Prevention, New Advances Highlighted at American Headache Society Meeting

Woman with a headache grasping her head in pain
Article Summary
  • Miller School of Medicine neurology faculty and fellows presented the latest in headache and migraine research at the American Headache Society’s Annual Scientific Meeting.
  • Migraine is the third most common disease in the world and fourth in years lived with disability.
  • Dr. Teshamae Monteith presented an abstract on the use of a remote, electrical neuromodulation device to prevent migraine.

From sharing findings on a noninvasive, remote device to prevent migraine to a nasal spray to thwart an acute headache attack, University of Miami Miller School of Medicine neurology faculty and fellows were front and center at the American Headache Society’s 66th Annual Scientific Meeting.

The meeting coincided with National Migraine and Headache Awareness month. Fitting, according to Teshamae Monteith, M.D. ‘04, professor of clinical neurology and chief of the Headache Division in the Department of Neurology, given the exciting advances in headache medicine and the urgent need for more headache specialists and public awareness.

Migraine is the third most common disease in the world, affecting one in four households in the U.S.

Dr. Teshamae Monteith

“Migraine also is among the most disabling of neurologic disorders and ranks fourth in the world for years lived with a disability,” Dr. Monteith said. “This professional headache meeting, coupled with a month focused on increasing headache awareness, presents opportunities to improve clinical care, drive research and let patients know they no longer have to suffer.”

Dr. Monteith presented an abstract on the use of a remote, electrical neuromodulation device to prevent migraine, a study that was published in Practical Neurology. Patients wear the device on their arms and stimulate a pain-relieving response with an application on their phones.

“It’s clear that remote neuromodulation can be an effective way to prevent migraine days and has the benefit of also providing acute relief. With the Nerivio® device that we analyzed, we found significant differences in average number of migraine days in a group that had a very high migraine burden,” said Dr. Monteith, who reviewed this and other such technologies in a recent update on noninvasive neuromodulation devices published in Practical Neurology. “This device has excellent safety and tolerability, and, in addition to one’s current regimen, can be an integral part of their migraine therapy.”

Novel Non-oral Options

Little is known about the use of migraine-specific, calcitonin gene-related peptide (CGRP) receptor antagonists in people with depression and anxiety. Dr. Monteith co-authored a study looking at zavegepant, the first nasal spray targeting the CGRP receptor, which is indicated for the acute treatment of migraine with or without aura in adults.

Miller School faculty members at the American Headache Society meeting
Miller School faculty and fellows presented the latest migraine and headache research at the American Headache Society annual meeting.

She and coauthors found that long-term use of zavegepant nasal spray (as many as eight doses a month for up to 52 weeks) for acute treatment of migraine was well tolerated and had a favorable safety profile for adults with a history of anxiety and/or depression and for people using antidepressants.

“It was important that we studied this patient population, because migraine and anxiety/depression can be a risk factor far more difficult to treat than migraine or progression to chronic migraine,” Dr. Monteith said.

As headache care advances, so does the need for multidisciplinary collaboration.

“Successful treatment of migraine or headache sometimes requires consulting physicians in other specialties and looking at therapeutic options that we might not know exist without looking beyond headache medicine,” said Michelle Bravo, M.D., assistant professor of clinical neurology with a specialty in headache medicine at the Miller School.

Dr. Bravo discussed one of Dr. Monteith’s patients that Dr. Bravo helped care for during her headache fellowship at the Miller School. The patient had an uncommon neurological disorder—a cerebrospinal fluid (CSF) leak that exerted pressure on the brain and spinal cord. The patient presented with headache and a subdural hematoma (a collection of blood in the brain).

Drs. Monteith and Bravo collaborated with UHealth experts including Robert M. Starke, M.D., associate professor of neurological surgery and neuroradiology at the Miller School and co-director of endovascular neurosurgery at UM/Jackson Memorial Hospital. Dr. Starke suggested the patient might benefit from middle meningeal artery (MMA) embolization.

Dr. Michelle Bravo in front of her poster at the American Headache Society meeting
Dr. Michelle Bravo (left) in a discussion at the American Headache Society annual meeting.

“The advantage of MMA is it can be done in isolation or with a craniotomy. It’s less invasive than other options and can be a good alternative treatment, especially for older patients,” Dr. Bravo said. “But there isn’t a lot of research in headache or neurology literature about using MMA embolization for treatment of subdural hematomas presenting in the setting of CSF leaks.”

MMA cured the patient’s hematoma and relieved his headaches, validating the multidisciplinary approach. The meeting, Dr. Bravo said, gave her the opportunity to educate other headache specialists about MMA embolization for similar cases.

Miller School headache fellow Guy Greco, M.D., presented on a patient who had an ablation for atrial fibrillation, which triggered post-operative migraine attacks. 

