query object

    array(20) {
  [0]=>
  int(110503)
  [1]=>
  int(104777)
  [2]=>
  int(104722)
  [3]=>
  int(101618)
  [4]=>
  int(101246)
  [5]=>
  int(101149)
  [6]=>
  int(100940)
  [7]=>
  int(100328)
  [8]=>
  int(100049)
  [9]=>
  int(70794)
  [10]=>
  int(116973)
  [11]=>
  int(116821)
  [12]=>
  int(116606)
  [13]=>
  int(116552)
  [14]=>
  int(116358)
  [15]=>
  int(116201)
  [16]=>
  int(116071)
  [17]=>
  int(115914)
  [18]=>
  int(115792)
  [19]=>
  int(115529)
}

feature query posts

    array(4) {
  [0]=>
  object(WP_Post)#7829 (24) {
    ["ID"]=>
    int(116973)
    ["post_author"]=>
    string(5) "45459"
    ["post_date"]=>
    string(19) "2024-03-22 09:20:00"
    ["post_date_gmt"]=>
    string(19) "2024-03-22 13:20:00"
    ["post_content"]=>
    string(18618) "

What’s the best way to curb vaping, especially among adolescents and young adults?

Despite Food and Drug Administration (FDA) regulation, vaping is flourishing, with a steady stream of e-cigarette products finding their way into stores as well as into the hands, lungs, and bloodstreams of America’s youth. Vaping, it seems, is the new smoking for teenagers and young adults.

“E-cigarettes have taken over the youth tobacco use landscape. They are the most commonly used tobacco product,” said Thomas Carr, Director of National Policy at the American Lung Association (ALA), in an exclusive interview.

Although there is not yet data to show whether vaping is as harmful as cigarette smoking, substantial harms have been documented — enough to show that vaping poses a threat to human health, especially to the lungs and the heart.1

Given that February has been designated by the Centers for Disease Control and Prevention (CDC) as heart health month, this report looks at what is being done — and what could be done — to curb youth vaping.

"
Taxation has worked well at reducing use in every other tobacco product, especially among youth. I feel pretty confident in saying it will reduce vaping rates.

“The [American Lung] Association is committed to reducing and eliminating use of e-cigarettes among youth users,” noted Carr. Moving forward, he added, the ALA is hoping to see:

  • better FDA regulation and enforcement with respect to e-cigarettes;
  • high levels of taxation on e-cigarettes;
  • an end to the sale of flavored e-cigarettes (a measure that has been taken by only 5 states thus far);
  • incorporating vaping into existing state tobacco-control programs;
  • more media campaigns against e-cigarette use; and
  • community education in schools about the dangers of vaping.

The American Heart Association (AHA) is similarly dedicated to curbing youth vaping, said Rose Marie Robertson, MD, AHA Science and Medical Officer, in an exclusive interview. “A comprehensive approach is needed to help reduce vaping among young people,” she said.

“We have heard from young people who recognize the dangers of vaping and their own addiction to these products, but don’t feel like they know the proper strategies to quit or even how to say no to e-cigarettes and other dangerous products to begin with,” said Robertson. “Therefore, our efforts focus on significant investments in research, youth engagement efforts, and support for schools to choose restorative rather than punitive approaches to students who vape,” she noted.

The AHA and the ALA are also united in their desire for better regulation and enforcement of vaping by the FDA and states.

Statistics on Youth Vaping

Although there has been “some decline since 2019” in the use of e-cigarettes, said Carr, “e-cigarettes remain the most commonly used tobacco product.”

CDC’s 2023 National Youth Tobacco Survey confirms that e-cigarettes are the most commonly used tobacco product by youth in the US. The 2023 survey found that 10% of high school students and 4.6% of middle school students used e-cigarettes. Notably:2

  • 25.2% of current youth e-cigarette users used an e-cigarette product every day;
  • 34.7% of youth e-cigarette users surveyed reported using e-cigarettes during at least 20 of the previous 30 days;
  • 89.4% of youth users used flavored e-cigarettes; fruit flavors were most popular, followed by candy, desserts/other sweets, mint, and menthol;
  • 57.9% reported using products with “ice” or “iced” in the branding;
  • the most common e-cigarette devices used were disposables (60.7%) followed by prefilled/refillable pods (16.1%); and
  • the most popular brands included Elf Bar (56.7%), Esco Bars (21.6%), Vuse (20.7%), JUUL (16.5%), and Mr. Fog (13.6%).

Taxation

One under-utilized strategy that may effectively curb the use of e-cigarettes by both youths and adults is heavy taxation — meaning taxation at the same level as cigarettes, said Carr.

Currently, there is no federal tax on e-cigarettes, and only 31 states and the District of Columbia have enacted excise taxes on vaping products.3 The level of taxation varies widely, with some surcharges hardly noticeable, said Carr.

According to the Tax Foundation, a nonprofit organization that researches tax policy in the US and elsewhere, methods used to tax vaping vary. “Authorities tax based on manufacturer, wholesale, or retail price (ad valorem), volume (specific), or with a bifurcated system that has different rates for open and closed tank systems,” noted a Tax Foundation blog on vaping taxes. “Of those that tax wholesale values, Minnesota levies the heaviest tax at 95 percent, followed closely by Vermont at 92 percent. On the other end of the spectrum, Connecticut levies a 10 percent wholesale tax and Wyoming applies a 15 percent wholesale tax.”

Other states levy a per mL tax. The states with the lowest per milliliter (mL) taxations are Delaware, Kansas, North Carolina, and Wisconsin, with a rate of $0.05 per mL. Louisiana has the highest rate per mL, after tripling this rate to $0.15 per mL in 2023, the blog noted.3

“Taxation has worked well at reducing use in every other tobacco product, especially among youth. I feel pretty confident in saying it will reduce vaping rates,” said Carr.  “We’re still sorting through what completely works,” he added.

