Associate Professor of Neurology, Mayo Clinic

Rashmi B. Halker Singh, MD

“There’s a lot of conversation happening, actually, at this meeting itself in terms of how we define status migrainosus. Is it different when someone has episodic migraine and then has a bout of status migrainosus? Can someone who has chronic migraine also have status migrainosus? And, do we treat that differently?”

International Classification of Headache Disorders, Third Edition

, as a debilitating migraine attack lasting for more than 72 hours, has been a challenge for physicians and patients.1 There currently are no evidence-based treatment guidelines for the condition, nor any rational-driven assessments with successful treatment outcomes. Findings from a 2020 observational study by Iljazi et al in 

 suggest that current treatment approaches to terminating status migrainosus are not satisfactory, pointing to a critical for a refined approach to define treatment response.

On top of this lack of standardized approach, there is limited epidemiological knowledge available. At the 2022 

American Headache Society (AHS) Annual Scientific Meeting

, June 9-11, in Denver, Colorado, a group of investigators including Rashmi Halker Singh, MD, FAHS, FAAN, associate professor of neurology, Mayo Clinic, and member, board of directors, AHS, presented data from their attempt to add to this lack of information, using the Rochester Epidemiology Project to identify incident cases of status migrainosus in Olmsted County, Minnesota between January 1, 2012, and December 31, 2017.

All told, the study identified an age- and sex-adjusted incidence rate of 26.60 per 100,000 (95% CI, 23.21-29.97). Those with status migrainosus reported a median age of 35 years (IQR, 26-47), and 88.6% (n = 210) of the individuals were women. Chronic migraine was recorded in 36.3% (n = 82) of people and aura in 35.7% (n = 76). At the time of presentation, the medication reconciliation reported involved triptan or ergotamine in 129 (55.4%) people and/or an opioid-containing analgesic in 43 (18.5%).

The median duration of attack was 5 days (IQR, 4-9), and the most frequently recorded triggers were stress (16.9%; n = 40) and too much/too little sleep (11.4%; n = 27). Recurrence occurred in 35 people (14.8%) at a median of 58 days (IQR, 23-130) following the initial attack. Notably, too much/too little sleep was associated with 12-month risk of recurrence (adjusted odds ratio, 3.59; 95% CI, 1.58-8.14; 

To find out the clinical implications of these data and about the difficulties in treating status migrainosus, 

 sat down with Halker Singh while on-site at AHS. She offered her perspective on the importance of collecting more information on status migrainosus and the need to develop a better approach and definition.

REFERENCES
1. Iljazi A, Chua A, Rich-Fiondella R, et al. Unrecognized challenges of treating status migrainosus: An observational study. 

. 2020;40(8):818-827. doi:10.1177/0333102420911461
2. VanderPluym J, Mangipudi K, Mbonde A, et al. Incidence of status migrainosus in Olmsted County, Minnesota, United States: Characterization and predictors of recurrence. Presented at: AHS Annual Scientific Meeting; June 9-11, 2022; Denver, CO. OR-17

Videos

The associate professor of neurology at Mayo Clinic and member of the board of directors at AHS shared her perspective on the importance of collecting more information on status migrainosus and the need to develop a better approach and definition. [WATCH TIME: 3 minutes]

The Incidence of and Difficulties in Defining Status Migrainosus: Rashmi Halker Singh, MD, FAHS, FAAN

"Despite how young we look, we both graduated from fellowship quite a while ago. I believe at the time there were 8 or 10 fellowship programs, and now there are over 40. That speaks volumes about how people are realizing the importance and value [in them], particularly in academic centers."

In recent years, there has been a lot of momentum built within the migraine field, mainly from the advancements in treatment options and the introduction of a new class of calcitonin gene-related peptide (CGRP) antagonists. Despite the positive progress, though, experts have continued to stress the lack of headache specialists for a disease that impacts nearly 10% of people worldwide and crosses over with several other neurological conditions.

