CONTINUUM Lifelong Learning in Neurology

RECENT FINDINGS: The vast majority of patients presenting with headache in clinical practice have a primary headache disorder. The most common primary headache disorder in clinical practice is overwhelmingly migraine. Unfortunately, a substantial proportion of patients with migraine do not receive an accurate diagnosis. In addition, the clinical features of migraine overlap with secondary causes of headache, making a careful history and deliberative evaluation for warning symptoms or signs of a secondary headache disorder of paramount importance.

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Pathophysiology of Migraine

Recober, Ana MD

doi : 10.1212/CON.0000000000000983

Issue: Volume 27(3), June 2021, p 586-596

RECENT FINDINGS: Recent functional neuroimaging studies focusing on the nonpainful symptoms of migraine have identified key areas of the central nervous system implicated in the early phases of a migraine attack. Clinical studies of spontaneous and provoked migraine attacks, together with preclinical studies using translational animal models, have led to a better understanding of the disease and the development of disease-specific and targeted therapies.

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Acute Migraine Treatment

Ailani, Jessica MD, FAHS, FAAN

doi : 10.1212/CON.0000000000000956

Issue: Volume 27(3), June 2021, p 597-612

PURPOSE OF REVIEW: Migraine is a disabling disease of attacks of moderate to severe pain with associated symptoms. Every person with migraine requires treatment for acute attacks. Treatments can range from behavioral management and nonspecific medications to migraine-specific medications and neuromodulation. For many with migraine, having a combination of tools allows for effective treatment of all types of attacks.

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Preventive Migraine Treatment

Burch, Rebecca MD, FAHS

doi : 10.1212/CON.0000000000000957

Issue: Volume 27(3), June 2021, p 613-632

PURPOSE OF REVIEW: This article provides an overview of preventive interventions for migraine, including when to start and how to choose a treatment, pharmacologic options (both older oral treatments and new monoclonal antibodies to calcitonin gene-related peptide [CGRP] or its receptor), nonpharmacologic treatment such as neuromodulation, and preventive treatment of refractory migraine.

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Cluster Headache and Other Trigeminal Autonomic Cephalalgias

Nahas, Stephanie J. MD, MSEd, FAHS, FAAN

doi : 10.1212/CON.0000000000000965

Issue: Volume 27(3), June 2021, p 633-651

PURPOSE OF REVIEW: The trigeminal autonomic cephalalgias (TACs) are relatively rare, but they represent a distinct set of syndromes that are important to recognize. Despite their unique features, TACs often go undiagnosed or misdiagnosed for several years, leading to unnecessary pain and suffering. A significant proportion of TAC presentations may have secondary causes.

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Other Primary Headache Disorders

Smith, Jonathan H. MD, FAHS

doi : 10.1212/CON.0000000000000960

Issue: Volume 27(3), June 2021, p 652-664

PURPOSE: This article provides an overview of a diverse group of primary headache disorders that are categorized in the International Classification of Headache Disorders, 3rd Edition (ICHD-3), as "other primary headache disorders." This article provides clinicians with a distilled understanding of the diagnoses and their epidemiology, pathophysiology, and management.

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Cranial Neuralgias

Robertson, Carrie MD, FAHS

doi : 10.1212/CON.0000000000000962

Issue: Volume 27(3), June 2021, p 665-685

RECENT FINDINGS: Most cases of trigeminal neuralgia are related to vascular compression, a demyelinating plaque, or a compressive mass affecting the trigeminal nerve. However, recent studies have shown that up to 11% of patients have a family history of trigeminal neuralgia, suggesting that some patients may have a genetic predisposition to demyelination or nerve hyperexcitability. In these patients, trigeminal neuralgia may occur at a younger age, on both sides of the face, or in combination with other neuralgias.

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Headache in Women

Pavlovic, Jelena M. MD, PhD

doi : 10.1212/CON.0000000000001010

Issue: Volume 27(3), June 2021, p 686-702

PURPOSE OF REVIEW: Women are greatly overrepresented among patients seeking treatment for symptoms of headache pain in general and migraine in particular. Understanding the presentation of headache in women in relation to hormonal changes both during the menstrual cycle and throughout the life span is essential for appropriate diagnosis and treatment.

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Headache in Children and Adolescents

Szperka, Christina MD, MSCE, FAHS

doi : 10.1212/CON.0000000000000993

Issue: Volume 27(3), June 2021, p 703-731

RECENT FINDINGS: The guidelines for acute and preventive treatment of migraine were updated in 2019. These guidelines summarize the available evidence and outline the questions that should be addressed in future research. The US Food and Drug Administration (FDA) approval of several new classes of drugs and devices to treat adult migraine in the past few years has resulted in ongoing or planned pediatric trials.

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Clinic-based Procedures for Headache

Robbins, Matthew S. MD, FAAN, FAHS

doi : 10.1212/CON.0000000000000959

Issue: Volume 27(3), June 2021, p 732-745

RECENT FINDINGS: After pivotal clinical trials, onabotulinumtoxinA has become an established preventive therapy for chronic migraine; it is better tolerated than many other treatments and may be useful for other headache disorders. Peripheral nerve blocks, especially greater occipital nerve blocks, have amassed evidence from randomized trials in the acute and short-term preventive treatment of migraine and cluster headache. Trigger point injections and sphenopalatine ganglion blocks have recent trials suggesting efficacy and safety in properly selected patients. Medical education initiatives are needed to train neurologists in these procedures to help manage the large population of patients with headache disorders who need them.

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Spontaneous Intracranial Hypotension

Wang, Shuu-Jiun MD

doi : 10.1212/CON.0000000000000979

Issue: Volume 27(3), June 2021, p 746-766

RECENT FINDINGS: The hallmark symptom of spontaneous intracranial hypotension is acute orthostatic headache; however, clinical presentations can be heterogeneous. New evidence shows that lumbar puncture is not always necessary or sufficient to establish the diagnosis. Some patients may have normal opening pressure, which suggests that insufficiency of CSF volume (hypovolemia) rather than CSF pressure might be the underlying mechanism. Several neuroimaging modalities can aid in diagnosis and localization of the CSF leakage, including brain MRI, spinal MRI, CT myelography, digital subtraction myelography, and radionuclide cisternography. Complications, such as subdural hematoma, can lead to a change in the headache pattern and potentially life-threatening consequences. Conservative treatments, such as fluid supplementation, can provide temporary relief; however, epidural blood patches, especially targeted ones, are more effective and definitive. For patients with refractory spontaneous intracranial hypotension, surgical repair of spinal CSF leakages should be considered.

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False Claims Act Overview and Implications for Neurologists

Rose, Rachel V. JD, MBA; Kass, Joseph S. MD, JD, FAAN

doi : 10.1212/CON.0000000000000976

Issue: Volume 27(3), June 2021, p 767-772

ABSTRACT: The US Department of Health and Human Services Office of the Inspector General identifies the five most important federal fraud and abuse laws that are most applicable to physicians: the False Claims Act, the Anti-Kickback Statute, the Physician Self-Referral Law (Stark Law), the Exclusion Authorities, and the Civil Monetary Penalties Law

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