FDA regulation

The FDA is acutely aware of the dangers that e-cigarettes pose to youth. A focused segment of their Comprehensive Plan for Tobacco and Nicotine Regulation aims to prevent youth from accessing e-cigarettes and other tobacco products. The FDA has claimed that “significant regulatory and research efforts related to access, marketing, and education are already underway.”4

Regulation enforcement for e-cigarettes is a stated FDA priority. As former FDA Commissioner Scott Gottlieb, MD, said in a 2019 press release, “As the number of children using e-cigarettes remains at epidemic levels, our enforcement work has been one cornerstone of our efforts to protect youth from the dangers of tobacco products.” Gottlieb noted that the FDA had been involved in “vigorous enforcement efforts.” These included “a number of actions to combat the illegal sales of e-cigarettes to youth at brick-and-mortar and internet storefronts, as well as steps to target companies engaged in kid-friendly marketing that can increase the appeal of these products to youth,” and other actions “focused on both retailers and manufacturers.”5

In its Guidance for Industry issued in April 2020, the FDA laid out its enforcement priorities, announcing its intent to target any electronic nicotine delivery system (ENDS) product being sold after September 9, 2020, “for which the manufacturer has not submitted a premarket application.”6

FDA’s Guidance for Industry also stated that for products marketed “without FDA authorization, FDA intends to prioritize enforcement against: [1] Any flavored, cartridge-based ENDS product (other than a tobacco- or menthol-flavored ENDS product); [2] All other ENDS products for which the manufacturer has failed to take (or is failing to take) adequate measures to prevent minors’ access; and [3] Any ENDS product that is targeted to minors or whose marketing is likely to promote use of ENDS by minors.”6

ALA, AHA: More Regulation, Better Enforcement Needed

Although the ALA is pleased that the FDA has not approved any flavored tobacco products to date, the FDA hasn’t yet enforced against any of these products, said Carr, who noted that the ALA would like to see a ban on the sale of all flavored tobacco products.7

https://infogram.com/pulm_feature_vapinglawsinfographic-1hxj48m5re8d52v?live

“The Lung Association has been dismayed at the delay with the FDA, although they have been making more progress recently. In some cases, the companies aren’t following the laws at all and selling products without premarket review. A lot of these products come from overseas so they’re hard to interdict — especially flavored disposable varieties,” said Carr.

Dr Robertson of the AHA echoed this sentiment. “While the FDA has fined retailers for continuing to sell unauthorized tobacco products, the agency must be given the proper resources to not only fund additional research on characterizing flavors, but also strengthen enforcement efforts to remove all illegal e-cigarettes from the marketplace,” she said.

“The [AHA] has continued to urge the Food and Drug Administration to complete its review of all e-cigarette product applications and we are working to ensure that state laws align with the federal minimum age for sale of tobacco products, which is 21,” she added.

E-Cigarette Smuggling

The smuggling of e-cigarettes across the border into the US complicates vaping regulation enforcement.7

“The Lung Association was pleased by the FDA announcement in May 2023 that e-cigarette products from several companies — Elf Bar, Esco Bar and Eon Smoke — were added to an FDA import alert red list with CBP [Customs and Border Protection] in order to be detained at the border without conducting a full inspection at the time of entry. Additional e-cigarette products have been added to the list,” stated the ALA’s State of Tobacco Control 2024 Report.7

“However, Elf Bar, the most popular e-cigarette with kids in 2023, was able to avoid enforcement initially by simply changing the name of its product, a disturbing loophole that needs to be closed. A recent US Department of Health and Human Services Inspector General report looked at FDA enforcement against retailers from 2010 to 2020, and found that FDA did not always follow through with more serious penalties such as civil monetary,” the ALA report continued.7

To date, the FDA and Customs and Border Protection have worked together to seize 1.4 million illegal cigarette products at the border, the report noted.7

The Manufacturers Strike Back

Taking a page from the litigation playbook of big tobacco companies, many e-cigarette manufacturers have filed lawsuits against FDA marketing denial orders for flavored e-cigarettes. The ALA has signed more than 20 amicus briefs with coalition partners in 2022 and 2023 asking courts to uphold these orders. To date, 6 of 8 US circuit courts have upheld these FDA marketing denial orders.7

In addition to leveraging litigation to fight to keep flavored e-cigarettes on retail shelves, manufacturers have kept on top of youth trends and interests when marketing their products to ensure sales. “They have proven expert at getting around regulations whenever they can by innovating their products,” Carr lamented.

Dr Robertson of the AHA agreed. “Big Tobacco and the vaping industry continue to foster addiction in younger generations by developing and marketing new tobacco products that appeal to youth and get them addicted.” This, of course, is nothing new, she added. “For decades, the tobacco industry has modified old products and created new ones to hook new users and keep them addicted, leading to tobacco use as a leading cause of preventable disease and death and a major risk factor in the development of heart disease and stroke.”

Second-Hand Vape

An issue of note that has yet to be talked about is the dangers of second-hand vape, said Carr. “Second-hand aerosol isn’t harmless,” he noted. This problem can be addressed by “adding e-cigarettes to smoke-free workplace laws that exist in a number of states … to prevent vaping in restaurants and other public places.”7

Public and Patient Outreach

Public outreach and education are imperative in the battle against rising rates of e-cigarette use in youth, said Carr. This includes efforts by clinicians, community education in schools, peer education on the dangers of tobacco and smoking, and the use of media campaigns.

One such media campaign is #DoTheVapeTalk.8 The American Lung Association (ALA) recently paired with the nonprofit Ad Council to launch this youth vaping awareness campaign, which involves a public service announcement showing how a dad talks to his teen about the dangers of vaping. #DoTheVapeTalk arms parents with the necessary facts to discuss the dangers of vaping with their kids “while they’re still willing to listen,” according to the ALA State of Tobacco Control 2024 report.7 Unfortunately, there is a paucity of youth-cessation resources like #DoTheVapeTalk, Carr noted.

“It’s vital that the harms and consequences of e-cigarettes and other addictive tobacco products be shared by trusted messengers, such as doctors and other health professionals, teachers, coaches and parents,” said the AHA’s Robertson. “But it is just as important that these influencers in young people’s lives specifically encourage them to quit and refer them to the proper resources and care to do so.”

