Program Abstracts tK AQQXaO 6cLHQtL¿c 0HHtLQg American Headache Society® June 26-29, 2014 Hyatt Regency Century Plaza Los Angeles, CA OR2 Sex, Stress, and Migraine: Differential Effects of Stress on the Migraine Relevant Responses of Males and Females Kaufmann, D.; Brennan, K.C. University of Utah, Salt Lake City, UT, USA.

OR1 Factors Associated with Emergency Department Visits for Migraine: An Observational Study Minen, M.T.1; Loder, E.W.1; Friedman, B.2 1 Graham Headache Center, Brigham and Women’s Faulkner Hospital, Boston, MA, USA; 2Emergency Medicine, Monte¿ore Medical Center and AlEert Einstein College of Medicine, Bronx, NY, USA.

Objectives: To test the effects of chronic stressors on two different models of migraine, in male and female mice. Background: The most common trigger of migraine is stress; the most potent trigger of migraine is menstruation. Two thirds of migraineurs are female. We wish to examine the interactions of sex and stress in migraine models. Methods: Adult males and females CBl mice were randomly divided into chronic stress and control groups. A chronic Eehavioral stress paradigm was done randomly, twice daily for 0 days. 2n day 1 anxiety measures were evaluated Eehaviorally using the open ¿eld test and elevated plus maze. Mechanical allodynia was evaluated in Eoth groups Eefore and after administration of 10 mg kg nitroglycerin (NTG) in a Elinded manner, followed Ey evaluation of cortical spreading depressions (CSD). Results: Chronically stressed male mice displayed anxiety Eehavior in the open ¿eld Eut not the elevated plus maze, while female mice did not show Eehavioral differences in either test. ,n the mechanical allodynia test chronically stressed males and females had a signi¿cantly lower pain threshold compared to their control counterparts, and a two-fold reduction in pain threshold after administration of NTG. No change in CSD frequency was seen Eetween chronically stressed and control male mice, however chronically stressed females showed a signi¿cant reduction in numEer of CSDs compared to controls. Conclusion: 2ur work Eegins to outline the effects of stress and sex differences on migraine. Chronic Eehavioral stress elicited a migraine-relevant pain phenotype in Eoth sexes, Eut Eut sexually dimorphic responses were oEserved in stress Eehavior and cortical excitaEility. These phenotypes underline the importance of sex differences in migraine, and open the door for further mechanistic evaluation. Supported Ey Migraine Research Foundation (DK, KCB);NS 083010(KCB)

Objectives: We sought to determine why patients with migraine present to an emergency department (ED). Background: Migraine is a signi¿cant puElic health proElem with consideraEle medical and economic consequences. Migraine accounts for more than 800,000 ED visits each year. The total national annual costs for ED visits is estimated to Ee 00 million. However, we were unaEle to identify any prospectively gathered data that examine reasons for an ED visit for headache. Methods: We prospectively interviewed 309 consecutive patients presenting to an urEan ED for headache. 3atients were asked 100 closed-ended questions regarding sociodemographics, headache history, and current headache attack. Research associates recorded the results of Erain imaging and spinal Àuid analyses if they had Eeen done. Two ED physicians independently coded the headache type Eased on the ,nternational Classi¿cation of Headache Disorders, 2nd Edition (,CHD-2) criteria. The primary outcome was the characteristics of the patients presenting to the ED and the reason for presentation to the ED. Results: 2f 18 patients who met migraine criteria,  (9C, 1, 83) had a primary care provider (3C3), approximately 90 had medical insurance, and 83 had drug coverage. 3 (9C, , 0) reported that they previously visited a doctor for headache.  (9C, 8, 2) previously received a migraine diagnosis. 22 (9C,1, 28) sought medical care for the current headache prior to ED presentation.  (9 C, 8, 3) took aEortive medication for migraine on the day of the ED visit. Median headache duration was 2 hours (,4R 12-2). 9 (9C, 2, ) screened positive for depression. The most common reason for visiting the ED was a perceived emergency condition or referred Ey MD (33.3). 2ther commonly cited reasons related to access to care. Conclusion: Most migraineurs presenting to the ED have a 3C3 and healthcare insurance. ED visits result from an inaEility to access care elsewhere and Eecause patients consider pain to Ee an emergent condition. Missed opportunities for diagnosis and treatment likely contriEute to ED visits. 1

Headache OR3 Inhibition of the p2x7 Receptor-Pannexin1 Pore Suppresses Spreading Depression and InÀammatory Downstream Mechanisms Chen, S.1; 4in, T.1; Seidel, J.1; Ferrari, M.2; van den MaagdenEerg, A.2; Ayata, C.1; Eikermann-Haerter, K.1 1 Neurovascular Research LaE, Massachusetts General Hospital, Charlestown, MA, USA; 2Department of Neurology, Leiden University Medical Centre, Leiden, Netherlands.

SD occurrence and SD-induced up-regulation of ,L-1`. The potential for p2x-panx1 antagonists in therapeutic suppression of SD and neuroinÀammation deserves further exploration. OR4 Acute Anti-Migraine Treatments Abort Established Central Sensitization of Trigeminovascular Neurons: Validation of a Novel Translational Approach Akerman, S.; GoadsEy, 3.J. Neurology, UCSF, San Francisco, CA, USA.

Objectives: To investigate the role of the ³p2x receptorpannexin1 (p2x-panx1) complex´ in spreading depression (SD) and consequent expression of the pro-inÀammatory cytokine interleukin (,L)-1`. Background: SD is a wave of neuronal and glial depolarization underlying migraine aura, and a likely headache trigger. SD also occurs in patients after stroke or trauma, and worsens the outcome. 32x is a purinergic receptor on neurons and glial cells that affects cereEral excitaEility and neuroinÀammation. ,t facilitates the release of glutamate and potassium, with potential relevance to SD susceptiEility and nociception. 32x exhiEits two possiEle conformations depending on its activation status – a ³channel form´ for small cations like calcium, and a ³pore form´ permeaEle to molecules up to 900 Da that opens upon sustained stimulation with AT3. The latter is presumaEly formed Ey the tight coupling of the p2x receptor to panx1 that was recently implicated in migraine pathophysiology, proEaEly due to inÀammasome activation following SD. Methods: We treated adult male rats with p2x inhiEitors targeting 1) Eoth ³channel and pore form´ (intracereEroventricular Brilliant Elue G and topical A3809), 2) ³channel form´ only (intracereEroventricular and topical calmidazolium), and 3) ³pore form´ only (intracereEroventricular Brilliant Elue FCF). We then measured 1) the electrical threshold to evoke SD, 2) the frequency of SDs during continuous topical 1M KCl or repetitive electrical stimulation (800+C every 6 min), and 3) cortical ,L-1` mRNA expression Ey qRT-3CR, h after KCl induction of six SDs over 1h. Male transgenic mice carrying the familial hemiplegic migraine type 1 R1924 mutation and wild-type mice (WT) were also tested for the effect of topical A3809 on SD frequency during continuous topical application of 300mM KCl. Results: ,nhiEition of the ³p2x-panx1 pore´ with Brilliant Elue G, A3809 or Brilliant Elue FCF suppressed KClinduced SD frequency Ey 30-0 (p0.0) in rats as well as in mice (Eoth R1924 and WT). A3809 also suppressed the numEer of SDs provoked Ey electrical stimulation at ¿xed intervals suggesting a prolonged refractory period for repeated SD induction (3.9(1.3 vs. 6.0(2.1 in rats, p 0.03). ,n addition, A3809 reduced SD-induced cortical ,L-1` mRNA expression Ey more than 60 (p 0.002). ,n contrast, selective inhiEition of the ³channel form´ with calmidazolium did not affect KCl or repetitive electrical stimulation-induced SD frequency. None of the p2x antagonists altered the electrical threshold for single SD induction. Conclusion: Blockade of the ³p2x-panx1 pore complex´, Eut not the ³ion channel form´ of p2x, inhiEits repetitive

Objectives: To study the effects of acute anti-migraine treatments on nitroglycerin (NTG)-triggered central sensitization of trigeminovascular neurons, and the hypersensitive responses to noxious and innocuous dural and cutaneous somatosensory stimulation. Background: Migraine is thought to involve activation and sensitization of trigeminovascular neurons that engages nociceptive pathways resulting in head pain. NTG is a trigger of migraine in two-thirds of patients, causing a delayed attack after several hours. 3reclinically it has Eeen demonstrated to cause a delayed central sensitization of trigeminovascular neurons, with hypersensitive responses to noxious and innocuous dural and cutaneous somatosensory stimulation, indicative of hyperalgesia and allodynia. This represents a novel, translational approach, although the aEility of acute anti-migraine treatments to reverse these responses, reÀecting the migraineurs’ response, is unknown. Methods: Rats were anesthetized with pentoEarEitone (80 mgkg-1) and cannulated for measurement of Elood pressure and intravenous administration of supplementary anesthesia with propofol (15-20 mgkg-1hr-1-i.v. infusion). An estaElished model of trigeminovascular nociceptive activation was employed, using noxious and innocuous dural and cutaneous stimulation, to activate the ophthalmic division of the trigeminal nerve, and central sensitization was triggered Ey NTG (10 mgkg, sc) and neuronal responses measured at intervals. The aEortive effect of a 5-HT1B1D and a speci¿c 5-HT1F receptor agonist, and a CGR3 and NK1 receptor antagonist, on hypersensitive responses to noxious and innocuous dural and cutaneous stimulation were determined after two hours, when sensitization was estaElished. Results: NTG caused sensitization of central trigeminovascular neurons for up to at least 3 hours, with signi¿cant increases in Easal trigeminal ¿ring (F.3,.8 = 5.2, P  0.005) and hypersensitive responses to dural (F2.9,31.8 = .6, P  0.01), cutaneous noxious (F,32 = 1.3, P  0.001) and innocuous (F,32 = 3.3, P  0.05) stimulation of the ophthalmic dermatome. The clinically effective aEortives 5-HT1B1D and 5-HT1F receptor agonists, and a CGR3 receptor antagonist were aEle to aEort the sensitization and inhiEit the hypersensitive responses to cranial stimulation to Easeline levels (P  0.05), whereas the NK1 receptor antagonist, which demonstrates no clinical ef¿cacy, was unaEle to reverse sensitization and its effects. Conclusion: These data demonstrate that NTG triggers a delayed central sensitization of trigeminovascular neurons accompanied Ey hypersensitive responses to noxious and 2

June 2014 innocuous dural and cutaneous stimulation. Furthermore, after sensitization is estaElished, clinically ef¿cacious acute migraine treatments are aEle to aEort the sensitization and inhiEit hypersensitive responses, whereas a treatment that failed in the clinic did not cause any changes. Using NTG to trigger central sensitization of trigeminovascular pathways, with neuronal measurement of noxious and innocuous dural and cutaneous stimulation, offers a novel translational approach to study the pathophysiological neuronal changes occurring during migraine, which accurately reÀects the migraineurs’ response to treatments. Funding source The Sandler Family Foundation

