16th European Headache Congress

Priv. Doz. Dr.

Chair

The effect of botulinum toxin on anxiety and depression scales in chronic and high frequency migraneurs

Migraine

Neuromodulation and nerve blocks

Abstract text (incl. figure legends and references) Objective: To evaluate the impact of botulinum toxin (BoNT) on depression and anxiety scales in patients with migraine. Methods: Unicentric prospective study, with data analysis of 40 patients with chronic and high frequency migraine, refractory to several oral migraine-preventive medications, from 2016 to 2022. Data concerning demographic, clinical, comorbid, and therapeutic data was obtained. Validated clinical questionnaires were applied regarding pain characteristics (Head Impact Test-6 – HIT-6, Headache Under-Response to Treatment – HURT, and Migraine Disability Assessment - MIDAS), and psychological comorbid states (STAI Form Y-1 and Form Y-2 and Zung Depression Scale). SPSS® 28 was used for statistical analysis. Results: Eighty-seven-point five percent were female, with a mean age at the end of treatment of 46 years (σ=12.52). 30% of patients were previously diagnosed with an anxiety disorder and 37.5% had been diagnosed with depression. At 6 months of treatment, all scales showed a consistent reduction, especially HIT-6 (R2=0.932) and HURT (R2=0.956) scores. On linear regression analysis, a positive relation was found between both STAI Y-1 and STAI Y-2 and MIDAS scales (R2=0.785, R2=0.878, p2 = 0.213, R2=0.266, p&lt;0.05), where STAI Y-2 (anxiety state) seemed to have a better correlation with pain variation. No significant statistical relation was found when analyzing the groups that had been previously diagnosed with anxiety and/or depression. No significant correlations were found when analyzing Zung Depression Scale with pain scales. Conclusions: BoNT seems to have a positive effect on anxiety. This effect is possibly related with treatment efficacy, as measured by MIDAS and HIT-6, and it does not seem to be affected by previous diagnosis of anxiety disorders.

ePoster

Prof.

Associate Professor

Intravenous lidocaine and ketamine infusions for headache disorders: a retrospective cohort study

Medication overuse headache

Abstract text (incl. figure legends and references) Objective: To assess the safety of real-world efficacy and safety of intravenous lidocaine and ketamien for headache disorders. Methodology: Patients admitted between 01/01/2018 and 31/07/2021 were identified by ICD code and electronic prescription. Efficacy of infusion was determined by reduction in visual analogue score (VAS), and patient demographics were collected from review of the hospital electronic medical record. Results: Through the study period, 83 infusions (50 lidocaine, 33 ketamine) were initiated for a headache disorder (77 migraine, 3 NDPH, 2 SUNCT, 1 cluster headache). In migraine, lidocaine infusion achieved a ≥50% reduction in pain in 51.1% over a mean 6.2 days (SD 2.4). Ketamine infusion was associated with a ≥50% reduction in pain in 34.4% over a mean 5.1 days (SD 1.5). Side effects were observed in 32% and 42.4% respectively. Infusion for medication overuse headache (MOH) led to successful withdrawal of analgesia in 61.1% of lidocaine, and 41.7% of ketamine infusions. Conclusion: Lidocaine and ketamine infusions are an efficacious inpatient treatment for headache disorders, however associated with prolonged length-of-stay and possible side-effects.

HEADWORK as innovative tool for monitoring MABs efficacy in migraine and their influence on work activity.