Carr urged clinicians to take an active role in public and patient outreach. In particular:

  • When seeing kids in the office, physicians should ask about tobacco use and vaping, assess their desire to quit, and refer to counseling.
  • Pediatric pulmonologists can share stories about patients and vaping in the form of letters to the editor or community outreach.
  • Clinicians can support public policy efforts.
" ["post_title"]=> string(80) "Protecting Youth From the Dangers of Vaping: What’s Been Done, What’s Needed" ["post_excerpt"]=> string(171) "In recognition of the CDC’s designation of February as American Heart Month, this report looks at what is being done — and what could be done — to curb youth vaping." ["post_status"]=> string(7) "publish" ["comment_status"]=> string(6) "closed" ["ping_status"]=> string(6) "closed" ["post_password"]=> string(0) "" ["post_name"]=> string(28) "protecting-youth-from-vaping" ["to_ping"]=> string(0) "" ["pinged"]=> string(0) "" ["post_modified"]=> string(19) "2024-03-22 11:45:35" ["post_modified_gmt"]=> string(19) "2024-03-22 15:45:35" ["post_content_filtered"]=> string(0) "" ["post_parent"]=> int(0) ["guid"]=> string(45) "https://www.clinicalpainadvisor.com/?p=116973" ["menu_order"]=> int(0) ["post_type"]=> string(4) "post" ["post_mime_type"]=> string(0) "" ["comment_count"]=> string(1) "0" ["filter"]=> string(3) "raw" } [1]=> object(WP_Post)#7828 (24) { ["ID"]=> int(116821) ["post_author"]=> string(5) "45562" ["post_date"]=> string(19) "2024-03-15 09:20:00" ["post_date_gmt"]=> string(19) "2024-03-15 13:20:00" ["post_content"]=> string(29660) "

Case Study

A 46-year-old Black woman presents with a history of migraines since age 13. She is a veteran who served 8 years in the military and has been diagnosed with post-traumatic stress disorder (PTSD) and anxiety, and works in the legal office of a big metropolitan police department. She has a strong family history of migraines, anxiety, and depression. Her headaches have progressed from episodic to chronic over the past 33 years. Her typical headache presentation is a throbbing unilateral headache of moderate to severe intensity accompanied by severe photophobia and nausea. She saw a neurologist and was diagnosed with chronic migraine (CM) 12 years ago. She has tried many different preventive and abortive medications with varying degrees of success, and has gone to the emergency department (ED) on average 2 to 3 times a year for severe migraine attacks. Triggers for her migraines include stress at work, intense emotions, and weather changes. 

Three years ago, the patient was prescribed 2 calcitonin gene-related peptide (CGRP) inhibitors: a preventive monoclonal antibody (MAB)  (fremanezumab, 225 mg/month/sc) and rimegepant (75 mg orally disintegrating tablet) as abortive migraine treatment. On fremanezumab, the patient’s daily migraines decreased to 4 to 6 migraine days a month on average. Her diagnosis changed from chronic migraine (CM) to low-frequency episodic migraine (EM). She was able to receive both fremanezumab and rimegepant for 3 years with no co-pays using coupon cards. She has not been to the ED for migraine for 3 years and is very satisfied with her treatment, reported significantly increased quality of life, as well as a promotion at work. 

In January 2024, she was informed that her insurance will only cover 1 medication from the CGRP class of drugs. She continued to take fremanezumab as a preventive treatment, per recommendation of her provider, but her migraine attacks have increased to 2 migraines a week on average (8 migraine days a month) in the last month and are now classified as high-frequency episodic migraines, which do not respond to nonsteroidal anti-inflammatory drugs (NSAIDs). 

The patient had unsuccessfully tried sumatriptan as an abortive medication for her acute migraines in the past, which made her sleepy and decreased her productivity at work. She is upset as her bi-weekly attacks significantly affect her ability to function in a high-stress work environment and could jeopardize both her job security and, as a result, her insurance coverage. The out-of-pocket cost for rimegepant ($1,000/month) was cost-prohibitive for the patient. She is now looking for nonpharmacological options to manage her migraines.

Migraine Prevalence

Migraine is the third most prevalent disorder in the world (after dental caries and tension headaches) and affects 15% of adults in the United States.1 Globally, headache disorders are the second leading cause of years lived with disability.2 Migraine disease is the leading neurologic cause of disability in the world and negatively affects quality of life, financial stability, employment, and social, family, and personal relationships.3 Headaches account for more years lived with disability than all other neurologic disorders combined.4 Migraine headache is the most prevalent disabling long-term neurologic condition and the number one cause of disability in people younger than  50 years of age.5 On average, a person with migraine loses 9 work days annually due to migraine.6

https://infogram.com/ca_feature_migraine_figure1-1hnq41ok80y8p23?live

Migraine is a chronic neuroinflammatory disorder, with episodic exacerbations and age-dependent changes in clinical presentation and prevalence.7 Migraines are classified as episodic (1 to 14 days per month) or chronic (15 to 31 days per month). Migraine attacks last for 4 to 72 hours, with 90% of migraine patients reporting moderate to severe pain and more than 50% reporting severe impairment or reduced productivity.8

Many patients with migraine consider photophobia to be the most bothersome symptom. Photophobia occurs in a wide range of neurologic, behavioral, and ophthalmic conditions, with migraine being the most common. In migraine, light aversion can be provoked by bright or flickering light, color, or patterns.9 Because eyes convert wavelengths of light into electrical signals in the cortex, light can dramatically affect the brain. For example, computer monitors and TV screens keep patients awake as blue light generates signals that energize the brain. However, a newly discovered band of green light relaxes the brain, quieting hyperactive neurons.10

Modern understanding of migraine pathophysiology has radically changed the migraine treatment paradigm,11 ushering in a new era of migraine-specific therapies, including 5-hydroxytryptamine 1F (5-HT1F) receptor agonists, CGRP monoclonal antibodies, and CGRP receptor antagonists.12 The new injectable migraine preventive CGRP antagonists (erenumab, galcanezumab, and fremanezumab) have changed the paradigm of migraine preventive management, as they have a good tolerability profile and proven efficacy.13 Targeting the CGRP pathway to treat migraines is the first focused migraine-specific preventive option in the history of headache medicine, and is revolutionizing migraine preventive management.14 However, many insurance plans will only pay for a single medication from the CGRP class of drugs.

