geoffrey modest medical blogs

The American Academy of Neurology just published 2 guidelines on migraine in kids, one on prevention and one on treatment (see migraine pedi prevention neuro2019 in dropbox, or doi:10.1212/WNL.0000000000008105 and migraine pedi treatment neuro2019 in dropbox, or doi:10.1212/WNL.0000000000008095) --------------------- Migraine prevention -- 15 studies on migraine prevention in children and adolescents met criteria, from 2000-2017 -- medications:     -- topiramate: more likely than those receiving placebo to have a decrease in the frequency of migraine or headache days, moderate confidence in the evidence, standardized mean difference (SMD) relatively low at 0.391 (0.127 to 0.655)         -- insufficient evidence whether topiramate leads to at least a 50% reduction in headache frequency, very low confidence in the evidence     -- divalproex:         -- insufficie...

A large data-mining study from Denmark found significant increases in many cardiovascular outcomes in young patients with migraine (see migraine inc cvd risk bmj2018 in dropbox, or doi.org/10.1136/bmj.k96 ). Details: --data from all hospitals (including ED visits) and outpatient clinics in Denmark, using routinely and prospectively collected administrative and medical registries, in a country with a national health insurance program (ie, these results reflect the whole population of Denmark), from 1995-2013 (19 year study) --51032 patients with migraine, compared to 510,320 from the general non-migraine population, matched by age, sex, and calendar year --median age 35, 71% women, 1.4% diabetes, 3.2% obesity, 0.2% hyperlipidemia, 3% hypertension, 1.3% COPD, 2.4% cancer [ie, a pretty young, low-risk group] Results: --incidence of outcomes, comparing migraine vs general population, absolute numbers followed by adjusted hazard ratio (HR):    --25 vs 1...

a rather disturbing article was just published on trends in the ambulatory management of headache  (see  headache treatment trend JGIM 2015  in dropbox, or DOI: 10.1007/s11606-014-3107-3). this analysis looked at a nationally representative sample from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey (not including ER visits) and excluded those patients with red flags (neurologic deficit, cancer, trauma), with the following findings: --9362 visits for headache assessed, which represents 144 million visits over the study period of 1999-2011 --mean age 47, 75% female, 75% white --use of CT/MRI rose from 6.7% of visits in 1999-2000 to 13.9% in 2009-10. report did not differentiate CT vs  MRI. --referrals to other physicians rose from 6.9% to 13.2% --but, clinician counseling declined from 23.5% to 18.5% (counseling includes: lifestyle modification, diet/exercise counseling, stress...

headache recommendations -- choosing wisely G Geoff A. Modest, M.D.     Reply all | Sat 11/23/2013, 12:53 PM Geoff A. Modest, M.D. here is the latest of the choosing wisely suggestions (these are 5 suggestions by different specialties, with an eye to decrease unnecessary testing).  see  headache choosing wisely 2013  in dropbox, or go to URL  http://www.choosingwisely.org/wp-content/uploads/2013/11/AHS-5things-List_112013.pdf . 1. Don’t perform neuroimaging studies in patients with stable headaches  that meet criteria for migraine. (no increase in intracranial disease in pts with migraine) 2. Don’t perform computed tomography (CT) imaging for headache when  magnetic resonance imaging (MRI) is available, except in emergency settings (MRI more sens in picking up neoplasms, vasc dz, posterior fossa and cervicomedullary lesions, and high or low in...