CGRP inhibitors in the clinic

Abstract text (incl. figure legends and references) QUESTION:Monoclonal antibodies (MABs) have been a game changer in the treatment of migraine since their approval. Their efficacy is generally assessed with disease related metrics, but there is an increasing need to evaluate the impact of disease treatment on the global burden on patients and society. HEADWORK (HW) is a new evaluation tool, developed specifically to assess the impact on work tasks and reduced productivity of migraineurs. The aim of this study was to test the performance of HW on migraine patients treated with MABs. METHODS:We enrolled 56 patients receiving treatment with MABs at the Headache Centres of IRCCS "C. Besta" (Milan) or IRCCS "C. Mondino" (Pavia). They were assessed with the HW questionnaire at baseline and at the 3rd (M3) and 6th month (M6) of treatment. HW questionnaire consists of two sections: "Work-related difficulties" (HW1),11 items dealing with the degree of difficulty in general skills, problems solving or starting new task; "Factors contributing to work-related difficulties" (HW2), 6 items to address the degree to which some factors, such as noise and brightness of the workplace, negatively impact work-related tasks. RESULTS:Population: 10M and 46F, mean age(49.5y±8.7), mean age at onset of disease(18y±8),mean duration of disease(34y±11.2). We observed a marked and consistent reduction in "classical" indicators: monthly migraine days(15±5.9 at baseline, 5±6.27 at M3, 7±6.8 at M6), medications per month(15±9.3 at baseline, 5±13.7 at M3, 6±7.4 at M6), MIDAS(48±36.8 at baseline, 8.5±17.4 at M3, 5±11 at M6), HIT-6(66±3 at baseline, 62±8.3 at M3, 59±8.2 at M6).HW scores paralleled the above parameters: HW1(20±8.3 at baseline, 10.5±5.8 at M3 , 7±8.5 at M6), HW2(10.5±5.8 at baseline,6±4.4 at M3, 4±4.1 at M6). CONCLUSION:Our findings confirm the effectiveness of MABs. HW1 and HW2 also show an extremely positive impact on work related activities. HW appears a suitable tool to assess migraine-related work disability in these patients.

Professor

Optimization of Acute Treatment in Migraine Patients Treated with Monoclonal Antibodies Acting on the CGRP Pathway

Abstract text (incl. figure legends and references) Question: We aimed at assessing the impact of monoclonal antibodies targeting the calcitonin gene-related peptide pathway (CGRP-mAbs) on migraine outcomes that are not usually captured by literature, including the optimization of acute treatments. Methods: Consecutive patients with chronic or episodic migraine from the Headache Centers of Avezzano-L'Aquila and Naples, were included from March 2021 to June 2022. We included and followed up to 3 months patients starting treatment with any CGRP-mAb (erenumab, fremanezumab, or galcanezumab) at the baseline visit. All patients filled out the Migraine Treatment Optimization Questionnaire (MTOQ) at the start and 3 months after the start of treatment with CGRP-mAbs. During the study period, they completed a headache diary, where they reported the number of migraine days, and acute drug intakes. Results: We included 41 patients, (87.5% women; 72.5% with chronic migraine), with a median age of 46 [interquartile range (IQR) 42.25–55] years. At baseline – i.e., during the 3 months before treatment start –, median MTOQ score was 6 (IQR 3-8), with 30 median monthly migraine days (IQR 20-53) and a median drugs intake equal to 30 doses (IQR 20.25-60). At the 3-month follow-up, median mTOQ scores increased to 10 (IQR 7-13; pvs. baseline), indicating better optimization of treatment during, while median monthly migraine days decreased to 20 (IQR 9-27.5; p=0.002 vs. baseline). The median number of acute treatment monthly doses decreased from 30 to 20 (IQR 5.75-29.25, p=0.010 vs baseline), during the 3 months of follow-up. Finally, higher scores on the mTOQ negatively correlated with lower use of acute treatments (p=0.028). Conclusion: Our study shows that, 3 months of preventive treatment with CGRP-MoAbs led to a significant increase in mTOQ scores, meaning improved effectiveness of acute treatments, paralleled by decreased monthly migraine days and acute treatment use.

Prof. Dr.

Dr. Dr.