"
As patients can benefit greatly from holistic treatment, PCPs should emphasize collaborative management of migraine that includes pain management education, mental health resources and counseling, patient support groups, and resources to reduce physical, emotional, social, and financial stress.

In addition, significant racial disparities in management of migraine still exist. According to the American Migraine Foundation, Black patients present with higher pain intensity but are less likely to receive acute pain medication. Only 14% of Black patients receive prescriptions for acute migraine medications compared with 37% of White patients.15

https://infogram.com/mcg_infogram_ca_prescription_figure2-1hxj48m5dzd9q2v

Migraine Management: Beyond Medication

Migraine is one of the most common and debilitating diseases encountered by PCPs.16 Primary care is the predominant site for migraine consultation and management for 70.3% of patients. Primary care is also the most common setting for veterans with migraine, with 93.3% of female and 86.1% of male veterans treated by their PCPs.17 However, successful treatment of chronic migraine (CM) still remains one of the greatest challenges for any PCP due to the cost of the new CGRP medications, insurance coverage, high co-pays, and limited availability of manufacturer’s coupons. While PCPs should use appropriate medications to reduce frequency and intensity of migraine symptoms, they should also strive to improve patients' biopsychosocial adaptation to migraine.1

This includes a collaborative management of migraine that includes pain management education, mental health resources and counseling, patient support groups, and resources to reduce physical, emotional, social, and financial stress from migraine disease.1 Successful integration of conventional biomedical treatment and non-pharmacological management has been shown to provide better results than either approach alone.18

Start with patient education. Many patients are willing to try at least 1 or 2 non-pharmacological treatments recommended by the American Academy of Neurology and the American Headache Society: biobehavioral therapy, biofeedback, neuromodulation devices, supplements, nutraceuticals, and complementary and integrative treatment modalities. These decisions depend on multiple factors, including clinician discretion and patient comfort level.19

Although medications are successfully used for acute and preventive treatment, the cost and insurance coverage prevent many patients from accessing the full benefits of CGRP medications. In this case, a range of successful psychological interventions for migraine management is used. Most biobehavioral interventions are a form of behavioral or cognitive‐behavioral therapy (CBT).20

Neuromodulation

Neuromodulation, an increasingly popular evidence-based treatment for migraine, involves the use of specific devices to excite either the central nervous system (CNS) or peripheral nervous system (PNS) with an electric current or a magnetic field in order to regulate the abnormal behavior of neural pathways.3 The goals of acute and preventive treatment with neuromodulatory devices are the same as the goals of acute and preventive pharmacological therapies.21 At the time of this writing, the US Food and Drug Administration (FDA) has cleared 5 noninvasive neuromodulation devices for acute or preventative treatment of migraine: (1) Nerivio, which uses remote electrical neuromodulation (REN); (2) Cefaly, which applies external trigeminal nerve stimulation (eTNS); (3) gammaCore, which utilizes noninvasive vagal nerve stimulation (nVNS); (4) SAVI Dual (by eNeura), a single-pulse transcranial magnetic stimulation device (sTMS); and (5) Relivion, which applies external combined occipital and trigeminal neurostimulation (eCOT-NS).22

Three devices (REN, sTMS, and nTMS) are also cleared for the acute and preventive treatment of migraine in patients 12 years of age and older. Relivion is intended to treat patients 18 years of age and older.23 The American Headache Society (AHS) recommends a neuromodulatory device as an adjunct to the existing treatment plan and an inadequate response to a migraine-specific medication.21

The REN wearable device (Nerivio) achieves therapeutic effects by delivering transcutaneous electrical stimulation to the upper arm by inducing conditioned pain modulation and activating a descending endogenous analgesia. REN has shown good tolerability and safety, with paresthesia in the area of the device being the most common side effect.21 

Real-world data confirms that REN provides meaningful clinical benefits with very minimal side effects and may reduce the use of acute migraine medications.24 Data from a US-based study (NCT05760638) of patients with migraine showed that treatment with Theranica’s Nerivio remote electrical neuromodulation (REN) device was safe and effective over a 1-year period, with low rates of adverse events and sustained pain relief and freedom from migraine status. Each patient underwent an average of 8.05 (SD, 1.15) REN treatments over the 12-month period. At 1 year, consistent efficacy in at least 50% of all treatments per patient was achieved by 74.1% (180 of 243) of patients for pain relief, by 26.0% (67 of 258) for pain freedom, by 70.2% (177 of 252) for functional disability relief, and by 33.7% (85 of 252) for functional disability freedom. For associated symptoms, treatment response in half or more of patients’ treatments per month was achieved by 43.2% (95 of 220) of patients for photophobia, by 52.7% (107 of 203) of patients for phonophobia, by 70.8% (121 of 171) of patients for nausea/vomiting, and by 73.5% (180 of 245) of patients for at least 1 associated symptom.25

The REN device also includes a secured, personal migraine diary for patients to record their symptoms before treatment and 2 hours post-treatment. The device can be used as a standalone replacement for pharmacological options or as an adjunct to medications.21 A treatment lasts for 45 minutes, and a single device provides 18 treatments. The Nerivio Savings Program will bring the max out-of-pocket cost for the first device down to $49.26

The device is applied to the upper arm and can be worn under clothes but should not be used by people with uncontrolled epilepsy, or an active implantable medical device, such as a pacemaker, hearing aid implant, or any implanted electronic device. Such use could cause electric shock, electrical interference or serious injuries or medical conditions.26 For full user instructions and safety information, please see the Nerivio User Manual.27

Figure. Remote Electrical Neuromodulation (REN) Device26

Source: Theranica Bio-Electronics Ltd, manufacturer of Nerivio.

