the TEAM-M (Treatment for Migraine and Mood) trial is to evaluate the feasibility of an abbreviated MBCT intervention (MBCT-Brief) delivered via telephone or videoconferencing in adults with migraine and elevated depressive symptoms. METHODS TEAM-M is a three-site trial with a goal sample size of 145 adults with episodic migraine and elevated depressive symptoms randomized to MBCT-Brief telephone, MBCT-Brief videoconferencing, or enhanced usual care (EUC). To be eligible, participants must meet criteria for migraine as defined by the International Classification for Headache Disorders, 3rd Edition, have ≥1 year of migraine history, and have mild-moderate depressive symptoms (score 5–19 on the Patient Health Questionnaire). RESULTS Our primary outcomes include feasibility, acceptability, and fidelity of treatment. Our secondary outcomes include headache disability, migraine-specific quality of life, and depressive symptoms. We began recruitment in November 2023. To date, we have randomized 145 participants, and of these, 81 have completed the intervention. We completed enrollment in January 2026. CONCLUSIONS The TEAM-M trial addresses a gap in clinical care by evaluating an abbreviated version of MBCT that has scalability and accessibility advantages over full-length MBCT and the potential to address both migraine and depressive symptoms. By reducing time commitment and maintaining core MBCT components, MBCT-Brief has the potential to address significant access barriers that often prevent patients from receiving evidence-based healthcare for comorbid physical and mental health symptoms. The remote-delivery model offers enhanced scalability. This trial will also yield information about potential differences in telephone versus videoconferencing delivery that will inform optimal integration into existing primary care and mental health clinic workflows, allowing for improving access to specialized care for mental health and migraine across diverse healthcare settings. CLINICALTRIAL ClinicalTrials.gov NCT05576467. Registered on October 10, 2022.

Objectives: The aim of this work was to develop an American Headache Society position statement addressing diagnostic screening for migraine among girls and women. Background: Despite its high prevalence and substantial negative impacts, migraine is underdiagnosed and undertreated. Diagnostic screening for migraine enables more patients to receive timely, appropriate, and effective management. Methods: Development of this position statement followed the rules established by the American Headache Society Guidelines Committee. The published literature was reviewed to determine if migraine meets criteria for when disease screening is justified, to guide recommendations for screening tools, and to determine subpopulation(s) for which migraine screening is indicated. After author consensus was reached, the position statement was reviewed and approved by the American Headache Society Board of Directors. Results: Migraine fulfills established criteria for conditions in which screening is appropriate since it is highly prevalent, results in significant morbidity, and exerts substantial economic and social costs. Migraine incidence and prevalence are exceptionally high among girls and women during adolescence and through menopause. Furthermore, there are valid and reliable diagnostic screening methods (e.g., ID Migraine) and effective treatments that reduce migraine symptoms and disease impact. Conclusion: Yearly diagnostic screening for migraine should be included as part of women's preventive healthcare services, particularly from adolescence to menopause.

Purpose of Review This goal of this paper is to identify the need to report adverse events (AEs) in mindfulness-based interventions (MBIs) for migraine and highlight conceptual issues related to their reporting. This paper reviews the benefits and AEs in MBIs broadly and considers their application to a migraine population. Recent Findings Due to a lack of standardized protocol for measuring and reporting, there is little published information on AEs in MBIs for migraine. Several recent trials have reported individual cases of AEs, including one instance of posttraumatic re-experiencing. Summary The increasing popularity of MBIs in the treatment of chronic pain conditions, including migraine, makes it necessary for providers to understand which AEs occur. Patients with migraine may be at an elevated risk of experiencing AEs in MBIs.

Aim: Despite its frequency in tertiary headache centers, the International Classification of Headache Disorders, 3rd edition (ICHD-3) does not include refractory migraine. Multiple definitions have been proposed with a recent 2020 proposal for both refractory migraine and resistant migraine by the European Headache Federation (EHF). The aim is to reach an international consensus on the definition of refractory migraine. Methods: This study is a Delphi consensus carried out by a group of international experts in headache medicine. Following a focus group, a panel of 20 experts and one facilitator reviewed the EHF proposed criteria to build upon their definitions. The Delphi consensus was conducted across five rounds. Questions with >70% consensus were deemed to have strong agreement, 60–70% consensus was deemed minor agreement, and <60% deemed no agreement. A final meeting was held to discuss any concerns and specific wording. Results: The Delphi consensus led to the development of four key categories: refractory migraine, probable refractory migraine, resistant migraine, and treatment-responsive migraine. Similar to the EHF 2020 definitions, refractory migraine requires treatment failure of all evidence-based classes, and resistant migraine requires failure of at least three classes. Probable refractory migraine criteria were designed to account for situations where treatment access barriers may prevent trials of certain medication classes (e.g. pediatrics, low to middle-income countries, lack of insurance coverage). Finally, treatment-responsive migraine criteria were developed to allow for standardization in research studies comparing refractory or resistant migraine to migraine that is treatment-responsive. Conclusions: These four categories may aid in enrollment for studies on pathophysiology, biomarkers, and new treatment targets. Clinically, the criteria for refractory and resistant migraine will help with clinical decision-making by reinforcing the need to try evidence-based treatments and by providing guidance regarding when to try more aggressive treatment approaches. These criteria may also increase attention to this population's disease burden to help advocate for them as a specific migraine subgroup. Field testing in diverse clinical settings will be needed, but it is recommended that ICHD-3 considers inclusion of these four categories in their appendix.

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)

This cross-sectional study compared patient satisfaction with headache care in Veterans Health Administration (VHA) Headache Centers of Excellence (HCoE) and HCoE facilities versus traditional headache care. Using the VHA Survey of Healthcare Experiences of Patients specialty care survey, we analyzed responses from 4317 (14% response rate) veterans with a VHA headache visit who received care from (1) a Veterans Affairs (VA) HCoE provider; (2) a non-HCoE provider within a VA medical center containing an HCoE; or (3) a provider in a VA medical center without an HCoE. Compared to patients at non-HCoE facilities, both HCoE patients and HCoE facility patients reported higher overall satisfaction with their VHA care in general (OR = 1.32, 95% CI = 1.05-1.64; OR = 1.46, 95% CI = 1.38-1.54), respectively. Despite a modest response rate, HCoE and HCoE facility patients reported significantly higher satisfaction across other domains including access and communication, in models adjusting for demographics. These findings advance the conversation regarding the value of HCoEs in delivering high-quality, patient-centered care and expanding HCoE resources may improve satisfaction. Future research should formally investigate methods of improving satisfaction.