Personalized Low-Glycemic Nutrition for the Prophylaxis of Migraine: Real World Data from two Prospective Studies using a Digital Therapeutic

Data science in research and digital medicine

Abstract text (incl. figure legends and references) Question: Migraine is a headache disorder associated with a high socioeconomic burden. We developed a digital therapeutic that provides an individualized low-glycemic diet based on continuous glucose measurement. We aimed to find out if this digital therapeutic can serve as a non-pharmacological migraine prophylaxis. Methods: We have performed two prospective studies with migraine patients who used our digital therapeutic over a period of 16 weeks. The patients used a headache diary and recorded their migraine-related daily life impairment using the assessment tools HIT-6 and MIDAS for a pre versus post comparison. In addition, continuous glucose data of patients were compared to healthy controls. Results: In both studies, patients reported a reduction of headache and migraine days as well as reductions in HIT-6 and MIDAS scores. More specifically, migraine days decreased by 2.40 days (95 % CI [-3.37; -1.42]), HIT-6 improved by 3.17 points (95 % CI [-4.63; -1.70]) and MIDAS by 13.45 points (95 % CI [-22.01; -4.89]). Glucose data suggest that migraine patients have slightly increased mean glucose values as compared to healthy controls but drop into a glucose range that is below one&quot;s individual standard range before a migraine attack. Conclusion: In conclusion, our digital therapeutic is a non-pharmacological migraine prophylaxis that induces a therapeutic effect within the range of pharmacological interventions.

Prof

Iprazochrome and codeine – unlikely winners in migraine treatment in Poland. Targeting areas for improvement in migraine treatment (results from Migraine in Poland - a nationwide cross-sectional survey)

Abstract text (incl. figure legends and references) Question: Defining migraine patterns of care in Poland. Methods: The Migraine in Poland study is a nation-wide cross-sectional online survey conducted from August 2021 to June 2022. Participants were recruited through various channels, targeting mostly persons suffering from headaches. Survey protocol included questions allowing for diagnosis of migraine without aura (MwoA). Moreover, the questionnaire assessed consultation rates with a medical professional, as well as the use of abortive or preventive treatment, including non-pharmacological methods. Results: 3225 respondents aged 13 to 80 (mean age 38.94) submitted their answers via online questionnaire (87.10% were women). MwoA diagnosis was confirmed in 1679 (52.73%) of subjects, and 1571 (93.57%) of them consulted their headache with a medical professional in the past. 1553 (92.50%) of MwoA participants declared the current use of some form of treatment. Combination analgesics (especially containing codeine) were the most frequently used (n=991, 59.02%) abortive medications. These were followed by non-steroidal anti-inflammatory drugs and acetaminophen (n=1318, 78.50%). Triptans/ergots were used by 959 (57.12%) respondents. 383 (22.81%) resorted to abortive treatment with frequency indicating medication-overuse. Prophylactic treatment was at some point used by 599 (35.68%), while 193 (11.49%) were currently on preventive medications. The most frequently prescribed migraine prophylaxis was iprazochrome 151 (8.99%), followed by flunarizine 136 (8.10%) and topiramate 99 (5.90%). 23.28% used nutraceuticals for prevention (most frequently magnesium). Conclusions: The consultation rate for migraine patients in Poland was relatively high, and most of the subjects received the correct diagnosis. However, there is a need for improving standards of care, especially in regard to choice of prophylaxis. There is also a need to raise public awareness of the dangers of codeine-based medications (available OTC in Poland).

Alternative Indirect Treatment Comparisons for Eptinezumab in Migraine Prevention

Abstract text (incl. figure legends and references) OBJECTIVE: To explore impact of delivery mechanism on 12-week change from baseline in monthly migraine days (MMDs) for indirect treatment comparisons (ITCs) of eptinezumab and other aCGRP mAbs. Intravenous (IV) eptinezumab was investigated for migraine prevention in episodic (EM) and chronic migraine (CM). The comparator aCGRP mAbs are delivered subcutaneously (SC). Influence of delivery mechanism on placebo (PBO) response may bias ITCs. METHODS: Evaluated 3 methodologies: (1) standard Bayesian network meta-analysis (NMA) of phase 3 clinical trials assuming PBOs are identical; (2) network meta-regression (NMR) regressing treatment effect on PBO response; and (3) unanchored simulated treatment comparison (STC) using only active arm data. RESULTS: NMA results favored eptinezumab 300mg over fremanezumab in CM but favored erenumab 140mg and galcanezumab 120mg over eptinezumab 100mg in EM. NMR found all treatments were similar. Unanchored STC in EM favored eptinezumab for most comparisons, while all comparisons in CM favored eptinezumab (one-sided p&lt;0.05). See Tables 1 and 2. CONCLUSIONS: Assumptions about delivery mechanism have a large impact on ITCs. NMA and NMR results are mixed and rarely differentiate treatments. The unanchored STC strongly and consistently favored eptinezumab over other migraine preventive treatments. Consideration of which approach best reflects drug-placebo interactions and real-world outcomes would be beneficial to clinical and formulary decision makers.