Biobehavioral Therapies as Preventive Migraine Treatment

Biobehavioral therapies as preventive migraine treatments are supported by grade-A evidence (as defined by the American Headache Society), and work best for patients who prefer nonpharmacologic interventions; who have either medical contraindications, poor tolerance or inadequate response to pharmacologic therapies; pregnant or lactating patients; patients with medication-overuse headache (MOH), high migraine-related disability, low health-related quality of life (HRQOL), or comorbidities; and patients with high stress levels or deficient stress-coping mechanisms.21,28

Evidence-based research has demonstrated that relaxation, biofeedback, and CBT strategies can be effective at reducing headache frequency and headache-related disability.  A therapist can help patients change maladaptive cognitive patterns and behaviors that increase migraine attacks. A significant improvement could result as quickly as after a 2-month course of CBT for migraine.29 

To calm one’s physiological response to stress, the following relaxation modalities can be used: biofeedback, progressive muscle relaxation, mindfulness meditation, and guided imagery. Combining CBT and relaxation modalities has been shown to produce more reduction in headache frequency and pain intensity.30

For patients with comorbid post-traumatic stress disorder (PTSD) symptoms and anxiety, eye movement desensitization and reprocessing (EMDR) is better than CBT in reducing post-traumatic symptoms and anxiety.31 A related modality, bilateral music (or EMDR music), produces 4 main effects: relaxation including decreased physiological arousal, increased attention, a distancing effect, and decreased worry.32

Case Resolution

Although the patient has been successfully treated with migraine-specific medication (fremanezumab, 225 mg/month) and can continue her preventive treatment, her acute migraine treatments needed to be modified due to new insurance restrictions. As a veteran and middle-aged perimenopausal Black woman employed in a high-stress occupation, the patient regularly faces multiple biologic, psychological, societal, and occupational stressors beyond her control.

The use of neuromodulation devices was discussed with the patient to help her manage her acute migraine attacks at work and she was prescribed REN as an abortive migraine treatment for acute attacks. The patient found REN helpful in aborting her acute attacks within 30 to 45 minutes after the first week of use.

As a patient with high migraine-related disability, high stress levels, and insufficient stress-coping mechanisms, the patient was also referred to a CBT therapist and started CBT and EMDR. She found these weekly appointments very helpful with her overall job-related stress reduction. At lunchtime and at bedtime, she started listening to EMDR music for 15 minutes, per the recommendation of her therapist. 

The weekly therapy sessions helped the patient realize that most of her current migraine triggers were occupational stressors beyond her control. The patient also realized that her military service and her high-stress police job had resulted in the development of mild to moderate PTSD symptoms. Learning to accept these facts was a huge step in her successful management. 

Although the patient was reluctant to try another triptan as an abortive treatment for her acute migraine attacks, eventually she agreed to try rizatriptan during acute migraine attacks. Rizatriptan was as effective as rimegepant, did not require prior authorization from her insurance, worked in 30 minutes, and did not cause any adverse effects.

To manage symptoms of photophobia, the patient invested in several non-pharmacological products available without prescription including a green light lamp (Allay) lamp to use in the evening.33 She also started wearing migraine glasses (Avulux), which significantly reduced her symptoms and allowed her to perform her job duties. The glasses filter up to 97% of amber, blue, and red light while allowing in over 70% of green light.34 Both the lamp and glasses were one-time financial investments.

After 3 months of combination treatment, the patient’s migraines decreased to 2 to 3 attacks a month. She expressed great satisfaction with her new treatment plan. She also started attending a Chronic Migraine Awareness support group online once a month. Her therapist also helped her modify her self-critical and perfectionistic attitude and change it to the more positive outlook of a female hero who has dedicated her life to serving her country and helping others while facing multiple challenges. 

Resources

To Find a Therapist 

To find a behavioral therapist who takes patient’s insurance, go to https://www.psychologytoday.com/us/therapists/category

Migraine Community Resources and Support Groups26

American Migraine Foundation – Facebook support group, advocacy training program

Association for Migraine Disorders – Provider and Patient Education resources, Shades for Migraine Awareness campaign

Chronic Migraine Awareness – Virtual support groups, Facebook groups, caregiver groups

Danielle Byron Henry Migraine Foundation – Free classes: Resources for Migraine Management courses for migraine patients, Yoga for Migraine, Migraine at School program

Disparities in Headache Advisory Council (DiHAC) – Cross-functional group of patient advocacy organization leaders, BIPOC headache patients, queer headache patients, and healthcare providers. The Council is tasked with identifying and supporting solutions to ALL health disparities in headache medicine.

Migraine.com – Articles on migraine and other headache diseases. Forums where patients can connect and ask questions.

Migraine MeanderingsFacebook support groups, patient education events with doctors and patient advocates

Migraine Again – Website with articles for patients by patients, Facebook support group

Migraine Nation – Patient connections in the Denver Metro area

Migraine Strong – Provides Migraine Education, Connection and Hope

Migraine World Summit – Patient education 

Miles for Migraine – Virtual and in-person support groups, Run, Walk, or Relax in person and virtual events, patient education events, social events, mindfulness virtual events, ACT Now advocacy training for patients and headache fellows

National Headache Foundation – Provider and patient resources, videos, Migraine at Work and Migraine University programs, CME and a free phone app for primary care providers. 

Parenting with Migraine – Facebook support group for parents who experience migraine disease

Patient Resources and Self-Help Tools

Relaxation videos from Dawn C. Buse, PhD, a licensed psychologist who specializes in migraine, other headache diseases, and chronic pain can be found on https://dawnbuse.com/relaxation/.

Bilateral music (EMDR music) is a type of music that one can listen to using headphones, where one can hear the music alternating between the left and right ears. This alternate stimulation of each side of the brain can be helpful when people have anxiety, stress, or trauma. 

Where to Find Bilateral Music Online:

" ["post_title"]=> string(85) "When Medication Isn’t Enough: Neuromodulation and Other Tools for Managing Migraine" ["post_excerpt"]=> string(100) "Primary care is the predominant site for migraine consultation and management for 70.3% of patients." ["post_status"]=> string(7) "publish" ["comment_status"]=> string(6) "closed" ["ping_status"]=> string(6) "closed" ["post_password"]=> string(0) "" ["post_name"]=> string(37) "neuromodulation-for-managing-migraine" ["to_ping"]=> string(0) "" ["pinged"]=> string(0) "" ["post_modified"]=> string(19) "2024-03-15 04:46:42" ["post_modified_gmt"]=> string(19) "2024-03-15 08:46:42" ["post_content_filtered"]=> string(0) "" ["post_parent"]=> int(0) ["guid"]=> string(45) "https://www.clinicalpainadvisor.com/?p=116821" ["menu_order"]=> int(0) ["post_type"]=> string(4) "post" ["post_mime_type"]=> string(0) "" ["comment_count"]=> string(1) "0" ["filter"]=> string(3) "raw" } [2]=> object(WP_Post)#7824 (24) { ["ID"]=> int(116606) ["post_author"]=> string(5) "45554" ["post_date"]=> string(19) "2024-03-08 10:20:00" ["post_date_gmt"]=> string(19) "2024-03-08 15:20:00" ["post_content"]=> string(11349) "

Our easy-to-read fact sheets provide clinicians with reliable information to share with patients and their caregivers.

