Ana Marissa Lagman-Bartolome

Objective: Chronic headache, including migraine, is often associated with psychiatric conditions and adverse childhood experiences. This study examines the feasibility of Creating Calm (CC), a modified form of Emotional Awareness and Expression Therapy (EAET) that targets the emotional impacts of adversity in headache patients at a tertiary headache center. We also explored changes in headache days, disability, psychosocial well-being and possible mechanisms to plan for a randomized controlled trial. Methods: We conducted a prospective single-arm pragmatic pilot study to evaluate the feasibility of CC delivered as nine weekly group telehealth sessions in a tertiary headache clinic for adults with high-frequency episodic and chronic headache. Continuation of medical treatments was consistent with the pragmatic design. CC integrates education, mindfulness, cognitive and behavioral approaches, with an emotion-focused mind-body approach used in EAET. Feasibility was based on recruitment, retention and adherence measures. Acceptability was measured through participant satisfaction. We also explored changes in headache, psychosocial and mechanism measures before, after, and 2 months post-treatment. Results: Of the 33 participants recruited, 30 (91%) completed at least 7 out of 9 sessions, and 28 (85%) completed surveys. Participants reported satisfaction with the intervention (mean [SD] 47.6 [10.4] out of 60 Satisfaction with Therapy and Therapist Scale-Revised [STTS-R]). Exploratory analyses found a signal of reduction in headache days per month (mean [SD], 20.8 [7.6] to 15.5 [7.8], p = 0.004), disability, depression and improvement in global mental health following intervention. Conclusion: This real-world pilot study supports the feasibility and acceptability of modified EAET for patients with headache, warranting a prospective randomized clinical trial.

Background: A comprehensive understanding of the burden of migraine in Canada is needed to inform clinicians, clinical care and policymakers. This study assessed real-world healthcare resource utilization (HCRU) and costs of patients with episodic migraine (EM) and chronic migraine (CM) in Ontario, Canada. Methods: This study utilized administrative databases from the Institute for Clinical Evaluative Sciences (ICES) containing publicly funded health services records for the covered population of Ontario. Patients ≥26 years old with a migraine diagnosis between January 2013 and December 2017 were selected. EM and CM were inferred in eligible patients based on previously studied predictors. Cases were matched with non-migraine controls and followed for two years. Results: 452,431 patients with migraine, 117,655 patients inferred with EM and 24,763 patients inferred with CM were selected and matched to controls. 39.4% of the inferred EM and 69.3% of the inferred CM subpopulations had ≥1 claims of preventive medications. Migraine-specific acute medications were underutilized (EM: 1.0%, CM: 3.3%), and high proportions of patients utilized opioids (EM: 38.8%, CM: 64.9%). Mean all-cause two-year costs per patient for the overall migraine population and inferred EM and CM subpopulations were $7,486 (CAD), $11,908 (CAD) and $24,716 (CAD), respectively. The two-year incremental all-cause cost of migraine to the Ontario public payer was $1.1 billion (CAD). Conclusion: Migraine poses a significant unmet need and burden on the Canadian healthcare system. These results demonstrate a gap between real-world care and recommendations from treatment guidelines, emphasizing the need for improved awareness and expanded access to more effective treatment options.

Background: Self-guided Internet-based cognitive behavior therapy (iCBT) for migraine interventions could improve access to care, but there is poor evidence of their efficacy. Methods: A three-arm randomized controlled trial compared: iCBT focused on psychoeducation, self-monitoring and skills training (SPHERE), iCBT focused on identifying and managing personal headache triggers (PRISM) and a waitlist control. The primary treatment outcome was a ≥ 50% reduction in monthly headache days at 4 months post-randomization. Results: 428 participants were randomized (mean age = 30.1). 240 participants (56.2%) provided outcome data at 4 months. Intention-to-treat (ITT) analysis with missing data imputed demonstrated that the proportion of responders with a ≥ 50% reduction was similar between combined iCBTs and waitlist (48.5/285, 17% vs. 16.6/143, 11.6%, p = 0.20), but analysis of completers showed both iCBT programs to be superior to the waitlist (24/108, 22.2% vs. 13/113, 11.5%, p = 0.047). ITT analysis with missing data imputed showed no difference between the two iCBTs (SPHERE: 24.8/143, 17.3% vs. PRISM: 23.7/142, 16.7%, p = 0.99). Uptake rates of the iCBTs were high (76.9% and 81.69% logged in at least once into SPHERE and PRISM, respectively), but adherence was low (out of those who logged in at least once, 19.01% [21/110] completed at least 50% modules in SPHERE and 7.76% [9/116] set a goal for trying out a given trigger-specific recommendation in PRISM). Acceptability ratings were intermediate. Conclusions: Self-guided iCBTs were not found to be superior in our primary ITT analysis. Low adherence could explain the lack of effects as completer analysis showed effects for both interventions. Enhancement of adherence should be a focus of future research.