Clinical pattern and response to treatment of predominant posterior migraine

Multidisciplinary clinical assessments

Abstract text (incl. figure legends and references) Background: There are few data about patients whose migraine headaches predominantly affect the head's back. Methods: Retrospective analysis of patients with the diagnosis of episodic or chronic migraine (according to the ICHD-3 classification) with posterior (occipital and back of neck) onset and predominant location from 2013 to 2020. Results: We identified 60 patients (mean age of headache onset: 27 years old; 81.6% were female) with episodic (78.3%) or chronic migraine (21.7%) with the posterior onset and predominant location. We identified 3 patterns of pain: patients with only posterior localized migraine (25; 41.7%); posterior and temporal or parietal migraine (posterior plus migraine; 16; 26.7%); and posterior onset with holocranial irradiation of pain (19; 31.6%). Regarding the headache characteristics, the most frequent pattern was bilateral or alternating pain (40% each); 63,4% described photophobia or phonophobia plus nausea or vomiting; 28.3% reported aura. The duration of each attack was mostly &lt;48hours (61.8%). Most patients had &lt;5 episodes of migraine attacks/month (51.8%). Only 10 patients (16.7%) reported modification of pain pattern since the onset of migraine. Regarding the treatment, 53.3% of the patients reported failure of at least one drug for the acute phase and 20% had a failure with at least one prophylactic drug. We identified that 18.4% of the patients also had a medication-overuse headache. Forty-three patients (71.7%) started a prophylactic drug. During follow-up, only 14 patients had treatment response (defined as a reduction in ≥50% of monthly headaches). Conclusions: In our cohort, patients with posterior predominant migraine have a young-onset headache, mostly localized pain, a short duration of each attack, and a low frequency of monthly headaches. In the future, it would be important to understand if there are clinical and therapeutic differences between patients with posterior versus anterior predominant migraine.

Classification of the pain curve and semiology of a migraine crisis

Secondary headaches

Abstract text (incl. figure legends and references) Objective: Previous studies have identified clinical characteristics of a migraine crisis; however, the evolution of the pain has been little studied. Our objective was to evaluate the semiology of a migraine crisis according to the type of pain curve. Methods: We analyzed the pain curve of patients with episodic migraine according to the current criteria (ICHD-III) included in a prospective real time study using a smartphone application. The follow-up period was one month, the patient marked start/end and evolution of the pain in at least 5 points depending on the intensity. Symptomatic treatment was allowed. At the end of the crisis, the patient completed the characteristics of the episode in the smartphone application. To generate the model K-means and a supervised validation technique using a logistic model tree was used. Results: A total of 344 migraine crisis from 51 patients (mean age 39 years, 90.2% women) were analyzed. Using the maximum pain intensity, time to achieve the maximum pain intensity, the relationship between both parameters and the total duration, all episodes were categorized in four types according to the main characteristics: 1(high intensity), 2(acute onset), 3(prolonged and intense) y 4(low intensity). Univariate analysis found statistically significant differences in the type of curve regarding the presence of nauseas (p&lt;0.001), sonophobia(p&lt;0.001), osmophobia(p&lt;0.03) and the number of simultaneous symptoms (p&lt;0.001); there were also differences in prodromic symptoms such as speech difficulties (p=0.029), dizziness (p=0.015), and postdrom symptoms such as appetite (p=0.029), whim (p=0.031), cognitive (p=0.019) and sleepiness (p=0.013). Conclusion: The evolution of the pain crisis can be successfully categorized in 4 types of curves, which represent different semiology characteristics of a migraine crisis

