Daniel Noam Lax

Aim: To evaluate the effect of treatment onset-time on the effectiveness of remote electrical neuromodulation (REN) for acute treatment of migraine. Methods: A real-world evidence study on migraine patients who treated with REN . REN treatments initiated within one hour of migraine attack onset (headache or aura) were classified as “early”; those initiated after one hour were classified as “late”. Treatments with baseline and two-hour reports were termed “evaluable” and analyzed. Results: Among 55,261 patients (37.9 ± 18.5 years, 83.4% female) who conducted 586,981 treatments, 56.5% were administered early. Effectiveness was calculated from “evaluable” treatments, varying between 6413 and 35,581 treatments depending on the outcome. Early treatments yielded higher responder-rates than late ( p < 0.001, significant following Bonferroni correction for multiple comparisons) for pain relief (65.1% vs. 46.6%; Δ = 18.5%), pain freedom (28.8% vs. 14.5%; Δ = 14.3%), functional disability relief (58.1% vs. 49.3%; Δ = 8.8%), functional disability freedom (35.4% vs. 20.9%; Δ = 14.5%), and freedom from photophobia (26.9% vs. 19.0%; Δ = 7.9%), phonophobia (34.0% vs. 25.9%; Δ = 8.1%) and nausea/vomiting (51.5% vs. 38.7%; Δ = 12.8%). Similarly, patients consistently treating early with REN (in 50% or more of their treatments) experienced higher efficacy ( p < 0.001). Similar effects were seen in youths. Conclusions: Early acute treatment with REN enhanced patient outcomes by up to two-fold compared to late treatment onset. Educating providers and patients to “treat as early as possible” boosts clinical and patient-centered results.

While migraine is the most common headache disorder in children and adolescents presenting to a neurologist, other primary headache disorders are important to recognize. Trigeminal autonomic cephalalgias represent a rare group of primary headache disorders with different characteristics, workup and management. Here, we present an adolescent with one common and one unique headache phenotype followed by a guided discussion of the differential diagnoses, workup, treatments and a brief summary of further management considerations.

Background: Nummular headache is a rare primary headache disorder potentially disabling and refractory to treatment. Of over 300 reported cases, only 9 are children. Design/Methods: We searched our institutional database and PubMed for “nummular headache” and synonyms and evaluated select articles from reference lists of substantial reviews. Results: Seven children were identified from our institution and nine from 107 unique publications. Mean age at onset was 9.7 and 11.9 years in our cohort and the literature, respectively, with a female:male ratio of 2:1. Location and quality varied, and allodynia was reported in five. Frequency ranged from every other week to continuous. Imaging was normal except in four cases. Migraine was often comorbid. Published cases were frequently refractory to treatment whereas four of our cohort improved with therapy for comorbid migraine. Conclusions: Nummular headache is rarely reported in children. We describe characteristics of seven new and nine previously published pediatric cases.

Objective: To investigate and characterize long‐term post‐ischemic stroke hemispheric and cellular loss, and fiber track injury. Also to investigate the sensory, motor and cognitive performance deficits for use in future restoration research. Methods: Middle cerebral artery occlusion (stroke) or sham surgery was performed in male Sprague‐Dawley rats. Neurobehavioral (sensory, motor, beam balance, reflexes, hindlimb and forelimb function, and cylinder placement tests) and cognitive (complex active place avoidance; APA and simple passive avoidance retention; PA tests) performance was measured. Electroretinograms (ERG), ischemic hemisphere, hippocampus neuronal loss and fiber track injury were measured. Results: Stroke surgery produced significant (p<0.01) sustained (10 weeks) deficits in motor, sensory, beam balance and hindlimb performance. Stroke produced large and prolonged cognitive performance deficits in APA learning (p<0.01) but smaller effects on PA retention. No effects on ERG or hippocampus neurons occurred but fiber tracts in the external capsule and striatum exhibited significant (p<0.01) damage. Conclusion: Specific, long‐term deficits in neurobehavioral tests were verified as endpoints for stroke restorative therapeutic research. Fiber track injury contributes to these deficits and is especially important for the complex cognitive control required for APA learning.