OR6 Trajectories of Headache Days in Persons with Chronic and Episodic Migraine: Results From the Chronic Migraine Epidemiology and Outcomes (CaMEO) Study Lipton, R.B.2; Serrano, D.1; Stewart, W.3; Manack, A.N.; Buse, D.C.2 1 Vedanta Research, Chapel Hill, NC, USA; 2The Saul R. Korey Department of Neurology, AlEert Einstein College of Medicine and The Monte¿ore Headache Center, Bronx, NY, USA; 3Sutter Health, Concord, CA, USA; Allergan, ,nc., ,rvine, CA, USA. Objectives: To determine variation in monthly headache (HA) days and predictors of variation in persons who have either episodic (EM) or chronic migraine (CM) at Easeline. Background: Variation in HA days per month has rarely Eeen studied in migraine, outside the context of randomized trials of preventive treatments. Most longitudinal oEservational studies have follow-up intervals of 1 year or longer, or focus on very short periods of time using daily diaries. Month-to-month variation in HA frequency has rarely Eeen studied, Eut is the heart of natural history and essential to an understanding of exacerEating and ameliorating factors, including treatment. Both the nature of variation in HA days and predictors of variation over months (e.g., quarterly) may Ee different from what is oEserved annually in community-Eased samples of persons with migraine. Methods: The CaMEO study is a longitudinal survey of a US-Eased weE-panel, which screened 80,83 respondents to identify persons with EM and CM. At Easeline, the validated American Migraine StudyAmerican Migraine 3revalence and 3revention diagnostic module was used to identify persons meeting ICHD-3 Eeta criteria for migraine. Baseline HA day frequency was classi¿ed as EM or CM. CM was de¿ned with modi¿ed ICHD-3 Eeta migraine diagnosis (criterion C from ICHD-3 not assessed) and *15 HA daysmo for past 3 mos; EM was de¿ned as ICHD-3 Eeta migraine diagnosis and 15 HA daysmo for past 3 mos. ,n persons with migraine at Easeline, follow-up surveys were oEtained quarterly for up to 1 year to reassess HA symptoms and frequency, among other factors. We used repeated measures regression modeling to descriEe variation in HA days within and Eetween individuals, and to evaluate the following potential predictors of HA days over time Easeline migraine frequency (i.e., CM, EM), sociodemographic characteristics (i.e., sex, employment status, education, race, annual household income, health insurance status), migraine disaEility assessment (M,DAS) score, age at migraine onset, duration of illness, and numEer of comorEidities. Analysis used all availaEle data. Results: The Easeline survey identi¿ed 16,89 respondents with migraine, including 15,313 (91.2) with EM and 1,6 (8.8) with CM. These participants contriEuted 0,09 usaEle data points across  waves of data collected over a quarters. The within-suEMect numEer of HA days per month reported in each survey wave varied suEstantially over time and Eetween suEMects. As expected, the numEer of HA days per month was higher for respondents with CM vs EM. However, HA days increased more rapidly in the

OR5 Infant Colic and Migraine: A Meta-Analysis Gelfand, A.A.1; GoadsEy, 3.J.1; Allen, ,.E.2 1 Neurology, UCSF, San Francisco, CA, USA; 2 Epidemiology and Biostatistics, UCSF, San Francisco, CA, USA. Objectives: To perform a meta-analysis of studies on the relationship Eetween infant colic and migraine. Background: ,nfant colic is a common and distressing disorder of early infancy. ,ts etiology is unknown, making treatment challenging. Several articles have suggested a link to migraine. Methods: Studies were identi¿ed Ey searching 3uEMED and ScienceDirect, and Ey hand searching references and conference proceedings. For the primary analysis, studies speci¿cally designed to measure the association Eetween colic and migraine were included. For the secondary analysis, studies that collected data on colic and migraine Eut were designed for another primary research question were also included. Data were aEstracted from the original studies, through communication with study authors, or Eoth. Two authors independently aEstracted data. The main outcome measure was the association Eetween infant colic and migraine using Eoth a ¿xed effects model and a more conservative random effects model. Results: Three studies were included in the primary analysis and a total of ¿ve studies were included in the secondary analysis. ,n the primary analysis, the odds ratio for the association Eetween migraine and infant colic was 6.5 (95 C, .6-8.9, p  0.001) for the ¿xed effects model and 5.6 (3.3-9.5, p = 0.00) for the random effects model. ,n a sensitivity analysis wherein the study with the largest effect size was removed, the odds ratio was 3.6 (1.-.6, p = 0.001) for Eoth the ¿xed effects model and random effects model. ,n the secondary analysis, the cumulative odds ratio was 3. (2.-.3, p  0.001) in the ¿xed effects model and 3.2 (1.-.5, p = 0.00) in the random effects model. Conclusion: ,n this meta-analysis, migraine was associated with increased odds of infant colic. ,f infant colic is a migrainous disorder, this would have important implications for treatment. The main limitation of this meta-analysis was the relatively small numEer of studies included.

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Headache CM (vs EM) group over time (quarterly RR=1.28, 95 C, 1.22–1.35; P0.0001). Conclusion: These ¿ndings demonstrate suEstantial within-person change and Eetween-person heterogeneity in quarterly estimates of HA days per month. TraMectories differed for the CM and EM groups. The numEer of HA days per month increased 28 faster per quarter for persons with CM than for persons with EM. This may result from a lowered threshold for migraine attack initiation in persons with CM, creating a positive feedEack loop that leads to more attacks. This process could make remission dif¿cult. Funding: Allergan, ,nc.

(HR 1.65, 95 C, 1.0-1.95), and anginacoronary revascularization procedures (HR 1.5, 95 C, 1.302.3). Furthermore, there was a signi¿cantly increased risk for all-cause mortality (HR 1.15, 95C, 1.05-1.26), which was driven Ey CVD mortality (HR 1.3, 95 C, 1.06-1.93). We did not identify a suEgroup of particular increased risk. Conclusion: Results of this large, prospective cohort study in women with over 20 years of follow-up indicate a consistent link Eetween migraine and any cardiovascular disease event. ,n addition, our data indicate increased risk of all-cause mortality, particular cardiovascular mortality. Assuming causality, our result suggests that 13 of all deaths in the study were due to migraine. Migraine should Ee considered a risk factor for increased risk of CVD and mortality of any cause in women. Future targeted research is urgently warranted to identify preventive strategies to reduce these risks.

OR7 Migraine and Risk of Cardiovascular Disease and Mortality in Women: Prospective Cohort Study Kurth, T.1; Winter, A.2; Rexrode, K.M.3 1 Research Center for Epidemiology and Biostatistics (U89), ,nserm, Bordeaux, France; 2Division of 3uElic Health Sciences, Washington University School of Medicine, St. Louis, MO, USA; 3Division of 3reventive Medicine, Brigham and Women’s Hospital, Boston, MA, USA.

OR8 Symptom Codes and Opioids: Disconcerting Headache Practice in Academic Primary Care Brennan, K.C.; Farrell, C.3.; Keough, G.; Baggaley, S.; 3ohl, S.; 3ippitt, K.; Digre, K.; Gren, L.H. University of Utah, Salt Lake City, UT, USA.

Objectives: To evaluate the association Eetween migraine and incident cardiovascular disease (CVD), all-cause and CVD mortality in women. Background: Migraine has Eeen associated with increased risk of ischemic stroke in numerous studies. While some studies have suggested associations Eetween migraine and any CVD, the evidence is less roEust. ,n addition, the association Eetween migraine and all-cause mortality remains inconclusive. Methods: 3rospective cohort study among 115,51 Nurses Health Study ,, participants who were Eetween 25 and 2 years old and free of angina and CVD at Easeline (1989). Follow-up information was included through June 2011. The primary outcomes of the study were total CVD, a comEined endpoint of fatal and non-fatal myocardial infarction (M,) and stroke, as well as all-cause mortality. Secondary outcome measures included M,, stroke, coronary artery Eypassvascularization and angina, and CVD mortality. All outcome events have Eeen con¿rmed after medical record review. Deaths were con¿rmed Ey review of autopsy reports, medical records and death certi¿cates. On the Easeline (1989) and two follow-up questionnaires (1991 and 1993), women were asked to indicate whether they have Eeen diagnosed with migraine Ey a physician. ,nformation on migraine aura was not availaEle. MultivariaEle-adMusted Cox proportional hazard models were used to calculate the association Eetween migraine and the outcome events adMusting for maMor confounding factors. Results: A total of 1,531 (15.2) women reported a physician’s diagnosis of migraine. During over 20 years of follow-up, 1,329 total CVD events occurred and 290 women died. After adMusting for potential confounding factors and compared with women without migraine, migraine was associated with increased risk for total CVD (hazard ratio (HR) 1.52, 95 con¿dence interval (C,) 1.36-1.1), M, (HR 1.2, 95 1.20-1.68), stroke

Objectives: Characterize headache diagnosis and treatment in the primary care clinics of an academic medical center. Background: Migraine affects 12 of the US population. ,t is thus a quintessential primary care proElem. We asked how headache is diagnosed and treated in the primary care setting. Methods: The University of Utah Electronic Data Warehouse was queried for primary care patient encounters (2008-2010) that contained one of 2 headache-related codes. Results: 16,955 patients were identi¿ed, in 50,29 headache encounters at 13 clinics. 55.2 of encounters received a headache symptom code (8.0) rather than a diagnostic code. 1.6 received migraine diagnostic codes (36.xx), 3.2 received another headache diagnosis. 30.1 of all headache encounters were associated with an opiate prescription (range 15.1-62 Ey clinic). 36.3 of encounters with migraine diagnostic codes received opiates (12.1-5.9); 19.1 received triptans (10.83.9). Both triptans (OR 5.9, 95C, 5.3,6.25) and opiates (OR 1.61, 95C, 1.5,1.68) were more likely to Ee prescriEed at migraine encounters than at headache symptom code encounters. The 9.1 of patients classi¿ed as heavy users (* encounters) generated 5.5 of total headache patient encounters. Heavy users were more likely to Ee prescriEed an opiate (OR 5.19, C, .9,5.2), less likely to Ee prescriEed a triptan (OR 0., C, 0.1,0.81), and more likely to receive a migraine diagnosis (OR 2.6 C, 2.36,2.55) than light users ()6 encounters). Heavy opiate prescriEers (*0 opiate prescriptions) represented 10.5 of the provider population Eut 65. of opiate prescriptions. Conclusion: The frequent use of a symptom code for headache may reÀect a discomfort with diagnosing migraine and other primary headaches in primary care. The 

June 2014 rate of opiate prescription for headaches is high; conversely the rate of triptan prescription is low, even in migraineurs. These diagnosis and prescriEing patterns may Ee related, and are the suEMect of an ongoing EMR-Eased intervention in our primary care clinics.

Hypothalamic Eidirectional proMections to the TCC may regulate trigeminovascular nociceptive traf¿c through N3Y, leptin and insulin signaling. These data demonstrate a link Eetween the potential origin of disturEed feeding and sleep regulation in migraine and the involvement of these homeostatic peptides in the modulation of trigeminovascular nociceptive traf¿c. Note: The data suEmitted herein has Eeen presented, in part, at the EHMT,C (London, SeptemEer 2012) and at the ,nternational Headache Congress (Boston, June 2013).

OR9 Modulation of Trigeminovascular Nociceptive Inputs by Peptides Involved in Sleep and Appetite Homeostatic Synchronization: Systemic Effects of Neuropeptide Y, Leptin and Insulin Martins Oliveira, M.; Akerman, S.; GoadsEy, 3.J. Neurology, University of California San Francisco, San Francisco, CA, USA.

OR10 In Vivo Cellular Dynamics of Cortical Spreading Depression Mendez, J.M.; Theriot, J.; Brennan, K.C. Neurology, University of Utah, Salt Lake City, UT, USA.