Evolution of practice guidelines for the treatment of acute migraine with Paracetamol (Acetaminophen)

Guidelines in headache

Abstract text (incl. figure legends and references) Objective: Qualitative assessment of evolution over time in different guidelines for paracetamol use in acute migraine Methods: The assessment was performed on 10 published guidelines from 5 scientific societies, American Headache Society (AHS), formerly American Academy of Neurology (AAN), French headache society ("Société Française d'Etudes des Migraines et Céphalées" - SFEMC), Canadian Headache Society (CHS), European Federation of Neurological Societies (EFNS), and European Headache Federation (EHF). Results: The comparison between earlier (1997-2014) and current (2009-2021) guidelines showed an evolution in the level of recommendations for paracetamol use in three of five scientific societies. There was a shift from no recommendation or recommendation only for mild attacks to recommendation for mild to moderate attacks without restriction in updated guidelines. Four of the five scientific societies (AHS, SFEMC, CHS, EFNS) now recommend Paracetamol for mild to moderate attacks. The 5th scientific society (EHF) recommends paracetamol when NSAIDs are contraindicated. Conclusion: This qualitative analysis emphasizes evolutions in practice guidelines over time in different scientific societies regarding the place of paracetamol in acute migraine. There was a positive evolution in paracetamol recommendations in the latest guidelines. Most guidelines now recommend it for mild to moderate pain.

Craniocervical Flexion Test in patients with migraine: discriminatory validity and accuracy

Abstract text (incl. figure legends and references) Objectives: To evaluate the discriminatory validity and provide a clinical cut-off of the craniocervical flexion test (CCFT) in migraineurs stratified by the report of neck pain, headache-related disability and neck disability. Methods: This study enrols 50 women without headache and 102 women with migraine recruited by convenience from a local tertiary care setting. The standard reference for migraine diagnosis was the International Classification of Headache Disorders. All volunteers underwent the CCFT and the patients with migraine patients answered the Migraine Disability Assessment (MIDAS) and Neck Disability Index (NDI) questionnaires. Discriminatory validity was verified by groups comparison. The clinical cut-off was obtained and classified according to the diagnostic accuracy of the CCFT. Results: The CCFT presented discriminative validity for comparing control (median = 28, IRQ = 6) with migraine (median = 26, IRQ = 4, p = 0.01) and migraine with neck pain (median = 26, IRQ = 4, p = 0.01), but not among the migraine subtypes with disability by migraine or neck pain related disability on the MIDAS and NDI. The diagnostic accuracies were classified between poor and not discriminating with the area under the receiver operating characteristic curve ranging from 57% to 69%, and non-acceptable values of sensitivity, specificity and positive and negative likelihood ratios. Conclusion: The CCFT is able to discriminate asymptomatic controls from migraine patients with and without neck pain. However, it cannot discriminate patients with migraine according to their pain-related disability. In addition, the CCFT does not offer a cut-off value adequate to identify the deficit of function of the deep flexor muscles in migraine patients.

Prevalence, disease profile, treatment patterns and burden of migraine in India: An internet-based survey