Pain occurring in the back can be a symptom of occipital neuralgia, migraine, or other causes. Pain from occipital neuralgia can cause headaches or migraine as a result of inflamed nerves that go from the top of the head down to the spinal cord. While there are many symptoms that overlap between occipital neuralgia and migraine, the treatments vary.

Occipital Neuralgia

Occipital neuralgia is a condition in which the nerves that run through the scalp are injured or inflamed, resulting in sudden stabbing or shooting pain that can be felt on the back of the head, upper neck, and forehead.1 Occipital neuralgia is a rare cause of severe headaches and can be difficult to treat.2

Pain can be felt on one or both sides of the head.1 In some patients, the scalp becomes extremely sensitive to even the slightest touch, making hair washing or lying on a pillow painful.2 In other patients, there may be numbness to the affected area or pain radiating toward one eye in particular.1 According to the International Headache Society, common triggers for occipital neuralgia include compression of the greater occipital nerve (90% of the time) or the lesser occipital nerve (10% of the time).3

Migraine Headache

A migraine headache, or migraine, is a disabling headache characterized by recurrent throbbing on one or both sides of the head and often associated with nausea and sensitivity to light or sound. Other symptoms can include mood and cognitive changes.4

Triggers for migraines include stress, sleep disturbances, menstrual cycle changes, weather changes, alcohol consumption, and emotional influences.4,5 Migraines are about 3 times more common in women than in men and research suggests that triggers may vary based on sex at birth.6 The most common triggers for women include menstruation, stress, and bright lights; common triggers for men include sleep deprivation, stress, and bright lights.4 There are 4 phases of a migraine:7

  1. Prodromal: Stage where symptoms normally appear. This occurs approximately 24 to 48 hours before the headache starts.
  2. Aura: Approximately 25% of patients with migraine experience aura, which can be present visually (eg, bright lights), through sound (eg, music, noises, tinnitus), through feel (eg, tingling or numbness), or through motor changes (eg, weakness on one side of the face or body).
  3. Headache: A painful throbbing or pulsating on one or both sides of the head with or without nausea or vomiting.
  4. Postdromal: Stage that includes residual headaches and is accompanied by extreme tiredness or exhaustion.

A diagnosis for migraine without aura includes at least 5 migraine attacks that fulfill the below criteria:8

  • lasts at least 4 to 72 hours if untreated;
  • has at least 2 of the following characteristics: unilateral location, pulsating, moderate or severe pain intensity, and aggravated by or leads to avoidance of routine physical activity; and
  • is associated with nausea and/or vomiting, avoidance of light, or avoidance of sound.

A diagnosis for migraine with aura includes at least 2 attacks that fulfill the below criteria:8

  • patient experiences at least 1 fully reversible aura symptom: visual, sensory, speech/language, motor, brainstem, retinal; and
  • has at least 3 of the following characteristics:
    • at least 1 aura symptom spreads gradually over 5 minutes,
    • 2 or more aura symptoms occurring in order
    • at least 1 aura symptom is unilateral,
    • at least 1 aura symptom is positive, and
    • the aura occurs during or within 60 minutes of headache.

Frequently Asked Patient Questions: Occipital Neuralgia vs Migraine

Diagnosis of occipital neuralgia vs migraine?

There isn’t one test to diagnose occipital neuralgia. A magnetic resonance imaging (MRI) test, CT scan, or X-ray allow for the visualization of surrounding soft tissues and can rule out underlying causes of pain. Your doctor may make a diagnosis using a physical examination to find tenderness and may temporarily treat it with an occipital nerve block. Relief from a nerve block may help confirm the diagnosis.2

A diagnosis for migraine with or without aura requires that the patient experience multiple migraine attacks that fulfill the criteria determined by the International Headache Classification Disorders III edition. A summary of the fulfillment criteria is outlined above.

What over-the-counter (OTC) medications can I use to treat my symptoms? 

OTC management options for occipital neuralgia include nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (Advil®) or naproxen (Aleve®). Other treatments may include heating pads or devices that are placed at the location of pain. Physical therapy and massage therapy can also help to relieve pain caused by occipital neuralgia.2 

Migraine can be treated with NSAIDs similar to those used to treat occipital neuralgia. Other medications that can be used to treat migraine include aspirin (Bayer®), caffeine, acetaminophen (Tylenol®), or a combination of all 3 (Excedrin® Extra Strength).8

If OTC medications are not improving my symptoms, what other options are available?

There is no clear consensus on the management of occipital neuralgia. If pain associated with occipital neuralgia continues to persist, your doctor may prescribe tricyclic antidepressants, serotonin reuptake inhibitors, anticonvulsants, or opioids. More invasive options include local anesthetic agent with a steroid, botulinum toxin A, or surgery such as occipital nerve stimulation.2

If migraine continues to persist despite the use of OTC medications, your doctor may prescribe medications such as:8

Doctors may also recommend external trigeminal nerve stimulation, single-pulse transcranial magnetic stimulation (to be administered during aura), non-invasive vagal nerve stimulation, or non-invasive multichannel electrical stimulation of the trigeminal and occipital nerves for adults. 