Objectives: To determine the role of peptides involved in sleep and appetite homeostatic synchronization on neuronal activity in the trigeminocervical complex (TCC) in response to dural electrical stimulation of the middle meningeal artery (MMA). Background: MetaEolic disturEances, such as Àuctuations in water Ealance, food intake and sleep, contriEute to triggering in migraineurs. 3eptides such as neuropeptide Y (N3Y), leptin and insulin are involved in hypothalamic appetite and sleep regulation and also in pain modulation. ,n addition, a state of insulin resistance has Eeen suggested to Ee present in migraineurs. Furthermore, the orexinergic system is known to modulate nociceptive activation of the TCC and is reciprocally inÀuenced, at some point, Ey N3Y, leptin and insulin. ,mportantly, the hypothalamus is known to Ee active and involved in migraine pathophysiology. Therefore, it seems important to unravel how these homeostatic systems modulate trigeminovascular activation in the context of migraine pathophysiology. Methods: Adult male Sprague-Dawley rats were anesthetized with pentoEarEitone (60 mgkg) and cannulated for measurement of Elood pressure and intravenous administration of supplementary anesthesia with propofol (15-20 mgkghr). The parietal Eone was removed over the MMA for electrical stimulation of the dura mater and electrophysiological recording of second order neurons in the TCC was made using a tungsten electrode. Rats received either N3Y human (30 +gkg), N3Y Y1 receptor agonist >Leu31,3ro3@-N3Y (30 +gkg), rat recomEinant leptin (1 mgkg) or human insulin (10 U kg), dissolved in sterile water, or sterile water alone as vehicle control. Glycemic levels were monitored in the insulin-induced hypoglycemia study. The effects of N3Y, leptin and insulin on TCC neuronal activity in response to MMA stimulation were recorded. Results: Dural-evoked neuronal ¿ring in the TCC was signi¿cantly reduced Ey N3Y human (30 +gkg, p  0.05, max inhiEition of 18 at 5 min), N3Y Y1 receptor agonist (30 +gkg, p  0.005, max inhiEition of 22 at 15 min), leptin (1 mgkg, p  0.02, max inhiEition of 13 at 5 min) and human insulin (10 Ukg, p = 0.000, max inhiEition of 1 at 25 min). Blood glucose levels were signi¿cantly reduced after insulin administration, comparing to controls. Conclusion: These studies demonstrate that N3Y, an N3Y Y1 receptor agonist, leptin and insulin cause perturEations in stimulus-evoked trigeminal activity.

Objectives: Cortical spreading depression (CSD) is involved in migraine, stroke, and Erain inMury. The electrical and hemodynamic changes caused Ey CSD have Eeen extensively descriEed, Eut this knowledge is not paralleled Ey a detailed cell level description. The availaEility of new genetic and imaging techniques provides the opportunity to study the phenomenon at this level with cellular speci¿city. Methods: We used in vivo two-photon excitation microscopy in mice to study calcium dynamics in neurons and in astrocytes, examine cell volume changes, image Elood vessels, and glutamate dynamics during CSD. Furthermore, we studied how CSD is modulated Ey pharmacological agents that reduce glutamate exposure andor induced activity. We tested the effects of 2-Methyl6-(phenylethynyl)pyridine (M3E3), a metaEotropic glutamate inhiEitor and modulator of neuron-glia coupling, and memantine a uncompetitive NMDA antagonist with extensive clinical use. Results: CSD affects different components of the neurovascular unit in different ways. Neurons and astrocytes responded to the passage of the depolarizing wave Ey an initial increase of intracellular calcium. ,n neurons this initial increase lasted for more than a minute followed Ey a long lasting period of inactivity. Astrocytes increased calcium activity for a period of approximately 20s. All visiEle neurons participated in the calcium transient whereas astrocytes presented a more variaEle response. Moreover, in contrast to neurons, astrocytes presented a second peak of activity with a non-wave pattern after passage of the initial CSD wave. A comparison Eetween interneurons and a general population of neurons yielded differences in the main characteristics of calcium transients. Examination of extracellular glutamate with the genetically encoded indicator iGluSnFr showed that the CSD glutamate transient is shorter than the oEserved calcium dynamics in neurons and similar to the duration of the initial astrocytic calcium activity. Also, there is an overall homogeneous exposure to glutamate across the neuronal population that contrasts with the calcium responses in all cell types. These changes in neurons and astrocytes were accompanied Ey a Eiphasic constriction-dilation of intracortical arterioles. M3E3 (1.8 mgkg) decreased calcium transients and attenuated the arterial constriction associated with CSD. The NMDA

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Headache antagonist and migraine preventive memantine (5mgkg) also attenuated CSD phenotypes. Conclusion: Our data provides a deeper understanding of CSD as a complex multicellular phenomenon which differentially involves neurons, astrocytes and Elood vessels. ,t points towards glutamate, perhaps more than potassium, as a main actor in its propagation. The cell speci¿c approach taken in this study provides important mechanistic information and could Ee used to uncover the effects of clinically suitaEle compounds.

OR12 Nitric Oxide Alters the Neuronal Firing of the Dopaminergic Hypothalamic Nucleus A11 Andreou, A.3.; ChamEerlain, J. Headache Research- Section of Anaesthetics, 3ain Medicine and ,ntensive Care, Chelsea and Westminster Hospital, ,mperial College London, ,mperial College London, London, United Kingdom. Objectives: To investigate potential changes in the neuronal ¿ring rate of the A11 hypothalamic nucleus in the nitric oxide infusion model. Background: ,nfusion of nitric oxide donors in migraine patients may evoke headaches with the clinical phenotype of migraine including premonitory symptoms, which have Eeen long assumed to Ee related with hypothalamic function. Recently, a Erain imaging study con¿rmed changes in the hypothalamic Elood Àow during the premonitory symptoms, induced Ey the nitric oxide donor nitroglycerin. 3otential changes in dopaminergic hypothalamic nuclei could explain many of the premonitory symptoms and might provide some insight into the neuropharmacology of the premonitory phase. The A11 hypothalamic nucleus has Eeen recently implicated in migraine pathophysiology, as it offers the only dopaminergic innervation to the trigeminocervical complex. Methods: ,n anesthetized male Sprague-Dawley rats, extracellular single neuron electrophysiological recordings were performed from the A11 hypothalamic area. To investigate whether meningeal nociceptive stimuli activate hypothalamic neurons in the A11 nucleus, electrical stimulation of the superior sagittal sinus was used, applying stimulating parameters previously shown to activated third order thalamic neurons. Neurons that displayed staEle spontaneous ¿ring rate for at least 30 min, were used for further investigation. The nitric oxide donor nitroprusside (SN3), or saline were intravenously infused over 20 min, and their effects for up to 90 min post infusion were examined. At the end of the experiment the recording site was marked Ey eMection of pontamine sky Elue and tissue was collected for histological con¿rmation of the A11 location. Results: None of the recorded neurons, located in the rostrocaudal extent of the A11 nucleus, demonstrated increased evoked-activity in response to electrical activation of the superior sagittal sinus. ,nfusion of the nitric oxide donor SN3 signi¿cantly attenuated spontaneous neuronal ¿ring for up to 60 min following infusion. ,n some units, a small, Eut signi¿cantly different, increase of spontaneous neuronal ¿ring was oEserved during the initial stages of SN3 infusion, lasting Eetween 5-10 min. Saline had not signi¿cant effects on the ¿ring rate of A11 neurons during or post-infusion. Conclusion: The A11 hypothalamic nucleus is susceptiEle to nitric oxide administration at the early period postapplication. Our data further suggest that meningeal nociceptive stimuli, at least Ey means of trigeminovascular electrical stimulation, may not activate this area. The physiological function of the A11 nucleus is to provide a dopamine-driven inhiEitory effect on nociceptive transmission in the trigeminocervical complex. Nitric

OR11 Innervation of Rat and Human Dura Mater and Pericranial Tissues by Meningeal Afferents Schueler, M.2; NeuhuEer, W.1; De Col, R.3; Messlinger, K.2 1 ,nstitute of Anatomy, Friedrich-Alexander University Erlangen-NrnEerg, Erlangen, Germany; 2,nstitute of 3hysiology and 3athophysiology, Friedrich-Alexander University Erlangen-NrnEerg, Erlangen, Germany; 3 Department of Anaesthesiology and Operative ,ntensive Care, University of HeidelEerg, HeidelEerg, Germany. Objectives: To re-investigate the innervation pattern of the dura mater of rat and human middle cranial fossa, the morpho-functional suEstrate of headache generation, including adMacent extracranial tissues using neuronal in vitro tracing. Background: This study was initiated Ey recent structural and functional ¿ndings of meningeal afferent ¿Eers that innervate the cranial dura mater and may proMect to extracranial tissues. Methods: Anterograde and retrograde neuronal in vitro tracing was made in formaldehyde ¿xed hemisected rat and human skulls. The Àuorescent tracer Di, was applied to proximally cut meningeal nerves in rat and to distal Eranches of the spinosus nerve in human calvaria lined Ey dura mater. After several weeks the dura mater and deep extracranial tissues were examined with Àuorescence microscopy. Results: ,n addition to a network of meningeal nerve ¿Eers, several ¿Eer Eundles were oEserved leaving the skull through emissary canals and ¿ssures to innervate the pericranial temporal, parietal and occipital periosteum. Traced ¿Eers were seen spreading into deep layers of the temporal and upper neck muscles. Retrograde neuronal tracing revealed laEeled cell Eodies exclusively in the mandiEular and maxillary division of the rat trigeminal ganglion, and centrally proMecting ¿Eers were identi¿ed in the spinal trigeminal tract. Electron microscopy of the cross-sected spinosus nerve showed myelinated and unmyelinated axons with similar numEers in human and rat Conclusion: We conclude that a proportion of meningeal afferents innervates extracranial tissues like periosteum and pericranial muscles via collaterals proMecting through the skull. These afferents may Ee nociceptive, some may suEserve proprioceptive functions. The ¿nding of extracranial proMections of meningeal afferents may Ee important for our understanding of extracranial impacts on headache generation and therapy

6

June 2014 oxide-induce attenuation of its function may decrease the dopaminergic control of the trigeminocervical complex, lowering its threshold for nociceptive transmission. Modulating the A11 hypothalamic nucleus during the early stage of a migraine attack may Ee useful in preventing the progression of events.

OR14 Trigeminal Sensitization in Migraine: Creation of the Perfect Storm Durham, 3.; Hawkins, J. JV,C-CBLS, Missouri State University, Spring¿eld, MO, USA.

OR13 In Vivo Single Neuron Effects of Traumatic Brain Injury in Wild Type and Migraine Mutant Mice Sawant, 3.; Brennan, K.C. University of Utah, Salt Lake City, UT, USA.

Objectives: To investigate the comEined effects of prolonged neck muscle inÀammation, REM sleep deprivation, and a pungent odor on trigeminal nociception. Background: Migraine is characterized Ey peripheral and central sensitization of trigeminal nociceptive neurons. Neck muscle tenderness, sleep deprivation, and sensitivity to strong odors are commonly reported risk factors Ey migraine patients. Stress can manifest as neck muscle pain and inÀammation, and can cause disruption of normal sleep cycles such that the amount of time spent in REM sleep is severely altered. REM sleep is associated with restoration of the nervous system. We investigated if neck muscle inÀammation and REM sleep deprivation lowers the activation threshold of trigeminal neurons to exposure of a pungent odor from an extract of the ³headache tree´ to cause increased nociceptive responses in the V1 and V3 dermatomes. Methods: Sprague-Dawley rats were inMected with complete Freund’s adMuvant (CFA) in the trapezius to cause prolonged inÀammation, and REM sleep deprived for one night using a modi¿ed version of the inverted Àower pot method. Animals were allowed to recover for  days following CFA inMection andor one night of REM sleep deprivation prior to exposure for 10 minutes to an extract of California Eay laurel, which is referred to as the headache tree. This tree is known to emit a strong odor and selectively activates TR3V receptors on C-¿Eers that function to transmit nociceptive (painful) information to the central nervous system. The Durham Holder was used to monitor nocifensive Eehavioral changes for up to 8 days post CFA inMection and 2 hours post odor exposure using von Frey ¿laments applied to the cutaneous area over the eyeErow (V1) and masseter muscle (V3). Results: Animals suEMected to prolonged muscle inÀammation, REM sleep deprivation, or headache tree extract alone did not exhiEit signi¿cant increases in nocifensive Eehaviors in the V1 or V3 in response to mechanical stimulation at any time point. However, animals that were suEMected to muscle inÀammation or sleep deprivation and then the pungent odor exhiEited signi¿cant increases in the numEer of nocifensive responses 2 hours post odor exposure. ,nterestingly, animals with neck muscle inÀammation and also REM sleep deprived exhiEited a more sustained sensitivity to mechanical stimuli that was more prominent in the V3 region when compared to V1. Somewhat surprisingly, animals suEMected to all three experimental conditions were unresponsive to mechanical stimuli applied to the V1 or V3 regions, exhiEiting a helpless Eehavioral response. Conclusion: Our results provide evidence that inÀammation in the trapezius followed Ey one night of REM sleep deprivation leads to prolonged sensitization of trigeminal sensory neurons such that a pungent odor is suf¿cient to increase nociception in the V1 and V3 regions. However,