Abstract text (incl. figure legends and references) Objective: To study the prevalence, disease profile, and disease burden of migraine patients in India using an internet-based survey. Methods: This is the second part of an internet-based survey using a structured questionnaire conducted from 27th April to 31st July 2020. The first part assessed the impact of the COVID-19 lockdown on Indian migraine patients(1). Persons aged 18 years and above were invited to participate. Previously known migraine patients being treated by physicians or those fulfilling 2 out of 3 criteria (limitation of activities for a day or more, associated nausea or vomiting, and photophobia or phonophobia) were diagnosed as migraine patients. Results: 5694 persons registered and 4078 completed the full survey. Migraine was diagnosed in 984 (24.1%) participants [(635 females); mean age 35.32 ±11.16]. The mean migraine days per month was 7.24±5.84 (median=5; range=0.5-30). 109 (11.1%) had ≥ 15 headache days per month. Moderate to severe pain was reported by 923 (93.8%). Acute drug treatment was used by 877(89.1%) and 10.9% used non-pharmacological measures. Preventive medications were used by 569 (57.8%). Of patients who required preventive medications (≥ 4 attacks per month),18.5% did not receive them. Headache yesterday was reported by 571 (58%). 52% were willing to spend from INR 1000 to 10000 (13.6 USD to 136 USD) per month to cure their headaches completely. Conclusion: Approximately 1 out of 4 persons suffers from migraine in India. More than half of the migraine patients have a significant burden as reflected by their willingness to pay for its cure. Reference: 1. Chowdhury D, Krishnan A, Duggal A, Datta D, Mundra A, Deorari V, Tomar A, Koul A. An Internet-based study on the impact of COVID-19 pandemic-related lockdown on migraine in India. Acta Neurol Scand. 2021;144(6):706-716.

Use of Carbamazepine in Patients with Migraine-Comorbid Epilepsy in The Uzbek Population

Abstract text (incl. figure legends and references) Purpose: Choice of the most effective anticonvulsant in patients with migraine comorbid epilepsy (MCE). Materials and methods: In the period from 2018 to 2021, 18 patients with a diagnosis of migraine comorbid epilepsy applied to the department of the consultative polyclinic of the Tashkent Medical Academy. The patients underwent examination, ID-Migraine test, VAS, MIDAS, IPSS-QoL and EEG (again in a month), MRI of the brain. Results: The diagnosis was made according to the ID-Migraine criteria and the International Headache Classification 3-Revision (ICHD-3). Women 12 (66.7%), men 6 (33.3%), mean age 27.4±0.4. Neurologic examination without features. The mean VAS was 6.9, which indicates a pronounced intensity of headaches. According to the MIDAS scale, the average value is 15.6 - in the main number of patients, headache makes everyday activity difficult. The quality of life was reduced according to the IPSS-QoL test - global index = 39.9. In 14 (77.7%) cases, convulsions had a primary generalized character, in 4 (22.3%) patients, partial convulsions with transitions to generalization were determined. On the EEG foci were determined. Patients were divided into equal 2 groups, while the difference between the VAS, MIDAS and IPSS-QoL scores of the 2 groups was not statistically significant. In order to prevent migraine and relieve seizures, the first group of patients was given Carbamazepine 400-600 mg/day, the patients of the second group received Valproic acid 1000 mg/day. Upon re-examination, in all patients, the frequency and intensity of headaches decreased, daily activity and quality of life improved with a predominance in the first group. The EEG also showed positive dynamics with prevalence in the first group. Conclusions:Patients with MCE Carbamazepine gave a better result compared to valproic acid.This conclusion is not a criterion for choosing the drug and requires further research.

Treatment of Migraine in children and adolescents

Epidemiology

Abstract text (incl. figure legends and references) Migraine headaches in children may cause attacks that require abortive treatment. This study evaluated the incidence and efficacy of medications used for relieving migraine headache attacks in the pediatric population in Israel. Children 6–18 years of age who were diagnosed in our pediatric neurology clinic as having migraine headaches were enrolled into the study. Children and their parents recorded the children response to abortive treatment during consecutive migraine attacks. Fifty children, with 116 migraine attacks, were included in the study (30 females; mean age 12; range 6–18). Forty-seven (94%) reported on abortive treatment on the first migraine attack, 43 (86%) on a second migraine attack and 26 (52%) on a third migraine attack. During the first recorded migraine attack, 41 children (87.5%) reported taking only one type of medication for each headache episode, mainly ibuprofen or acetaminophen; less than a quarter used dipyrone (metamizol). Overall the improvement rate after two hours was 65.4% ± 27 for ibuprofen, 59.8 ± 35.3 for acetaminophen and 50.9 ± 27.4 for dipyrone without statistical difference. However, in the first recorded headache episode, males had a significantly better response to acetaminophen, compared to ibuprofen (95% ± 28 vs 75 ± 20). In conclusion, Children with migraine in Israel mainly use a single medication for each headache episode. Ibuprofen is the most commonly used abortive treatment; however, acetaminophen was associated with a better response among some of our patients.