Click here for PDF

" ["post_title"]=> string(67) "Occipital Neuralgia vs Migraine: Comparing Diagnoses and Treatments" ["post_excerpt"]=> string(178) "We've developed a comprehensive fact sheet for clinicians to share with patients and caregivers on the differences in diagnosis and treatment for occipital neuralgia vs migraine." ["post_status"]=> string(7) "publish" ["comment_status"]=> string(6) "closed" ["ping_status"]=> string(6) "closed" ["post_password"]=> string(0) "" ["post_name"]=> string(31) "occipital-neuralgia-vs-migraine" ["to_ping"]=> string(0) "" ["pinged"]=> string(0) "" ["post_modified"]=> string(19) "2024-03-08 12:58:32" ["post_modified_gmt"]=> string(19) "2024-03-08 17:58:32" ["post_content_filtered"]=> string(0) "" ["post_parent"]=> int(0) ["guid"]=> string(45) "https://www.clinicalpainadvisor.com/?p=116606" ["menu_order"]=> int(0) ["post_type"]=> string(4) "post" ["post_mime_type"]=> string(0) "" ["comment_count"]=> string(1) "0" ["filter"]=> string(3) "raw" } [3]=> object(WP_Post)#7822 (24) { ["ID"]=> int(116552) ["post_author"]=> string(5) "45459" ["post_date"]=> string(19) "2024-03-01 09:20:00" ["post_date_gmt"]=> string(19) "2024-03-01 14:20:00" ["post_content"]=> string(16478) "

National Women in Medicine Day, celebrated earlier this month, “acknowledges the vital roles that female physicians play in patient care, medical research and leadership within the health care field,” according to the American Medical Association (AMA).1

Established on February 3, 2018, (on the birthday of Dr Elizabeth Blackwell, who became the first US woman to earn a medical degree in 1849), the Women in Medicine Day observance “underscores the importance of fostering gender diversity and equitable opportunities in the medical profession, ensuring that the legacy of pioneering women physicians endures,” states the AMA website.1

Despite the vital role played by women in today’s health care system, female physicians still face many challenges. These challenges were highlighted at the fifth annual Women in Medicine Summit, a continuing medical education conference hosted late last year by Women in Medicine (WIM), a Chicago-based nonprofit organization. Since then, WIM has also worked with Sheryl Sandberg, author of the best-selling book Lean In: Women, Work and the Will to Lead and the creator of the nonprofit organization Lean In, to create professional networking and mentoring groups for female physicians.

To mark Women in Medicine Day as well as International Women’s Day on March 8, this report offers highlights of the latest Women in Medicine Summit along with details of WIM’s newly created Lean In Circles and other initiatives aimed at empowering and advancing women in medicine.

"
Female physicians encounter gender bias from both other medical professionals and patients, which often manifests as an overall lack of respect for their expertise and accomplishments.

Addressing Systemic Challenges

The first Women in Medicine Summit was organized in 2019 by Shikha Jain, MD, an associate professor of medicine in the Division of Hematology and Oncology at the University of Illinois in Chicago. Dr Jain subsequently founded the Women in Medicine organization. After hearing many of her female colleagues tell stories about the challenges and barriers they had faced early in their careers — challenges that she herself had also faced — Dr Jain determined that many of these problems were systemic and needed to be identified and addressed as such. She noted that many of these pressures are even greater for female physicians with intersectional identities, such as women of color.

As Dr Jain explained, “We wanted women to have a space to come together and talk about challenges. We wanted to provide tools, education, and opportunities for people to work towards changing the systems within their own institutions and organizations while also pursuing professional development and personal growth.”

Systemic challenges that still affect women in medicine include:

Gender Bias

Female physicians encounter gender bias from both other medical professionals and patients, which often manifests as an overall lack of respect for their expertise and accomplishments. Gender bias is often expressed unconsciously. For example, women in medicine are less likely to be called by their professional titles than are men. This under-use of titles and differential use of formality can influence perceived competence and authority.2 Various forms of gender bias can also indirectly contribute to the experience of imposter syndrome among women and even to physician burnout.3

Sexual Harassment

Awareness of sexual harassment as a problem in the medical field has grown over the past several years, yet incidents still occur. Dr Jain pointed out that the current systems do a poor job of holding harassers accountable; women who report harassment are often the ones who end up penalized. Trainees and young career professionals may especially be afraid to report harassment, fearing possible career retaliation, and offenders with the highest status are often the most protected.4

Balancing Career and Family

Another ongoing challenge for women is balancing their career responsibilities with their personal obligations, such as caring for children and aging parents. Institutions and workplaces differ in terms of the support and flexibility allotted to women during pregnancy and breastfeeding. Even beyond that, women often end up taking on more household and family responsibilities compared to their male counterparts.

Dr Jain pointed out that after a woman has a child, people sometimes make certain assumptions – such as thinking that motherhood will ultimately limit the woman’s career growth and options. These assumptions often affect the advice and opportunities offered — or not offered — to women who are both physicians and mothers. It should not be assumed that women with children can’t or shouldn’t take on demanding career roles, Dr Jain stressed; women should have the opportunity to make their own choices about how to best manage their professional and personal lives.

Compensation and Career Paths

Relatedly, salary gaps persist for women in every medical specialty. It’s not clear to what extent this is mediated by the different financial effects of parenthood on women compared with men, but the effect seems to persist even after accounting for factors such as maternity leave and part-time hours.5 Some evidence suggests that, on average, female physicians more often provide preventive care, perform more psychosocial counseling and patient-centered communication, adhere more closely to clinical guidelines, and provide care with better overall patient outcomes.6 Yet female physicians are sometimes not compensated for many of the activities that improve both patients’ experience and overall outcomes, like responding to patient online questions, spending more time on documentation, or helping with diversity, equity, and inclusion (DEI) initiatives.7

Women are now graduating from medical school at slightly greater numbers than men, although some specialty areas are still somewhat male dominated, such as orthopedics or neurosurgery. However, at the highest levels of medicine, women are significantly underrepresented compared with men — for example, as deans, department chairs, or full professors in academic medicine.8 This disparity may be partly because promotions are determined more by factors such as grants obtained and less by other factors that are also important to women, such as mentorship, volunteering, and advocacy work.