Objectives: Examine the effects of traumatic Erain inMury on the excitaEility of individual neurons in vivo, to understand Easic mechanisms underlying post-traumatic headache. Background: 3ost-traumatic headache (3TH) affects Eoth military and civilian populations after traumatic Erain inMury (TB,). ,ts mechanisms are pooly understood. Studying the cellular consequences of TB, is a ¿rst step toward understanding the link Eetween TB, and 3TH. 3TH is much more common in migraineurs; here again the mechanisms are unclear. We examined the effect of controlled cortical impact (CC,) on neuronal intrinsic memErane properties and synaptic processing from layer 23 neurons in mouse somatosensory cortex, using in vivo whole-cell current-clamp recordings in wild type and casein kinase 1 delta (CK1d) mutant mice. Methods: CC, TB, was induced in the Earrel cortex using a 1 mm diameter Àat tipped impactor at a depth of 1 mm at a velocity of  ms and 100-ms dwell time. Sham animals received the same surgery, without impact. Results: There was a signi¿cant reduction in the frequency and amplitude of spontaneous postsynaptic potentials (s3S3s) of CC,-inMured animals compared to sham, suggesting possiEle decreased glutamatergic synaptic connectivity at 2 days post-inMury. ,nput resistance was the same in Eoth groups, making it unlikely that the phenotypes we oEserved were due to memErane inMury. ³Upstate events´ were dramatically reduced in CC,-inMured animals, suggesting alterations in thalamocortical network function. ,nput-output curves (action potential frequency to increasing current inMection) con¿rmed a decrease in neuronal excitaEility after inMury, showing a signi¿cant decrease in slope and signi¿cant increase in rheoEase (minimum current needed to elicit action potential). Next we examined CC,-induced changes in CK1d mice. ,nterestingly, CK1d mice had an opposite phenotype to wild-type mice, with a decrease in rheoEase after TB,. There was also a trend toward increased frequency of s3S3s in CK1d mutants. Conclusion: Our data show that intrinsic, synaptic and network properties of cortical neurons are altered Ey TB,; these effects may contriEute to the circuit dysfunction underlying 3TH. Differences Eetween normal and migraine mutant animals may help explain why 3TH is more common in migraineurs.



Headache exposing an animal to the three conditions resulted in not hyperalgesia, Eut rather a state of helplessness in which the animal was unresponsive. Based on our ¿ndings, we speculate that the comEination of these physiological conditions may create a perfect storm of cellular activity within the trigeminal system that is representative of the nociceptive responses reported during a migraine attack. Research supported Ey N,H.

gyrus (MN, coordinates -12 -62 -9; kE = 152; ZE = 3.28; p = 0.001). Conclusion: ComorEid migraine aggravates the clinical phenotype of the ‘visual snow’ syndrome Ey worsening some of the additional visual symptoms and tinnitus. This might Eias studies on ‘visual snow’ Ey migraineurs offering study participation more likely than non-migraineurs due to a more severe clinical presentation. The independence of entoptic phenomena from comorEid migraine indicates ‘visual snow’ is the main determinant. The hypermetaEolic lingual gyrus con¿rms a Erain dysfunction in patients with ‘visual snow’. The metaEolic pattern differs from interictal migraine with some similarities to migrainous photophoEia. The ¿ndings support the view that ‘visual snow’, migraine and typical migraine aura are distinct syndromes with shared pathophysiological mechanisms that need to Ee addressed in order to develop rational treatment strategies for this disaEling condition.

ORWA The Relation Between Migraine, Typical Migraine Aura and Visual Snow™ Schankin, C.; Maniyar, F.; Sprenger, T.; Chou, D.E.; Eller, M.; GoadsEy, 3.J. Department of Neurology, University of California, San Francisco, UCSF Headache Center, San Francisco, CA, USA. Objectives: To assess the relationship Eetween the phenotype of the µvisual snow’ syndrome, comorEid migraine and typical migraine aura on a clinical Easis and using functional Erain imaging. Background: 3atients with µvisual snow’ suffer from continuous TV-static-like tiny Àickering dots in the entire visual ¿eld. Most patients descriEe a syndrome with additional visual symptoms of the following categories palinopsia (‘afterimages’ and ‘trailing’), entopic phenomena arising from the optic apparatus itself (Àoaters, Elue ¿eld entoptic phenomenon, photopsia, self-light of the eye), photophoEia, nyctalopia (impaired night vision), as well as the non-visual symptom tinnitus. The high prevalence of migraine and typical migraine aura in this population has led to the assumption that ‘visual snow’ is caused Ey persistent migraine aura. Methods: (i) The prevalence of additional visual symptoms, tinnitus and comorEid migraine as well as typical migraine aura was assessed in a prospective semistructured telephone interview of patients with ‘visual snow’. Correlations were calculated using standard statistics with p  0.05 Eeing considered statistically signi¿cant. (ii) Areas with increased Erain metaEolism in a group of ‘visual snow’ patients in comparison to healthy controls were identi¿ed using >[email protected] 3ET and statistical parametric mapping (S3M8 with whole Erain analysis; statistical signi¿cance was de¿ned Ey p  0.001 uncorrected for multiple comparisons). Results: (i) Of 120 patients with ‘visual snow’, 0 patients also had migraine and 3 had typical migraine aura. Having comorEid migraine was associated with an increased likelihood of having palinopsia (OR 2.8; p = 0.0 for ‘afterimages’ and OR 2.6; p = 0.01 for ‘trailing’), spontaneous photopsia (OR 2.9; p = 0.00), photophoEia (OR 3.2; p = 0.005), nyctalopia (OR 2.; p = 0.01), and tinnitus (OR 2.9; p = 0.006). Typical migraine aura was associated with an increased likelihood of spontaneous photopsia (OR 2.; p = 0.0). (ii) After adMusting for typical migraine aura, comparison of 1 ‘visual snow’ patients with 1 age and gender matched controls showed Erain hypermetaEolism in the right lingual gyrus (MN, coordinates 16 -8 -5; kE = 101; ZE = 3.1; p  0.001) and the left cereEellar anterior loEe adMacent to the left lingual

OR15 Comorbidity of Headache and Depression Following Mild Traumatic Brain Injury Lucas, S.; Smith, B.M.1; Hoffman, J.1; Temkin, N.2; Bell, K.R.1; Dikmen, S.3 1 RehaEilitation Medicine, University of Washington, Seattle, WA, USA; 2RehaEilitation Medicine, Neurological Surgery, and Biostatistics, University of Washington, Seattle, WA, USA; 3RehaEilitation Medicine, Neurological Surgery, and 3sychiatry and Behavioral Medicine, University of Washington, Seattle, WA, USA; Neurology, Neurological Surgery, and RehaEilitation Medicine, University of Washington, Seattle, WA, USA. Objectives: To assess the prevalence of headache, depression and co-occurring headache and depression among suEMects following mild traumatic Erain inMury (mTB,). Background: Headache is one of the most common and persistent symptoms following mTB,. Depression is among the most common psychiatric diagnoses after mTB,, and also after TB, regardless of severity of inMury. Headache and depression have Eeen found to Ee two of three independent factors related to poor outcome following inMury. There is paucity of research speci¿cally exploring the comorEidity of headache and depression after mTB, in civilian populations. Methods: 212 suEMects with mTB, admitted to a Level 1 trauma center for oEservation or for other system inMuries were interviewed aEout headache and depression within one week of inMury and at 12 months after inMury. SuEMects were classi¿ed as having depression if their score on the 3atient Health 4uestionnaire-9 (3H4-9) was *10 at either time point. Headache was assessed Eased on response to whether the suEMect had headaches since hospitalization at Easeline and assessed at 12 months for headaches that occurred at one year or within 3 months leading to the one year time point. Results: 3revalence of headache and depression at Easeline was 6 and 15, respectively. At 12 months prevalence was 68 and 2, respectively. The prevalence of comorEid headache and depression increased from the 8

June 2014 Easeline assessment of 11 to the one year prevalence of 25. SuEMects who had headaches after inMury were 5. times more likely than those who did not have headache to Ee depressed at one year after inMury (p.001). The corresponding risk ratio at Easeline was 1.6 (p=.23). Conclusion: Headache and depression are each common and frequently co-occur after mTB,. Rates of headache remain high over one year after inMury. Rates of depression increased over time as did the rates of comorEid headache and depression. Few individuals had isolated depression without headache. Further study is necessary to determine how co-occurrence of depression and headache affects daily function. However, for those with headache over the ¿rst year after mTB,, additional assessment and treatment of depression, in addition to treatment of headache, may Ee useful in improving functional outcomes.

Half (50.6) the patients had previously received 3NB. Headache intensity Eefore 3NB was most often Eetween -810 (1.2), and headache attack duration was over hours (13.), days (32.3), weeks (23.6), or months (30.). 66. were on prophylactic therapy and 81. reported nerve region tenderness. 3NB sites most commonly inMected included greater occipital (9), supraorEital (96), supratrochlear (9), and auricular temporal (9). Agents used for the greater occipital nerve most commonly included Eupivacaine (95.0), lidocaine (25.), and dexamethasone (9.3) and for other 3NB locations included Eupivacaine (92.), lidocaine (39.1). Duration of headache relief was over weeks (1.), days (30.3), or hours (25.0). 3atients were either very satis¿ed (6.2), satis¿ed (2.8), dissatis¿ed (10.1), or very dissatis¿ed (10.1). 3NB site soreness was the most common adverse effect (.8), followed Ey nausea and vomiting (3.9) and head or neck pain (2.3). Conclusion: 3NB for headache in clinical practice seems to Ee an effective and well-tolerated therapy that yields prolonged headache improvement and high satisfaction rate (). Most practitioners use local anesthetics only and 3NB at greater occipital, auricular temporal, supraorEital, and supratrochlear sites. Future analyses will explore 3NB success with individual headache disorders, demographic and procedural factors.

OR16 Peripheral Nerve Blocks for Headache in Clinical Practice: A Multicenter, Prospective Registry Study Ailani, J.3; RoEEins, M.S.2; Blumenfeld, A.M.1 1 Neurology, The Headache Center of Southern California, Encinitas, CA, USA; 2Neurology, Monte¿ore, Bronx, NY, USA; 3Neurology, Georgetown University Hospital, Washington, DC, USA. Objectives: To create a dataEase of patients who receive 3NB for the treatment of headache in routine care across a variety of practice sites, to survey practice patterns and to examine demographics, indications, and methodology for their associations with outcomes, adverse effects and patient satisfaction. Background: 3eripheral nerve Elockade (3NB) of occipital and trigeminal nerve Eranches can rapidly aEort headache attacks in patients Studies suggest Eetween 588 of patients have improvement in headache after 3NB, though there is insuf¿cient evidence to suggest predictive markers of success and real-time practice patterns have not Eeen surveyed across a large scale. Which peripheral nerves are Elocked can Ee Eased on pain location, Eut there is little evidence to suggest that Elock location, volume, and agents used inÀuences headache relief. Methods: This was a multi-center, prospective study that created a dataEase of patients who have received 3NB to treat headache at 12 US sites, including 6 private practice and 6 academic institutions. ,RB approval was oEtained Ey individual academic institutions and an independent ,RB for the private practice sites. A universal protocol and consent form was used Ey all sites. ,nclusion criteria were patients *18 years with a diagnosed headache disorder not responding to their standard treatment. Exclusion criteria were patients with a known history of sensitivity or allergy to lidocaine or Eupivicaine. 3NB locations, volume, and agents were utilized at the discretion of the treating clinician. Outcomes were oEtained 2 weeks after the 3NB (via of¿ce visit or phone call) to assess response and adverse effects. De-identi¿ed data was entered into a datasheet and suEmitted into an electronic dataEase. Results: 16 patients received 3NB, most of whom were women (82.) and Caucasian (.8). The most common indication for 3NB was migraine (53.8).