Vitamins and migraine? Is it a matter? The possible effects and suggested pathophysiology

Abstract text (incl. figure legends and references) Objective: This review aims to look at the possible effects of vitamins on migraine in terms of pathophysiology and clinical presentation. In the last years, there are several articles indicative of the positive role of food supplements in migraine. Methods: Our research team has had some studies on the effects of vitamins on migraine. Here we are going to present the result of our studies on Vitamin B groups and Vitamin D. Result: It seems that the positive effect of Vitamin D3 on migraine is through suppressing neuroinflammation, such as its effect on CGRP, TGF-β, IL-17 levels and Th17/Treg-related cytokines balance. Supplementing migraineurs with vitamin D reduced the frequency of attacks, according to our study. In another study, we found that CGRP level was significantly lower following vitamin D supplementation than patients in the placebo arm (P-value = 0.022). Energy-deficit syndrome with mitochondrial dysfunction should be considered an upstream disorder in migraine pathophysiology. A majority of vitamin B group including Thiamine, Riboflavin, Niacin, and Pantothenic Acid are involved in metabolic and energy production pathways. Besides vitamin B12 is thought to be involved in important pathways that seem to be related to the pathogenesis of migraine including scavenging against NO and prevention of hyperhomocysteinemia. The findings of our study on migraine patients suggest that participants with lower vitamin B12 and higher MMA levels that are considered to lower functional activity of B12 had higher odds of migraine. Our team also found that supplementation with folic acid, vitamin B6, vitamin B12, and vitamin B1 significantly reduced headache frequency and intensity. Conclusion: It seems that deficiency of vitamin D3 and vitamin B group might lead to initiation or aggravation of migraine and supplementation of these vitamins could improve it possibly through their effects in the neuroinflammation pathway or/and energy generation in the mitochondria.

Vestibular Migraine: Management differences between General Neurology and Neuro-Otology

Abstract text (incl. figure legends and references) Question: Patients with a diagnosis of vestibular migraine (VM) are frequently referred to Neurology. Here we assessed if the management received is similar comparing a general with a specialised clinic. Methods: We audited clinical notes of patients seen in Neuro-Otology clinics (NO) and General Neurology clinics (GN) from the same tertiary hospital, from January 2021 to January 2022 diagnosed with VM. Demographics, treatment and outcomes were analysed with Jamovi. Results: Of VM patients (n = 85), 22 were seen in GN, and 63 in NO. Sixty-seven (77%) were females, and sex distribution was similar. Age (median, IQR) was 48.7, (38.8-56.6) in the NO group, and 35.8 (27.3-50.8) in the GN (P=0.031). Preventives were advised in 77% in NO in comparison with 59% in GN (P=0.107) and there were no differences in the choice of preventive between groups. Most patients were on tricyclics (38.8%) followed by beta-blockers (15.3%), supplements (14.1%), candesartan (11.8%) and antiepileptics (3.5%). In the GN group, 2 patients were on pizotifen, and in the NO, one patient was on sertraline, prochlorperazine, botulinum toxin A and perimenstrual naproxen, respectively. In the NO group, 17.5% of patients were discharged, in comparison with 54.5% in the GN (P&lt;0.001). Conclusion: VM patients seen in NO are older, require more preventive medication and follow-up than those seen in GN. This could be due to a more complex clinical presentation, delay in diagnosis or failure of previous management. Patients would possibly benefit from an earlier referral to a clinic with expertise in VM.

Poster session 15

Appointment

Chair

Programme