The shortage of migraine specialists is not a new phenomenon. A 2013 study found uneven shortages across states, with 6 states having no migraine specialists at all. At the time, only 416 specialists were certified by the United Council for Neurologic Subspecialties to treat the estimated 36 million migraine sufferers over the age of 12. To combat this shortage, 

, chair and vice-chair of the Headache and Facial Pain Section of the American Academy of Neurology (AAN), explained that there have been increased efforts made to attract more young neurologists to headache medicine.

, April 2-7, in Seattle, Washington, Halker-Singh and Mathew sat down to discuss the ways of tackling this issue. Additionally, they touched upon the research they’re currently involved with and some of the necessary efforts to improve overall migraine and headache management.

The chair and vice-chair of the Headache and Facial Pain Section of the American Academy of Neurology provided insight on projects they feel are needed to advance the care of patients with migraine-related disorders. [WATCH TIME: 4 minutes]

Building the Next Generation of Migraine Specialists: Rashmi B. Halker-Singh, MD, FAAN, and Paul Mathew, MD, DNBPAS, FAAN, FAHS

"Hopefully, some of the newer intranasal delivery medications that are coming out will have trials looking at the acute cluster [headache]. That’s something we’re hoping to see come to fruition."

After more than 2 years of mostly virtual settings, clinicians from across the globe gathered in-person for the 

2022 American Academy of Neurology (AAN) Annual Meeting

, held April 2-7, in Seattle, Washington. Among the attendees were Rashmi B. Halker Singh, MD, FAAN, and Paul G. Mathew, MD, DNBPAS, FAAN, FAHS, the respective chair and vice-chair of the Headache and Facial Pain Section of the AAN.

For years, the duo have been leaders within the migraine field, both in research and in their clinical practice. Halker-Singh, a neurologist at 

 in Arizona, is also the department education coordinator for headache neurology and a member of the department of neurology’s Headache Medicine Search Committee. Outside of her practice, she remains a chair of the Women’s Leadership Subcommittee and ally of the DEI Taskforce Committee at the American Headache Society (AHS). In addition to his obligations with the AAN, Mathew is currently an assistant professor of neurology at Harvard Medical School (HMS) and an affiliate member of the HMS Division of Sleep Medicine. He is the current chairman of the AHS Procedural Special Interest Section, a member of the board of directors of the 

, and an executive board member of the Indian Medical Association of New England.

 to discuss some of the most pertinent topics related to headache and migraine medicine. In this interview, they provided commentary on some of the top focuses within the field, including the need to improve diagnosis rates, therapies for cluster headache, and attracting the next generation of headache specialists.

Click here for more coverage of AAN 2022.

The chair and vice-chair of the Headache and Facial Pain Section of the American Academy of Neurology discussed some of the key research needs for migraine care going forward. [WATCH TIME: 3 minutes]

Top Priorities Within the Migraine Field: Rashmi B. Halker-Singh, MD, FAAN, and Paul Mathew, MD, DNBPAS, FAAN, FAHS

Recently, sphenopalatine ganglion (SPG) block has been generating interest as another extracranial nerve block that may be used as part of treatment for migraine. The SPG is a group of neurons within the pterygopalatine fossa that lies behind the nasopharynx posterior to the middle turbinate and inferior to the sphenoid sinus.

 The SPG contains sensory and sympathetic fibers but is largely a parasympathetic structure and the largest extracranial parasympathetic ganglion of the head.

The SPG receives parasympathetic innervation from the superior salivatory nucleus in the pons and projects ipsilaterally to extracerebral and intracerebral arteries, the lacrimal gland, nasal mucosa, conjunctiva, and Muller muscle in the upper eyelid.

 The SPG is crucial for mediating the cranial autonomic symptoms produced by primary headache disorders, particularly trigeminal autonomic cephalalgias.

SPG activation in these disorders produces unilateral eye redness, rhinorrhea, eyelid edema, facial flushing/sweating, ear fullness, and ptosis. It also has been proposed that because the SPG provides parasympathetic input to cranial blood vessels, its stimulation, through the superior salivatory nucleus, causes plasma protein extravasation in the dura and may activate meningeal nociceptors and trigger a migraine through neurogenic inflammation.