OR17 Cognitive Behavioral Therapy Plus Amitriptyline for Chronic Migraine Improves School Functioning and Quality of Life 3owers, S.W.; Kashikar-Zuck, S.M.; Slater, S.; Zafar, M.; Allen, J.R.; LeCates, S.L.; KaEEouche, M.; O’Brien, H.; Kacperski, J.; Shenk, C.; Rausch, J.; Hershey, A.D. 3ediatrics, Cincinnati Children’s Headache Center, Cincinnati, OH, USA. Objectives: Determine if cognitive Eehavioral therapy plus amitriptyline (CBT+A) versus headache education plus amitriptyline (HE+A) leads to improvement in school functioning and quality of life. Background: Overall quality of life and school functioning is impaired for youth with migraine compared to controls as measured Ey the 3ediatric 4uality of Life ,nventory (3eds4L). The impairment is similar to illnesses such as cancer and arthritis. ,mpact is greatest for those with chronic migraine (3owers et al., 3ediatrics, 2003;112e1e5). 3eds4L was used as a secondary endpoint in a randomized clinical trial focused on pediatric chronic migraine (3owers et al., JAMA, 2013;3102622-2630). Methods: Randomized clinical trial of CBT+A compared to HE+A with treatment effects measured at Easeline, 20 weeks (post-treatment), and follow-up (12 months post-treatment as ¿nal assessment). The 3eds4L is a 23item, generic measure of quality of life (4OL) during the last month. Higher scores indicate Eetter 4OL. ,t has excellent reliaEility and validity and has a childteen report and a parent report format (Varni et al., 2001, Medical Care;39800-812). For this investigation of secondary outcomes, the childteen report total 3eds4L score and the

9

Headache School Functioning suEscale were examined. 3ost-hoc, completer analyses were conducted using t-tests. Results: For childteen report on the 3eds4L Ey healthy controls, total scores are around 83 ( 15 and school scores are around 9 ( 20 (3owers et al., 2003). ,n this trial at Easeline, 135 participants reported a total 3eds4L of  ( 13.8 (CBT+A = .; HE+A = 3., no difference) and a School SuEscale of 61.6 ( 19 (CBT+A = 62.5; HE+A = 60.8, no difference). At 20 weeks (N=125), total score was 82.6 ( 12 for CBT+A and 8.3 ( 13.6 for HE+A (no difference, Eut Eoth improved from Easeline, p  0.01) and school score was 2.3 ( 16.5 for CBT+A and 65. ( 19.5 for HE+A (p  0.05). At the 12 month follow-up (N=125), total score was 86. ( 10 for CBT+A and 83 ( 1 for HE+A (no difference, Eut Eoth improved from Easeline, p  0.01) and school score was 80.3 ( 13.9 for CBT+A and 3.9 ( 20. for HE+A (p  0.05). Conclusion: At the Eeginning of this trial, participants reported quality of life and school functioning levels similar to those seen in a large pediatric headache center (3owers et al., 3ediatrics, 2003). These levels changed as a result of intervention. Total 4OL scores improved to a level consistent with healthy controls for Eoth CBT+A and HE+A. School functioning was more improved in the CBT+A group when compared with the HE+A group, and notaEly, was at the healthy control level only for the CBT+A group. Cognitive Eehavioral therapy plus amitriptyline for chronic migraine in children and adolescents not only reduces headache days and disaEility, Eut has a favoraEle and clinically meaningful impact on school functioning as reported on the 3eds4L. Our results provide further evidence for the suggestion that CBT+A Ee the ¿rst-line treatment for pediatric chronic migraine (3owers et al., 2013, JAMA). Funded Ey R01NS050536, R01NS050536-S1, UL1TR0000, and T32DK063929 from the N,H. clinicaltrials.gov identi¿er NCT00389038

Methods: Methods the VA has offered medical care to all OEFO,F Veterans. 3articipants undergo a Erief screen for DTB,, and those who are screen positive are referred to the TB, Clinic where a second screen is used to con¿rm presence of DTB,. SuEMects determined to have a de¿nite DTB, were recruited randomly from the clinic attendees. These were then matched Ey age, sex, race, and time of deployment with control suEMects (C) drawn from the Veterans in the medical care program who were negative for TB,. Data was oEtained through telephone interview of Eoth groups using questionnaires dealing with the TB,, headache, and depression with the same questionnaires used for DTB, and C suEMects. For this study, only the most severe Headache (HA) experienced Ey each individual was evaluated. These headaches were analyzed for frequency of occurrence, HA intensity, and type of HA Ey ,HS classi¿cation. Frequency was expressed as HA occurring a) !3 daysweek (dwk); E) 2-3 dwk; c) 1dwk to 1d month and d) 1month (including the category of no HA). HA intensity was measured Ey extent of HA-associated disaEility as DA (disaEling) – in Eed or 90-100 decrease in activity, S (severe) – 50-90 decrease in activity, or MM (mild moderate) -  50 decrease in activity. Statistical analysis employed the Chi Square test for comparison for data from DTB, and C groups. Results: RESULTS The study includes 6 pairs of DTB, suEMects and matched controls. All DTB, suEMects had HA while 11 (23.9) of controls had no HA. The HA type was migraine in 89 of TB, and in 28 of C suEMects (p.0001 for comparison of DTB, to C). With regard to HA intensity, for DTB, suEMects, 19.6 were MM, 32.6 were S, and .8  were DA. For C suEMects, 58. were MM, 8. were S, and 8. were DA (p=.003 for comparison of DTB, to C). As to frequency of HA, for the DTB, group 19.6 had HA !3 dwk, 3.8 had HA 2-3 dwk, 1.3 had HA 1dwk to 1month, and 2.2 had HA  1month. For the C suEMects, 6.5 had HA !3 dwk, 8.8 had HA 2-3 dwk, 28.3 had HA 1 dwk -1month, and 55.3 had HA 1month or no HA (p.0001for comparison of DTB, to C). Conclusion: CONCLUS,ONS For Veterans deployed to a comEat zone, DTB, is associated with a marked increase in migraine occurrence. DTB, is associated with a strong and highly signi¿cant increase in frequency and intensity of headache, the maMority of which are migraine. The incidence of Chronic Daily HA, (worst headache !3 times week) is 3 times greater in the TB, group as compared to controls.

OR18 Comparison of Headache in Veterans Who Were Deployed to Combat Zones and Did or Did not Suffer a Deployment-Related Traumatic Brain Injury (DTBI) Couch, J.R.1; Stewart, K.E.2 1 Neurology, University of Oklahoma Medical School, Oklahoma City, OK, USA; 2Biostatistics, University of Oklahoma School of 3uElic Health, Oklahoma City, OK, USA. Objectives: OBJECT,VE Compare headache type, severity and frequency in Veterans of ,raq (O,F) and Afghanistan (OEF) wars to evaluate the effect of deployment to a comEat zone with and without a TB,. Background: BACKGROUND TB, is the signature inMury of the OEFO,F wars occurring in 15-20 of deployed soldiers. ComEat zone deployment, Ey itself, is stressful. Both TB, and stress are known to Ee associated with headache. This study evaluates the differences in headache occurrence and severity Eetween matched groups with (1) deployment and (2) deployment accompanied Ey a TB,, Ey using data from TB, suEMects and matched controls.

OR19 Primary Outcome Results of the Idiopathic Intracranial Hypertension Treatment Trial (IIHTT) Friedman, D.,. Neurology & Neurotherapeutics and Ophthalmology, UT Southwestern Medical Center, Dallas, TX, USA. Objectives: OBJECT,VE To determine whether acetazolamide is Eene¿cial in restoring vision when added to a low-sodium, weight reduction diet in patients with idiopathic intracranial hypertension (,,H) with mild visual ¿eld loss 10

June 2014 Background: ,,H primarily affects oEese women of childEearing age. The maMor morEidities are headaches and visual loss, which may Ee permanent. There are no randomized controlled trials on which to Ease a rational treatment strategy for ,,H. Methods: The ,,HTT is a multi-center, randomized, douEle-masked, placeEo-controlled study comparing acetazolamide to placeEo in patients with ,,H and mild visual ¿eld loss (Humphrey perimetric mean deviation -2 to - dB). 165 participants enrolled at 38 sites in the United States and Canada were randomized to receive either the maximally tolerated dose of acetazolamide (up to  gm daily) or matching placeEo taElets for 6 months. All suEMects were offered a low-sodium weight loss program supervised Ey weight loss coaches. The mean age was 29 years and all Eut four enrollees were women. The primary outcome measure was the change in perimetric mean deviation (3MD) from Easeline to month 6 in the most affected eye. Secondary outcome variaEles included papilledema grade and changes in quality of life, headache disaEility (H,T-6), and weight at Month 6. Results: The mean improvement in 3MD was greater with acetazolamide (1.3 dB, n-86) than with placeEo (0.1 dB, n=9); the difference was 0.1 dB (95 C,, 0.00 to 1.3 dB, p=0.05). Acetazolamide treatment led to greater improvement in papilledema grade (-0.0; 95 C,, 0.99 to 0.1; p0.001) and reduction in weight (-.05 kg, 95 C,, -6.2 to -1.83 kg; p0.001) than placeEo. There was no signi¿cant different in headache disaEility at 6 months Eetween the two treatment groups. Conclusion: We found a statistically signi¿cant improvement in visual ¿eld function with acetazolamide and recommend using the maximally tolerated dosage of acetazolamide with a low sodium weight reduction diet in ,,H patients with mild visual loss. Additional therapies may Ee needed to manage the headaches associated with ,,H.

Methods: This study is a retrospective review of 23 patients, 21 of whom had chronic migraine and 2 of whom had chronic cluster headache. All 23 have undergone C1 spinal nerve Elock with intraoperative stimulation where the patient in the awake state would descriEe location of pain felt during C1 sensory stimulation at 50Hz and under 2milliamperes. Exam ¿ndings and operative reports were reviewed in the patients’ charts. A positive Elock was de¿ned as over 50 reduction in pain as documented Ey patient recorded pain diary for 2 hours post-procedure. The pain reduction must last for the duration of the anesthetic to Ee considered positive. Results: Of the 23 patients, 1 () had GON tenderness on exam with periorEital referred pain and 6 (26) had only occipital tenderness. Both cluster patients did not have periorEital nor orEital pain on palpation of the GON. All 1 with periorEital referred pain on GON palpation had reproduciEle periorEital pain intraoperatively on direct stimulation of the C1 spinal nerve with Àuoroscopic guidance. Of those, 151 (88) had a positive Elock. Those 21 (12) with a negative C1 Elock went on to have a successful C1-2, 2-3, 3- medial Eranch Elock. Of the 623 (26) with a negative Elock, only two had periorEital pain reproduced on exam Ey GON palpation. The remaining  did not have periorEital pain on GON palpation nor on intraoperative stimulation. Both cluster headaches had negative Elocks. Neither had intraoperative periorEital or orEital pain on C1 stimulation. Conclusion: Tenderness over the GON with referral to the periorEital region during exam predicts positive outcome of C1 spinal nerve Elock in patients with migraine. P1 Canadian Headache Society Systematic Review & Recommendations on the Acute Treatment of Migraine Pain in Emergency Settings Orr, S.L.1; AuEe, M.2; Becker, W.3; Davenport, W.3; Dilli, E.; Dodick, D.9; Giammarco, R.5; Gladstone, J.; Leroux, E.6; 3im, H.6; Dickinson, G.8; Christie, S.1 1 Neurology, University of Ottawa, Ottawa, ON, Canada; 2 Neurology, McGill University, Montreal, 4C, Canada; 3 Neurology, University of Calgary, Calgary, AB, Canada;  Neurology, University of British ColumEia, Vancouver, BC, Canada; 5Neurology, McMaster University, Hamilton, ON, Canada; 6Neurology, Universite de Montreal, Montreal, 4C, Canada; Neurology, University of Toronto, Toronto, ON, Canada; 8Emergency Medicine, University of Ottawa, Ottawa, ON, Canada; 9Neurology, Mayo Clinic College of Medicine, Scottsdale, AZ, USA.