Sponsorship Is Key

One of the reasons Dr Jain wanted to found the Women in Medicine Summit and WIM nonprofit was to provide more opportunities for mentorship and sponsorship. Mentorship is key for providing guidance on specific career development steps, said Dr Jain, but sponsorship is also critical and is often absent for many women. Sponsorship goes one step further than mentorship: a sponsor actively advocates for the person being supported. For example, a sponsor may recommend someone for an opportunity in a hospital, and then mentor the person to succeed in that role, or nominate someone for an award or a position at a national organization.9,10

New Power to Create Change

Female physicians can best tackle these and other challenges by working collaboratively, said 2023 WIM Summit Keynote Speaker Megan Ranney, MD, MPH, an emergency physician, dean of the Yale School of Public Health, and an advocate for innovative approaches in public health. Collaborative efforts can improve an individual’s sense of empowerment and control, which in turn protects against burnout and promotes resilience, she noted. “We can’t control so many things, like viruses that emerge, or actions of the CEO at our hospital, but we can control the coalitions we make,” Dr Ranney said.

By working collectively, physicians and other advocates can achieve what otherwise would not be possible. This is part of the concept of “New Power,” an understanding of power that defines it as being open, participatory, and peer-driven — where power is shared with many, rather than hoarded by a limited few, and channeled for good.11 The “New Power” concept was detailed in the 2018 book New Power: How Power Works in Our Hyperconnected World — and How to Make It Work for You, by Jeremy Heimans and Henry Timms.

“Old Power” models are often authoritarian, competitive, exclusive, formal, and rooted in longstanding institutions, Dr Ranney explained. In contrast, “New Power” is more informally governed as well as more inclusive, collaborative, and transparent, and sometimes more temporary in nature, depending on the specific situation. Dr Ranney noted that this “New Power” approach is very consistent with the way many women intuitively come together and collaborate to solve problems.11

Although using “New Power” models can be very effective, “Old Power” and “New Power” systems exist on a continuum, and it’s critical to be realistic about working with existing structures. “As women in medicine, we are inherently living in an “Old Power” world, and we still need to follow “Old Power” structures,” Dr Ranney stressed.

To illustrate how “New Power” models can scaffold onto “Old Power” structures, Dr Ranney talked about her involvement with the American Foundation for Firearm Injury Reduction in Medicine (AFFIRM). In 1996, a congressional spending bill rider prohibited use of Centers and Disease Control and Prevention (CDC) funds for advocating or promoting gun control. In the 20 years that followed, research on firearm prevention ground almost to a halt. In contrast to other public health problems — such as car crashes or HIV deaths — which had improved with the aid of public health research and investment, the rate of firearm deaths was not improving. Dr Ranney said she was urged to stay away from this topic, as it would pose a problem for her career.

Determined to not let the issue drop, Dr Ranney instead connected with others who began talking about the topic publicly via social media and professional publications. When the National Rifle Association (NRA) sent a tweet criticizing “anti-gun” doctors for not “staying in their lane,” it set off an avalanche of tweets, in which many people both inside and outside the medical community shared their personal stories of gun violence.12,13 Eventually this work led to attention from “Old Power,” leading to over 75 million dollars over 3 years in monetary appropriations from the federal government, with additional donations from philanthropic organizations.

After AFFIRM achieved its initial aim of getting funding from the federal government, group leaders decided to merge with an “Old Power” organization, the Aspen Institute, in order to most effectively use resources. This example illustrates the fluidity of “New Power” movements and the potential need for such movements to scaffold onto existing “Old Power” structures as part of the change-making process.

“We want to organize and empower and work with inclusive communities, but for us to create true impact, we often need to work with universities or politicians or hospitals or the supply chain or other ‘Old Power’ institutions,” Dr Ranney explained.

Other Women in Medicine Initiatives

In addition to its annual summit, the Women in Medicine organization offers other leadership development and education opportunities for both women and male allies, a research lab to promote investigation into relevant topics, as well as a speakers’ bureau of that connects women in medicine with speaking opportunities.  

The 2023 Summit also was the launch point for WIM “Lean In Circles,” formed through a partnership with Sheryl Sandberg’s Lean In organization. Through these Lean In Circles, small groups meet virtually or in-person on a regular basis to share skills, expertise, and inspiration. A number of circles are now meeting on an ongoing basis, and opportunities are still available to found new circles (with the help of training and support from WIM) and to join existing circles.

The Lean In Circles offer a way for women in different fields or areas to collaborate, said Dr Jain. Different circles may have the goal of bringing together specific types of professionals, people from a particular locale, or individuals with certain common interests. This format “creates great opportunities for women to learn from each other, grow their networks, and potentially even help [one another] with professional advancement,” said Dr Jain.

WIM has also launched an auxiliary council, providing women across the country with more opportunities to take on leadership positions and plan events in their respective communities. Later this year, WIM is also launching an online social networking platform for female physicians. As Dr Jain explained, “We wanted to create a safe space for women physicians to have a social and professional network along with educational content.”

The sixth annual Women in Medicine Summit will take place September 13 to 14, 2024, in Chicago.

" ["post_title"]=> string(76) "Celebrating Women in Medicine: Progress, Challenges, and a New Kind of Power" ["post_excerpt"]=> string(166) "To mark Women in Medicine Day and International Women’s Day, this report highlights the latest Women in Medicine Summit and other initiatives for female physicians." ["post_status"]=> string(7) "publish" ["comment_status"]=> string(6) "closed" ["ping_status"]=> string(6) "closed" ["post_password"]=> string(0) "" ["post_name"]=> string(41) "women-in-medicine-progress-and-challenges" ["to_ping"]=> string(0) "" ["pinged"]=> string(0) "" ["post_modified"]=> string(19) "2024-03-01 05:33:45" ["post_modified_gmt"]=> string(19) "2024-03-01 10:33:45" ["post_content_filtered"]=> string(0) "" ["post_parent"]=> int(0) ["guid"]=> string(45) "https://www.clinicalpainadvisor.com/?p=116552" ["menu_order"]=> int(0) ["post_type"]=> string(4) "post" ["post_mime_type"]=> string(0) "" ["comment_count"]=> string(1) "0" ["filter"]=> string(3) "raw" } }

Featured Conference

American Headache Society

Clinical Tools

Powered by

Powered by   

CME/CE

MORE COURSES