 This provides a rationale for targeting the SPG as a potential migraine treatment.

SPG blockade was pioneered in 1908. Among primary headache disorders, it has been reported most often in the treatment of cluster headaches. SPG blockade can be performed topically by placing an anesthetic-soaked cotton-tipped applicator at the middle turbinate, by transnasal injection with endoscopic guidance, by lateral-infratemporal injection with fluoroscopic guidance, or by oral injection routes.

 Recently, several new devices have been marketed as a noninvasive way to deliver anesthetics topically to the nasal mucosa for SPG blockade.

To date, there is only 1 trial investigating the role of SPG blocks in the treatment of migraine. A recent small, industry-funded, placebo-controlled, randomized clinical trial evaluated an SPG block device, the Tx360®, as a treatment for chronic migraine.

The trial randomized 38 subjects with International Classification of the Headache Disorders 2 criteria for chronic migraine to either treatment with 0.5% bupivacaine or placebo (normal saline) with the device. The Tx360® device allows a small flexible catheter to advance intranasally below the middle turbinate and 0.3 mL of anesthetic or saline to be sprayed topically on the mucosa superficial to area of the SPG. In this trial, both groups received bilateral treatment twice weekly for 6 weeks. The primary outcome of the study compared numeric rating scale scores (NRS) following treatment at 15 minutes, 30 minutes, and 24 hours posttreatment with pretreatment baseline.

The results of the study showed that the treatment group had a significant decrease in pain at 15 minutes, 30 minutes, and 24 hours posttreatment (

<.001). In addition, the NRS showed a mild drop from a pooled baseline of 3.18 to 2.53 at 15 minutes, 2.41 at 30 minutes, and 2.85 at 24 hours in the active-treatment group.

Comparison between the two groups over the 6-week time course did not show a statistically significant decrease in NRS scores from baseline; however, the authors noted a trend toward improvement. No significant change in utilization of acute migraine medication was noted over the course of treatment between the two groups. There were no serious adverse effects in either group. Headache impact test scores (HIT-6) were lower in the active-treatment group by -4.5 points (

In a follow-up study, no significant differences in headache days, average pain, acute medication use, or quality-of-life measures were seen at 1 and 6 months posttreatment between active treatment and placebo.

 However, a trend of improvement in these areas was noted in the active-treatment group as compared with baseline.

The study had several limitations, including small sample size and difficulty with true blinding. Although the acute treatment results were statistically significant, the small magnitude of pain improvement combined with the feasibility of twice weekly procedures is of uncertain clinical relevance.

It is possible that a subgroup of migraineurs with more prominent cranial autonomic features may have a more robust response, and this would be an interesting future area of study. In addition, comparative studies with simple intranasal lidocaine spray, which has several small previous studies showing effectiveness in acute migraine treatment,

 would be important, because it is unclear from the current literature whether a directed device is truly required.

 The SPG is a promising target for migraine treatment. However, noninvasive device–mediated SPG blockade currently lacks robust evidence of efficacy for routine use as a migraine preventative and further study is warranted.

1. Piagkou M, Demesticha T, Troupis T, et al. 

The pterygopalatine ganglion and its role in various pain syndromes: from anatomy to clinical practice. 

Sphenopalatine ganglion neuromodulation in migraine: what is the rationale? 

Unitary hypothesis for multiple triggers of the pain and strain of migraine. 

4. Cady R, Saper J, Dexter K, Manley HR. 

A double-blind, placebo-controlled study of repetitive transnasal sphenopalatine ganglion blockade with Tx360® as acute treatment for chronic migraine. 

5. Cady RK, Saper J, Dexter K, et al. Long-term efficacy of a double-blind, placebo-controlled, randomized study for repetitive sphenopalatine blockade with bupivacaine vs saline with the Tx360® device for treatment of chronic migraine. 