OR20 Exam Findings Predict Outcome of C1 Block for Migraine Treatment Johnston, M.M.; Jordan, S.; Charles, A. Neurology, UCLA, Los Angeles, CA, USA. Objectives: The oEMectives of this study are to predict the outcome of C1 spinal nerve Elock Eased on exam ¿ndings of patients with migraine who also have greater occipital nerve tenderness and periorEital pain. Background: 3revious micro-anatomical studies have shown the C1 spinal nerve has sensory neurons, which suggests that C1 has sensory function. 1 Direct stimulation of the C1 spinal nerve provokes orEital and peri-orEital pain in patients with migraine thus providing a rationale for C1 directed interventions. 2 Currently, there is no literature descriEing exam features which would predict positive outcome for C1 nerve root Elock. Tenderness over the greater occipital nerve (GON) has Eeen shown to predict outcome of GON Elock. 3 We propose that tenderness over the GON with periorEital referral on exam predicts periorEital referral on direct C1 stimulation and predicts a positive outcome of Elock.

Objectives: To descriEe the results of a systematic review and evidence-Eased recommendations on the acute treatment of migraine pain in emergency settings. Background: Migraine headaches are amongst the most common and painful reasons for presenting to emergency departments. Despite this, there is a consideraEle amount of practice variation in managing migraines in emergency settings and evidence-Eased therapies are often not used ¿rst line. Methods: A peer-reviewed search of dataEases (MEDL,NE, EmEase, CENTRAL) was carried out in order to identify 11

Headache randomized and quasi-randomized controlled trials of interventions for acute pain relief in adults presenting with migraine to emergency settings. Where possiEle, data was pooled into meta-analyses using either a ¿xed or random effects model, depending on the heterogeneity of the data. Results: Two independent reviewers screened 831 titles and aEstracts for eligiEility. Three independent reviewers suEsequently evaluated 120 full text articles for inclusion, of which  were included. ,ndividual studies were assigned US 3reventative Services Task Force quality ratings. The Canadian Headache Society then held a concensus meeting where the GRADE scheme was used to assign a level of evidence and a recommendation strength to each intervention. Conclusion: We strongly recommend the use of prochlorperazine Eased on a high level of evidence, lysine acetylsalicylic acid, metoclopramide and sumatriptan, Eased on a moderate level of evidence, and ketorolac, Eased on a low level of evidence. We weakly recommend the use of chlorpromazine Eased on a moderate level of evidence, and ergotamine, dihydroergotamine, intranasal lidocaine and meperidine, Eased on a low level of evidence. We found evidence to recommend strongly against the use of dexamethasone Eased on a moderate level of evidence, and granisetron, haloperidol and trimethoEenzamide Eased on a low level of evidence. Based on moderate quality evidence, we recommend weakly against the use of acetaminophen and magnesium sulfate. Based on low quality evidence, we recommend weakly against the use of diclofenac, droperidol, intravenous lidocaine, lysine clonixinate, morphine, propofol and tramadol for this indication.

Results: The age of the suEMects ranged from 18 to 66 years. The median reduction of migraine-related pain on a VAS at the completion of tSNS session was 3.5 points. One individual (6.25) could not tolerate the full 30-minutes of tSNS therapy; however, verEally reported some reduction of migraine-related pain and inquired as to how the device may Ee purchased. 56.25 of individuals agreed that they would continue to utilize the Cefaly device at home if affordaEle. Conclusion: There is a mild reduction of migrainerelated pain with tSNS, via the Cefaly device, as a rescue therapy for individuals with 2-hours or greater duration of symptoms. The Cefaly device offers tSNS that is well tolerated. Most individuals agree that home therapy with the Cefaly would Ee a consideration if affordaEle. Overall, further randomized controlled studies are warranted. Additionally, variaEles which may suggest a predictiEility for a therapeutic gain should also Ee taken into consideration. P3 Ease of Use of the Dihydroergotamine Oral Inhaler (MAP0004): Results From Instructions-for-Use Testing and At-Home Use Aurora, S.K.2; Earl, N.L.3; Davar, G.3; HoldErook, F.; Kellerman, D.1 1 Formerly of Allergan, ,nc., Mountain View, CA, USA; 2 Department of Neurology, Stanford University, 3alo Alto, CA, USA; 3Allergan, ,nc., ,rvine, CA, USA; Allergan, ,nc., Bridgewater, NJ, USA. Objectives: This analysis presents ease-of-use (EOU) data from an in-of¿ce study and an optional patient (pt) survey from a phase 3 (33) MA3000 trial. Background: Orally inhaled products (O,3s) can produce rapid drug aEsorption, making them potentially attractive therapeutic options for acute treatment of migraine. To Ee effective, pts must successfully use the O,3 at the time of an acute migraine; thus, EOU is important, particularly for pts with episodic migraine in whom many days may elapse Eetween use training and a migraine. 3revious press-and-Ereathe metered-dose inhalers (MD,s) were cumEersome, hard for some pts to coordinate, and required priming Eefore each inhalation. MA3000 was designed as a Ereath-synchronized MD, with a primeless valve and audiEle click when a dose is administered to address these usage issues. Methods: 60 suEMects (63 migraineurs) from 3 sites not involved in the 33 trial were recruited (BioTrak Research, CarlsEad, CA) for an in-of¿ce evaluation of draft MA3000 instructions for use (,FU); evaluations were used to create a ¿nal ,FU for 25 additional suEMects (100 migraineurs) to evaluate dose administration without coaching. ,n the 33 trial, pts watched an instructional video, were instructed Ey research staff, and received written directions on how to use the MD,. An optional survey was added part-way through the open-laEel extension. Results: 2 out of 25 suEMects (96) from the in-of¿ce study used the MD, correctly to administer 2 inhalations without verEal instruction; the remaining suEMect used the MD, correctly after Erief coaching. Of 65 pts who entered

P2 Transcutaneous Supraorbital Nerve Stimulation as a Rescue Therapy Kozminski, M. Texas Star Neurology, Harker Heights, TX, USA. Objectives: To assess whether Eilateral transcutaneous supraorEital nerve stimulation (tSNS) with the Cefaly device is an effective and well tolerated rescue therapy for individuals with migraines symptoms 2-hours or longer in duration. Background: At least two prior randomized controlled trials and a survey have demonstrated ef¿cacy and toleraEility with tSNS for episodic migraine. There are no studies that demonstrate the utility of tSNS as a rescue therapy. Methods: Between OctoEer 2013 and January 201, Sixteen suEMects seeking urgent walk-in services to an outpatient neurology clinic for headache symptoms 2-hours in duration or greater where offered 30-minutes of tSNS with the Cefaly device prior to any pharmacological intervention. All suEMects were estaElished patients with the outpatient clinic and had prior Eeen diagnosed with migraine. SuEMects were asked to grade the pain related to migraine from 0 to 10 on a visual analog scale (VAS) Must prior to the adminstration of tSNS and at the completion of tSNS therapy. Additionally, at the completion of tSNS, all suEMects were asked if heshe would consider the usage of the Cefaly device at home if affordaEle" 12

June 2014 the open-laEel 33 trial and were treated for *10,000 migraines for up to 1 yr with MA3000, 1 pt withdrew from the study Eecause of dif¿culty using the MD,. 18 pts who completed 1 yr answered EOU questions from the optional survey 86 of respondents agreed or strongly agreed (5 disagreed, 1 strongly disagreed,  neutral) with the statement that the MD, was easy to use, and 80 agreed or strongly agreed (8 disagreed, 3 strongly disagreed, 9 neutral) that the MD, was convenient to use. Asthmatics (n=2) also found the MD, easy (86) and convenient (6) to use. StrengthsLimitations These studies were not humanfactors validation studies Eecause MA3000 use-related tasks were not designed Eased on risk assessment. Also, the in-of¿ce assessment provided less instruction than expected under normal commercial use. The studies did, however, meet several important requirements for humanfactors validation studies, including an adequate sample of representative users assessing the commercial con¿guration of the MD, and ¿nalized ,FU, using contextual inquiry, suEMective interviews, functional testing, and task analysis. The use of a nonvalidated survey during the 33 trial limits conclusions from these data. Conclusion: These data demonstrated that the MA3000 MD, was easily used Ey pts in an of¿ce setting and an openlaEel trial, representing real-world and controlled settings. Through careful development of the MA3000 ,FU, a large proportion of respondents (6–86) in the 33 trial thought that the MD, was easy and convenient to use, and only 1 pt withdrew Eecause of dif¿culty using it. Thus, the unique Ereath-synchronized MD, design contriEuted to pt acceptance of MA3000. Funding Allergan

oEtained from 5 studies of 163 healthy suEMects (65 >0@ men, 98 >60@ women; mean age 29. y) who received 1.0 mg or 3.0 mg orally inhaled DHE (MA3000). The Kaplan-Meier curves were generated using all availaEle data. Results: The Kaplan-Meier plot demonstrated that the proEaEility of nausea is 2 when plasma DHE Cmax )5 ngmL, Eut increases rapidly when Cmax approaches 6.2 ngmL. At Cmax !13. ngmL, the proEaEility of nausea is *50. The Kaplan-Meier plot showed a multiphasic pattern; the largest increases in nausea occurred Eetween approximately 6.1–9.2 ngmL and !13 ngmL. Conclusion: Nausea after oral inhalation of DHE appears to Ee correlated with Cmax. ,n addition, a multiphasic increase in the likelihood of nausea is seen with increasing plasma DHE Cmax after orally inhaled DHE. These data are evidence that (1) DHE may act at different CNS receptors or loci to produce nausea in a dose-dependent manner, and (2) peak plasma concentrations associated with exposures known to produce ef¿cacy after treatment with orally inhaled DHE are well Eelow those that produce clinically meaningful rates of nausea. Funding Allergan, ,nc. References (1) Cook RO, ShrewsEury SB, Ramadan NM. Headache. 2009;9123-3. (2) Jividen H Nausea associated with dihydroergotamine (DHE) is a function of maximum concentration and not route of administration. 3resented at the 53rd Annual Scienti¿c Meeting of the American Headache Society, Washington, DC, June 2–5, 2011. (3) Aurora SK, et al. Headache. 2011;5150–1. P5 Comparable Ef¿cacy and Safety For Exploratory Endpoints Regardless of Pain Severity and Treatment Time after Migraine Onset: Results From a Phase 3 Trial of Orally Inhaled Dihydroergotamine (MAP0004) for the Acute Treatment of Migraine Tepper, S.J.3; Newman, L.; HoldErook, F.2; Earl, N.L.1; Davar, G.1 1 Allergan, ,nc., ,rvine, CA, USA; 2Allergan, ,nc., Bridgewater, NJ, USA; 3Cleveland Clinic, Cleveland, OH, USA; St. Luke™s-Roosevelt Hospital Center, New York, NY, USA.