While tension-type headache (TTH) is the most common primary headache disorder, its effect according to sex, race and ethnicity remains unclear. We investigated disparities in sex, racial and ethnic representation in TTH clinical trials with comparison to global disease burdens. In this cross-sectional analysis, TTH clinical trials had female overrepresentation and racial and ethnic minority underrepresentation, which may affect understanding of the impact of TTH on different populations and personalized treatment development. Trial enrollment that is diverse and reflective of global disease burdens is crucial for improving study generalizability, understanding of diverse clinical presentations, and ensuring healthcare equity.

This study aims to gain a better understanding of the current scope of headache education received in Canadian medical schools. The Women’s College Hospital Centre for Headache at the University of Toronto, Canada, distributed a questionnaire to administrators and physicians involved in medical student education at Canadian medical schools and gathered information surrounding headache education. Overall, the degree of headache education varied between schools in regard to the hours of training that occurred and year the training took place. This survey provides an initial insight into the current standards of headache-specific education in Canadian medical schools.

In this brief communication, we discuss the current landscape and unmet needs of pediatric to adult transition care in neurology. Optimizing transition care is a priority for patients, families, and providers with growing discussion in neurology. We also introduce the activities of the University of Toronto Pediatric-Adult Transition Working Group – a collaborative interdivisional and inter-subspeciality group of faculty, advanced-practice providers, trainees, and patient-family advisors pursuing collaboration with patients, families, and universities from across Canada. We envision that these efforts will result in a national neurology transition strategy that will inform designation of health authority attention and funding.

Objective: In this narrative review, we summarize relevant literature pertaining to psychosocial risk factors for headache and migraine progression, current behavioral and psychological treatments, and consider promising treatments. Background: Headache and migraine are common and associated with significant burden and disability. Current treatments targeting psychosocial risk factors show modest outcomes and do not directly address the impact of early life adversity, including the development of maladaptive emotional processing. An intervention that could address these factors and include components of current evidence‐based interventions may lead to improved outcomes. Methods: We searched PubMed and Google Scholar for articles through December 2022. Search terms included headache, migraine, psychological interventions, behavioral interventions, cognitive–behavioral therapy, mindfulness, psychiatric comorbidities, adverse childhood experiences, trauma, and emotional processing. Results: Trauma and childhood adversity show a correlation with headache and migraine progression. Developmental adversity and trauma interfere with adaptive emotional processing, which may worsen headache and migraine symptoms, while adaptive ways of experiencing emotions are shown to improve symptoms. Current behavioral and psychological interventions, such as cognitive–behavioral and mindfulness therapies, are effective treatments for headache, but they produce small to medium effect sizes and do not directly address the impact of trauma and emotional conflicts—common factors that contribute to chronicity and disability, especially among certain subpopulations of headache patients such as those with migraine. Thus, there exists a gap in current treatment. Conclusion: There is a gap in headache and migraine treatment for those patients who have a history of trauma, childhood adversity, and maladaptive emotional processing. We suggest that an integrated psychological treatment that includes components of current evidence‐based interventions and addresses gaps by focusing on processing trauma‐related emotions may improve chronic and debilitating symptoms.

Adverse childhood experiences (ACEs) are a risk factor for progression from episodic to chronic migraine. Risk factors for medication overuse headache (MOH) are incompletely understood, but opioid overuse may carry a higher risk than overuse of other medication types. We performed a retrospective chart review investigating the frequency and impact of ACEs in patients with MOH. Of 68 included patients, 37 (54.4%) reported ACEs. There was no significant inter-group difference in baseline migraine disability assessment (MIDAS) or monthly headache days. Patients with ACEs reported more opioid overuse, and worse headache-related disability at follow-up, despite similar monthly headache days. Patients with ACEs require complex, multidisciplinary treatment.

Trainee Headache Education and Management Enhancement (THEME) Study