2015 Mar 31. doi:10.1111/head.12546. [Epub ahead of print]

Intranasal lidocaine for treatment of migraine: a randomized, double-blind, controlled trial. 

Intranasal lidocaine for migraine: a randomized trial and open-label follow-up [published correction appears in 

Articles

The SPG is a promising target for migraine treatment, but robust evidence of efficacy for routine use of noninvasive device–mediated SPG blockade is needed. 

Sphenopalatine Ganglion Block for Migraine?

The Cefaly device is a transcutaneous supraorbital neurostimulation device recently FDA-approved for the prevention of episodic migraine. It is described as a futuristic-appearing silver headband that is worn over the forehead and generates stimulation to the supratrochlear and supraorbital branches of the first division of the trigeminal nerve (

). The device is programmed to run for a 20-minute session once activated: during that time it delivers increasingly strong biphasic electrical impulses.

In the United States the device is meant to be used daily in the prevention of episodic migraine; however, European versions of the device include “acute treatment” and “relaxation” settings that have not been reviewed in an available published study.

The device was validated in a double-blinded, randomized, sham-controlled trial of 67 subjects with episodic migraine (the PREMICE study) published in Neurology in 2013.

The study included adult patients who met ICHD-II criteria for episodic migraine, with or without aura, who experienced at least 2 migraines per month and who were not taking a preventative medication. Patients were excluded if they failed more than 3 migraine preventatives or also had the diagnosis of medication overuse headache. Subjects were randomized to either sham or treatment arms, and received treatment for 20 minutes daily. They were followed for 3 months.

In the treatment group, there was a trend toward a decrease in migraine frequency by the third month of treatment: 38% of those in this group had a greater than 50% reduction in migraine days compared to 12% in the sham group. There was no difference in migraine severity between the two groups. There was also no difference in outcomes between subjects who had migraine with or without aura.

While there were no significant adverse events during this trial, compliance was somewhat poor. The treatment group used the device on average only 62% of the time recommended, which was statistically similar to the sham group. The authors speculated the compliance issues were due to the relatively long 20-minute duration of each treatment session, rather than to any intolerances to the device. Overall the study demonstrated moderate, Class III level, evidence for the device for episodic migraine prevention.

The initial efficacy study was followed by a published survey of 2313 users of the Cefaly device in Europe to determine safety and tolerability.

 This survey found that the Cefaly was considered safe: only 4.3% of patients noted adverse events, none serious. The most common side effects were paresthesias to the area of stimulation and fatigue. The most serious adverse effect was a local skin reaction, presumed to be a response to the acrylate in the adhesive, and was seen in 2 subjects. After the 40-day trial, 54.4% of patients noted they were satisfied and would be willing to purchase the device for continued use.

In clinical practice, the Cefaly device can be considered a low risk preventative option that may reduce headache frequency in about half of patients with episodic migraine. While the available clinical data regarding its efficacy are modest, this may be in part to due to limited sample size in the initial clinical trial, poor adherence, and the current lack of additional confirmatory studies. It remains to be seen whether device is more helpful if used as an adjunct to preventative medications or other therapies, or if there are particular migraine subtypes in which the device may be particularly beneficial.

Given that it is an FDA-approved treatment for migraine, however, the Cefaly device has very little potential downside when compared with the side effect profile of many existing migraine medications. This is a welcome alternative for the many patients with migraine who have significant medication intolerances or who wish to try a non-pharmacologic approach to treatment.

The Cefaly device is currently available with a prescription through the company’s US website.

1. Schoenen J, Vandersmissen B, Jeangette S, et al. 

Migraine prevention with a supraorbital transcutaneous stimulator: a randomized controlled trial.

 2013;80:697-704.
2. Magis D, Sava S, Sasso d’Elia T, et al. 

Safety and patients’ satisfaction of transcutaneous supraorbital neurostimulation (tSNS) with the Cefaly device in headache treatment: a survey of 2,313 headache sufferers in the general population.

This FDA-approved treatment for migraine is a welcome alternative for patients who have significant medication intolerances or who wish to try a non-pharmacologic approach to treatment.