P4 Relationship Between Plasma Dihydroergotamine (DHE) Concentrations and the Occurrence of Nausea after Treatment with Orally Inhaled DHE SilEerstein, S.D.2; Basile, A.S.3; Kellerman, D.1; Davar, G.3 1 Formerly Allergan, ,nc., Mountain View, CA, USA; 2 Thomas Jefferson University Hospital, 3hiladelphia, 3A, USA; 3Allergan, ,nc., ,rvine, CA, USA. Objectives: To assess the proEaEility of nausea as a function of maximum plasma concentration (Cmax) of dihydroergotamine (DHE) after oral inhalation of 1.0- or 3.0-mg doses of DHE (MA3000). Background: The occurrence of nausea after DHE administration is Eelieved to Ee mediated Ey dosedependent activation of dopaminergic (D2) receptors. Cook1 and Jividen2 reported that the proEaEility (28– 50) of nausea is associated with the plasma DHE Cmax oEserved after either intravenous (,V) administration of 1.0 mg DHE or inhalation of 3.0 mg DHE. The proEaEility of nausea drops to 5 at the inhaled dose of DHE (1.0 mg) known from the pivotal trial to produce ef¿cacy.3 This suggests that nausea after DHE administration is correlated with Cmax and that orally inhaled DHE may offer ef¿cacy at doses that produce little or no nausea. Methods: Kaplan-Meier curves of the incidence of nausea as a function of plasma DHE Cmax were plotted using data

Objectives: To determine the ef¿cacy of orally inhaled DHE (MA3000) for reducing migraine recurrence among patients (pts) with moderate or severe Easeline pain, as well as the rate of comEined pain relief (3R) + no adverse events (AEs) Ey treatment time after migraine onset. Background: MA3000 reduces migraine pain and symptoms at 2 h postdose and provides sustained 3R from 2–2 h.1 Additional ef¿cacy outcomes important to pts should Ee considered when determining the utility of a novel migraine therapy. Methods: This unplanned post-hoc analysis used data from the douEle-Elind period1 of a phase 3 study of MA3000 to evaluate (1) migraine recurrence for pts with 2-h 3R (no or mild pain with no rescue medication at 2 h postdose; recurrence de¿nition return of moderate or severe pain at , 2, or 8 h postdose) and (2) 2-h 3R + no AEs during the douEle-Elind period, evaluated Ey treatment time 13

Headache after migraine onset ()1 h; >1 to ) h; > to )8 h; >8 h). Statistical comparisons were calculated using the CochranMantel-Haenszel test, adMusted Ey Easeline pain score (moderate; severe). Results: 2–2-h recurrence rate for the MA3000 group was signi¿cantly reduced in Eoth Easeline pain severity groups (moderate, 6.; severe, 6.2) vs placeEo (3BO) group (moderate, 12.8; severe, 18.0; P=0.01 for MA3000 vs 3BO). 2–8-h recurrence rates were also signi¿cantly reduced in Eoth Easeline pain severity groups for those taking MA3000 (moderate, 11.3; severe, 8.6) vs 3BO (moderate, 16.3; severe, 20.0; P=0.0 for MA3000 vs 3BO). The therapeutic gain (TG; MA3000– 3BO), in favor of MA3000, was greater for those with severe Easeline pain (2–2-h 11.8; 2–8-h 11.) vs moderate Easeline pain (2–2-h 6.1; 2–8-h 5.0). 3ts treated with MA3000 experienced higher rates of comEined 3R + no AEs than those receiving 3BO at all treatment times examined ()1 h 9.1 vs 32.2; >1 to ) h 3.1 vs 28.0; > to )8 h 39. vs 22.2; >8 h 38.5 vs 19.6; all P0.0 for MA3000 vs 3BO). TG, in favor of MA3000, was relatively constant regardless of treatment time ()1 h 16.9; >1 to ) h 15.1; > to )8 h 1.5; >8 h 18.9). Similarly, other suEsets of treatment times ()1 h vs >1 h, )2 h vs >2 h) showed greater rates of comEined 3R + no AEs for MA3000 vs 3BO, regardless of treatment time. Conclusion: These data are evidence that MA3000 signi¿cantly and meaningfully reduced headache recurrence 2–2 h and 2–8 h postdose in pts with moderate or severe Easeline pain. TG for recurrence was greatest for those with severe Easeline pain, suggesting that MA3000 may Ee a uniquely effective option for this typically dif¿cultto-treat patient population. Also, comEined 3R + no AEs signi¿cantly favored MA3000 over 3BO at all timepoints. TG for this comEined treatment outcome measure was relatively constant regardless of treatment time for patients with moderate or severe Easeline pain, indicating that MA3000 may provide an effective treatment option for patients who are unaEle to treat early. References: (1)Aurora SK, et al. Headache.2011;5150-1. Funding: Allergan

³drug seekers,´ use of nonspeci¿c remedies (especially opiates) and lack of use of more speci¿c or evidence-Eased remedies (such as triptans, ergots, antiemetics, steroids and parenteral NSA,D’s). They experience only non-signi¿cant transient relief of their migraine symptoms. Methods: A retrospective review of routinely collected pre-treatment and post-treatment patient questionnaires was performed for a 60-day period on patients seen in our community-Eased outpatient infusion suite. All patients were treated with parenteral therapy for acute migraine attacks unresponsive to their usual therapy. The questionnaires collected data on pre-treatment and posttreatment severity (Eased on a 0-3 scale). Similar data was collected for nausea, photophoEia, phonophoEia and osmophoEia. An overall patient impression of satisfaction with treatment was likewise recorded. During this time period, data was availaEle on 30 consecutively treated patients. Medications used intravenously could have included any comEination of the following ketorolac, diphenhydramine, metoclopramide, prochlorperazine, ondansetron, magnesium sulfate, methylprednisolone, dexamethasone or dihydroergotamine. SuEcutaneous sumatriptan could also have Eeen used. No opiates or EarEiturates were ever employed. The treating physician determined the actual comEination of drugs used. Results: 2 of 30 patients (91) felt overall satis¿ed and clinically improved. 2 patients felt there was no Eene¿t, and 1 patient reported feeling worse. The average pre-treatment pain intensity was 2. on a  point 0-3 scale. 3ost-treatment average pain intensity decreased to 1.2. Similar reductions in symptom intensity were found for the other parameters measured. Conclusion: Outpatient, community-Eased parenteral treatment of migraine is feasiEle and very well accepted Ey patients when their usual acute therapy has not worked. This is readily accomplished and widely accepted Ey patients in a comfortaEle out-patient, of¿ce-Eased infusion setting without the proElems often seen in ER settings. P7 Comparable Ef¿cacy and Safety Among Patients with and Without Aura: Orally Inhaled Dihydroergotamine (MAP0004) for the Acute Treatment of Migraine Winner, 3.2; HoldErook, F.1; Davar, G.3 1 Allergan, ,nc., Bridgewater, NJ, USA; 23alm Beach Headache Center 3remiere Research ,nstitute, West 3alm Beach, FL, USA; 3Allergan, ,nc., ,rvine, CA, USA.

P6 Community-Based Outpatient Infusion Center Experience in the Acute Treatment of Migraine Turner, ,.; Harding, T. The Center for Headache for Headache Care and Research at ,sland Neurological Associates, 3.C., 3lainview, NY, USA.

Objectives: To assess the ef¿cacy and safety of orally inhaled DHE (MA3000) in migraine patients (pts) with aura (MA) at the time of the attack vs those without aura (MO). Background: MA may have a different prognosis (eg, higher stroke incidence, vascularcardiovascular events) than MO,1 suggesting an underlying difference in pathophysiology. A diagnosis of MA is made even if only some of the pt’s migraine attacks have aura. MA is more dif¿cult to treat than MO, with low response to 5-HT1D agonists or triptans.2,3, Methods: This unplanned post-hoc analysis used data from the douEle-Elind period of a phase 3 MA30005 study

Objectives: To retrospectively evaluate overall patient satisfaction and responsivness for the acute treament of migraine in a community-Eased outpatient infusion center. Background: Migraine patients, who experience occasional attacks where their usual acute therapy fails, often seek treatment in hospital emergency rooms (ER). The overwhelming maMority of these patients, in our experience, express extreme dissatisfaction with how they are treated in ER settings. The reasons for this include long waiting times, Eright light, noise, Eeing treated as 1

June 2014 to evaluate these outcomes for pts with MA (n=302) vs MO (n=6) at the time of treatment (1) 2-h pain relief (no or mild pain with no rescue drugs at 2 h), (2) 2-h pain-free (no pain with no rescue drugs at 2 h), (3) 2–2-h sustained pain relief (S3R-2; for pts with 2-h pain relief, maintained at 2 h with no rescue drugs), () 2–2-h sustained pain-free (S3F-2; for pts with 2-h pain-free, maintained at 2 h with no rescue drugs), (5) 2–8-h sustained pain-free (S3F8; for pts with 2-h pain-free, maintained at 8 h with no rescue drugs), and (6) adverse events (AEs). MA3000 and placeEo (3BO) were compared using the Cochran-MantelHaenszel test (adMusted Ey Easeline pain score or Easeline pain and aura >ie, 2-h [email protected]) or Fisher’s exact test (AEs).Therapeutic gain (TG) was calculated (MA3000 minus 3BO). Results: Baseline demographics were generally similar for MA and MO groups. For all ef¿cacy endpoints evaluated in Eoth MA and MO groups, MA3000 was superior to 3BO (P)0.001 for all). 2-h pain relief rate was higher with MA3000 (MA, 5.9; MO, 61.5) vs 3BO (MA, 33.6; MO, 35.0) and TG was less for MA (21.3) than for MO (26.5); similarly, S3R-2 was signi¿cant in Eoth groups (MA3000 MA, 2.0; MO, 3.0 vs 3BO MA, 2.3; MO, 1.1), and TG was less in the MA (1.) vs MO (25.9) group. ,n contrast, TG was higher in the MA vs MO groups for the following endpoints 2-h pain-free (MA3000 MA, 2.2; MO, 29. vs 3BO MA, .1; MO, 12.2; TG 20.1 and 1.2), S3F-2 (MA3000 MA, 22.8; MO, 23.1 vs 3BO MA, 5.0; MO, .; TG 1.8 and 15.), and S3F-8 (MA3000 MA, 16.; MO, 1.2 vs 3BO MA, 3.6; MO, .3; TG 13.1 and 9.9). ,n general, no suEstantial Eetweengroup differences in MA vs MO groups were seen in AEs for MA3000 or 3BO. AEs reported more frequently for MA3000 (>5 of pts) were pharmaceutical product complaint (MA3000 MA, 8.0; MO, 5. vs 3BO MA, 2.9; MO, 2.8) and nausea (MA3000 MA, 3.; MO, 5. vs 3BO MA, 1.; MO, 2.0); none was signi¿cantly different for MA3000 vs 3BO. Conclusion: Across all ef¿cacy endpoints, MA3000 was superior to 3BO in Eoth MA and MO groups. MA3000 is a uniquely effective and toleraEle option for acute treatment of migraine, including those with dif¿cult-to-treat attacks (ie, MA). Funding: Allergan References: (1) Kurth T, Diener HC. Curr Pain and Headache Rep. 2006;1021–20. (2) Olesen J, et al. Eur J Neurol. 200;1161–. (3) Bates D, et al. Neurol. 199;158–92. () Dowson A, et al. Eur Neurol. 1996;36 Suppl 228–31. (5) Aurora SK, et al. Headache.2011;5150–1.