“That phenomenon post-ablation has been described on occasion. Dr. Greco summarized it extensively across the literature and talked about the course in this patient, hypothesizing why patients, after post-cardiac ablation, may experience migraine,” Dr. Monteith said. 

Again, this was a case of collaboration. Raul D. Mitrani, M.D., professor of clinical medicine and director of clinical cardiac electrophysiology at the Miller School, successfully treated the patient’s atrial fibrillation and contributed to the case study.  

“Atrial fibrillation is the most common, sustained heart arrhythmia, with its incidence and prevalence increasing in the U.S.,” Dr. Greco said. “Catheter ablation is a common, first-line therapy in selected patients, so it’s important that we understand how migraine might impact these patients, post-ablation.”

American Headache Society leadership selected Liza Smirnoff, M.D., assistant clinical professor of neurology with a clinical specialty in headache at the Miller School, to co-chair the Society’s Refractory Headache Group.

The special interest section is focused on refractory, or difficult-to-treat, migraine and headache disorders that fail to respond to treatments.

“I’m excited to co-lead the group to work on a number of complex projects that will drive research and actual experience to an area of headache medicine that lacks information,” said Dr. Smirnoff, whose research focuses on women’s health and neurology, including the intersections of hormones and migraine. “I see a lot of women in clinical practice struggling with refractory headaches who experience migraine attacks as often as daily.”

Paige Kalika, D.O., assistant professor of clinical neurology and pediatric neurology, leads the pediatric headache clinic at the Miller School and Jackson Memorial Hospital. She recently published an update on a highly disabling, refractory headache disorder, new daily persistent headache.

“We don’t really understand what happens when migraine becomes refractory. One of the benefits that the Miller School offers is we do inpatient treatment for some headache patients with infusions of medication,” Dr. Kalika said. “We are among the academic programs in the country that can share its experience treating refractive patients to help develop best practices.”

Dr. Smirnoff has also been chosen as one of six American Headache Society junior members to participate in the Emerging Leaders Program for future leaders in the field.

“We aim to not only fuel the workforce, but to develop leaders in headache medicine, thereby increasing the positive impact on patient care,” said Dr. Monteith, co-chair of the society’s Leadership Development Committee.

The fellow population should mirror the ethnicity and race of their patients, according to Dr. Monteith. She points to Ricardo Herrera, M.D., a Miller School headache fellow who attended the meeting. Dr. Herrera is from South Florida and is of Cuban American descent. 

“Hispanics are underrepresented in headache clinics,” Dr. Monteith said. “Dr. Herrera is working with Dr. Bravo and our team on an important project to assess satisfaction of telemedicine among Hispanics with headache.”

Exposing neurology residents to headache medicine at meetings by the American Headache Society and other specialty groups also helps to build the workforce, according to Alexandra Cocores, M.D., assistant professor of clinical neurology in the Miller School’s Headache Division.

Dr. Cocores decided on a career as a headache specialist during her neurology residency at UHealth and Jackson Memorial Hospital, after she attended the American Headache Society meeting.

“I was interested in headache medicine and, every year, an early year resident is invited to join the American Headache Society meeting, for which the society pays for the resident’s travel to the meeting and attendance,” Dr. Cocores said. “It is meant to motivate more resident neurologists to enter the headache field, because there is such a big need.”

The emphasis on early clinical work at the Miller School can influence career decisions, according to Dr. Monteith.

“Dr. Cocores started seeing headache encounters with me since her first year in medical school,” Dr. Monteith said.

Improving Patient Care Efficiency

Patients are experiencing long waits to see headache physicians due to a shortage of specialists, said Dr. Monteith, who also moderated an American Headache Society workshop, “Putting Computers to Work for You: EMR and AI in Clinical Practice.”

“Utilizing digital health methods to improve quality of care and efficiency of care is yet another important endeavor that can help us reach and treat patients with headache more efficiently,” Dr. Monteith said. “Meetings like this allow us to educate one another about how to more efficiently utilize available tools, including artificial intelligence, to better care for our patients.”

Building the workforce in headache medicine starts at the Miller School for Dr. Monteith. She is grateful for the support of Jose Romano, M.D., professor of neurology and interim chair of the Department of Neurology at the Miller School, who Dr. Monteith said supports the division’s growth and professional development.

“I’m thrilled that our Miller School department is investing in neurology and in an increasing number of fellowship-trained headache specialists,” Dr. Monteith said. “That’s important because there is a massive need in South Florida, and we are one of only three headache fellowships in the state.”

Tags: Dr. Alexandra Cocores, Dr. Liza Smirnoff, Dr. Michelle Bravo, Dr. Paige Kalika, Dr. Raul Mitrani, Dr. Ricardo Herrera, Dr. Teshamae Monteith, headache medicine, migraine