P8 National Trends of Opioid Treatment for Adult and Pediatric Migraine Headache Patients in the Emergency Department Eaton, K.; Kao, M.; Barad, M. 3ain Management, Stanford University, Cupertino, CA, USA. Objectives: To determine the frequency and national trend of opioid use for treatment of headaches (including migraine headaches) in the Emergency Department from 2002 to 2009 Methods: Data on 288,199 ED visits in the National AmEulatory Medical Center Survey (NAMCS) Eetween 2002 and 2009 are oEtained. VariaEles extracted and investigated include reasons for visit, ,CD9 diagnoses, demographics, and payer type. ,CD-9 codes of Migraine Headache include Migraine with aura, Variants of migraine, no elsewhere classi¿ed, Hemiplegic migraine, Menstrual migraine, 3ersistent migraine aura wo cereEral infarction, 3ersistent migraine aura with cereEral infarction, Chronic migraine without aura, Other forms of migraine, and Migraine unspeci¿ed. Weighted model estimation and inference was performed in SAS 9. (Cary, NC). Results: From 2002 to 2009, the numEer of visits to the Emergency Department (ED) for headache has Eeen consistently at 5 of total ED visits in adults. ,n children (less than 16 years old), ED visits for headache has increased from 2.96 (SE 0.33) in 2002 to 3.9 (SE 0.) in 2009. For adults with a diagnosis of migraine headaches in the ED, 6 (SE 3.8) of patients received opioid prescriptions in 2002 compared with 53.0 (SE 6.0) in 2009. For pediatric patients (less than 16 years old) who received a diagnosis of migraine headaches in the ED, aEout 10-20 received treatment with opioid medications. However, Eecause this estimate is unstaEle due to sample size, we will not have the aEility to look at the temporal trend. Conclusion: Though the trend of opioid management for migraine headaches in adult patients in the ED decreased Ey 11 from 2002 to 2009, it it still an aEortive therapy Eeing prescriEed in over half of migraine patients presenting to the ED. Due to a smaller pediatric sample size, we are unaEle to accurately assess the temporal trend of opioid use for aEortive therapy in this migraine population. However, this coding system may allow us to continue to follow trends of medication management for various RFV and ,CD-9 codes in the ED in the future. P9 Multi-Centered, Double-Blind, Placebo-Controlled Pilot Study of Mycratine in Treatment of Acute Migraine at the Onset of Pain Cady, R.K.1; Cady, R.J.2; Manley, H.R.2; Tarrasch, J.2; Cadle, R.2 1 Headache Care Center, Spring¿eld, MO, USA; 2Clinvest, Spring¿eld, MO, USA. Objectives: 1) To evaluate the ef¿cacy of Mycratine vs. placeEo as measured Ey migraine headache relief 15

Headache 2) To assess the toleraEility of Mycratine vs. placeEo through the monitoring of adverse advents Background: While there are many therapeutic options for the treatment of acute migraine, limitations such as cost and unwanted side effects cause many patients to delay treatment or search for other treatment options. A meta-analysis of triptan ef¿cacy demonstrated a 2-hour pain-free ef¿cacy of approximately 35 when the treated headache had reached an intensity of moderate-to-severe. Thus, there are many attacks of acute migraine that are not Eeing effectively treated with triptans. Mycratine is a homeopathic product containing Safe Nicotinic Receptor Agonist (SNRA), caffeine, L-3henylalanice, L-Tyrosine , and L-Tryptophan. While the exact mechanism of action is unknown, Mycratine could modulate several receptors systems important in the pathogenesis of migraine. Methods: This was a ¿ve-center, randomized, douEleElind, placeEo-controlled study consisting of 50 screened suEMects, 18 to 65 years of age, meeting ,CHD-,, criteria for migraine with or without aura. SuEMects were instructed to treat their next four migraines at the onset of pain with 2 oz. of Mycratine or matching placeEo. SuEMects were randomized 11 and received study product (Mycratine) or placeEo as treatment for the ¿rst 2 migraines. For the 3rd and th migraine, all suEMects received active treatment. SuEMects rated their migraine pain severity on a scale from 0-3. Results: There was no difference in pain severity at headache onset (1.39 vs. 1.3, p = 0.1) or Eefore treatment (1.5 vs. 1.59, p = 0.0) Eetween groups. However, suEMects receiving Mycratine had a signi¿cant reduction in pain severity starting 1 hour after treatment (1.0 vs. 1.1, p = 0.0) when compared to placeEo. These suEMects continued to have a signi¿cant reduction in pain severity compared to placeEo after two hours (0.96 vs. 1.5, p = 0.01) and 2 hours (0.25 vs. 0.61, p = 0.02) post treatment. SuEMects receiving Mycratine also reported a signi¿cant decrease in pain (-0.1, p = 0.03) 10 minutes after treatment when compared to headache onset. ,mportantly there was no difference in the average incidence of adverse advents Eetween the two groups (0.6 vs. 0.9, p = 0.88). Conclusion: Mycratine was a rapid, effective, and long lasting treatment option when used early during a migraine attack. ,mportantly, Mycratine signi¿cantly reduced migraine pain and was well tolerated in suEMects. This study provides evidence for the use of Mycratine as a simple ¿rst-line therapeutic option for the treatment of migraine.

P10 Comparative Safety of Triptans, Non-Steroidal AntiInÀammatory Drugs, and Ergotamines for the Acute Treatment of Migraine: A Network Meta-Analysis Thorlund, K.1; Wu, 3.2; Kanters, S.3; Druyts, E.2; BhamEri, R.; Ramos, E.; Mills, E.1 1 stanford prevention Research Center, stanford University, Stanford, CA, USA; 2Faculty of Health Sciences, university of ottawa, Ottawa, ON, Canada; 3School of 3opulation and 3uElic Health, University of British ColumEia, Vancouver, BC, Canada; GloEal Targeted Brands, 3¿zer ,nc, New York, NY, USA. Objectives: To determine the relative safety of triptans, NSA,Ds, and ergotamines for the treatment of acute migraine considering several important adverse events. Methods: We performed a systematic review of key medical dataEases to identify randomized controlled trials (RCTs) assessing the safety of triptans, NSA,Ds (nonselective COX inhiEitors and selective COX-2 inhiEitors), and ergotamines. We included RCTs comparing any triptan(s), NSA,Ds, or ergotamines with placeEo or with each other. The primary outcomes were any adverse events and serious adverse events. The secondary outcomes were dizziness, fatigue, chest discomfort, and somnolence. The primary and secondary outcomes were chosen as they were the most widely and consistently reported outcomes across trials. We performed Bayesian network meta-analysis and produced odds ratios with 95 crediEle intervals (Cr,) to estimate the relative safety of all triptans, NSA,Ds and ergotamines. Results: A total of 150 randomized controlled trials were eligiEle and included in the analyses. For any adverse events, zolmitriptan was associated with the highest increased odds compared with placeEo (OR=2.19, 95 Cr, 1.8 to 2.0), followed Ey ergotamines (OR=2.0, 95 Cr, 1.3 to 2.93), sumatriptan (OR=1.92, 95 Cr, 1.66 to 2.21), rizatriptan (OR=1.81, 95 Cr, 1.52 to 2.19), and eletriptan (OR=1.6, 95 Cr, 1.2 to 2.13). Frovatriptan, almotriptan, and naratriptan were associated with nonsigni¿cant odds ratios Eetween 1.20 and 1.25. Both nonselective COX inhiEitors, and selective COX-2 inhiEitors yielded identical risk compared with placeEo (i.e., OR=1.01 and OR=1.02, respectively). For serious adverse events, naratriptan was associated with an odds ratio of 8.52 (95Cr, 0.93 to 6.) compared with placeEo and the other triptans with odds ratios close to 1.00. Non-selective COX inhiEitors and ergotamines appeared protective when compared with placeEo (OR=0.25, 95 Cr, 0.0 to 1.2; and OR=0.5, 95 Cr, 0.05 to 2.93, respectively), and selective COX-2 inhiEitors exhiEit same risk pro¿le as placeEo (OR=1.01, 95 Cr, 0.0 to 9.61). For the secondary outcomes, eletriptan, sumatriptan, rizatriptan, and zolmitriptan were signi¿cantly worse than placeEo with odds ratios ranging ffrom 1.55 to .86. Non-selective COX inhiEitors were similar to placeEo for all secondary outcomes. Selective COX-2 inhiEitors and ergotamines were worse than placeEo for dizziness, and selective COX2 inhiEitors were statistically signi¿cantly worse than placeEo for somnolence (2.28, 95 Cr, 1.21 to .8). The placeEo aEsolute risk of experiencing each safety outcome 16

June 2014 any adverse event (18), serious adverse event (0.1), dizziness (1.8), fatigue (2.), chest discomfort (1.0), and somnolence (1.9). Conclusion: ConsideraEle differences exist across safety pro¿les of migraine treatment differ. For any adverse event, zolmitriptan and ergotamines were associated with the highest odds ratios and signi¿cantly worse than placeEo, whereas naratriptan appeared worse for serious adverse events, and ergotamines and non-selective COX-inhiEitors protective. Considered the already known comparative ef¿cacy pro¿les of the investigated agents, our analyses add valuaEle insight to inform clinical practice.

36.9X) in 90-day period prior to index date (6 vs 3, respectively); (3) receipt of an antiepileptic drug within 365 days of index date (6 vs 2); () receipt of migraine prophylaxis on *90 of the time in 90-day period prior to index date (69 vs 51); (5) receipt of acute therapies for migraine *90 of the time in 30-day period prior to index date (60 vs 3); (6) receipt of any prescription nonsteroidal anti-inÀammatory drug (NSA,D) in 180-day period preceding index date (66 vs 51); and () receipt of any antidepressant within 365 days of index date (66 vs 51) (all p0.01). Conclusion: 3atterns of healthcare utilization among identi¿ed chronic migraineurs differ signi¿cantly from those of patients with only episodic migraine. Further study is needed to explore how knowledge of these differences might aid in identifying patients in healthcare claims data who have chronic migraine Eut have not received onaEotulinumtoxinA or a diagnosis code speci¿c to this disorder.

P11 Identi¿cation of Chronic Migraineurs in Health Insurance Claims Data Berger, A.2; CorEell, C.3; Moynahan, A.3.2; Messali, A.3; Oster, G.2; SilEerstein, S.1 1 Jefferson Headache Center, 3hiladelphia, 3A, USA; 2 3olicy Analysis ,nc., Brookline, MA, USA; 3Allergan, ,nc., ,rvine, CA, USA.

P12 Tolerance and Dependence on Symptomatic Medication in Patients with Medication Overuse Headache (MOH) Rueda-Sánchez, M.2; Munoz, J.1; Diazgranados-Sánchez, J.3; Silva, F.; Takeuchi-Tan, Y.5 2 1 Hospital Mederi, Bogotá, ColomEia; Clínica Bucaramanga, Bucaramanga, ColomEia; 3Neurólogos Occidente, Cali, ColomEia; Fundación Cardiovascular, Bucaramanga, ColomEia; 5,CES,, Cali, ColomEia.

Objectives: ,t is well-estaElished that counts of the numEer of persons with healthcare encounters for chronic migraine (,CD-9-CM 36.X) in health insurance claims dataEases may suEstantially underestimate the Eurden of this condition due to less-than-universal use of this diagnosis code. The oEMective of our study is to determine whether it is possiEle to identify patterns of migraine-related care characteristic of persons with chronic migraine that could Ee employed to identify heretofore ³missed´ chronic migraineurs. Methods: Using a large US health insurance claims dataEase, we identi¿ed all patients with any healthcare encounters Eetween January 1, 2009 and March 31, 2012 with a diagnosis of migraine (,CD‘9‘CM 36.XX). Those with a diagnosis of chronic migraine (36.X) or who received onaEotulinumtoxinA were designated ³chronic migraineurs´; the date of ¿rst ³qualifying´ encounter was designated the ³index date´. Each chronic migraineur was matched to  persons with healthcare encounters for migraine (Eut not chronic migraine) in the index month (³controls´). Comparing claims histories in the 30-, 90-, 180-, and 365-day periods prior to index date, respectively, we examined how patterns of healthcare utilization differ Eetween persons with and without healthcare encounters with diagnosis of chronic migraine, including numEers and types of pre-index healthcare encounters, use of triptans, and use of migraine prophylaxis (other than onaEotulinumtoxinA). Results: We identi¿ed 12,36 chronic migraineurs (868 with ,CD-9-CM diagnosis code 36.X) >0 of all such [email protected], 29 >2@ with receipt of onaEotulinumtoxinA, and 81 >6@ with evidence of Eoth); these patients were matched to 8,052 controls. 3atients in Eoth groups were similar with respect to age (mean, 6 years) and gender (86 women), Eut differed signi¿cantly in a numEer of pre-index characteristics, including (1) any visit for ³migraine without aura´ (,CD-9-CM 36.0X, 36.5X, 36.6X) )90 days prior to index date (60 of chronic migraineurs vs 21 of matched controls); (2) no visits for ³other migraine´ (36.2X, 36.3X, 36.X, 36.8X,

Objectives: The aim of this study was to determine the prevalence of tolerance and dependence in patients with chronic migraine and medication overus. Background: Migraine is considered the th disaEler disease around the world. One of the most common complications is chroni¿cation associated to medication over use. The former phenomenon could Ee related to tolerance and dependence. Methods: Descriptive study including Sociodemographic information and determination of prevalence of tolerance and dependence in adult patients with chronic migraine and medication overuse. We also determined disaEility and co morEidities with depression and anxiety, Results: We studied  patients, of whom 5 (95.) were women. 93.6 ( patients) met the de¿nition of acute migraine symptomatic medications dependence. 83 (39 patients) show medication tolerance symptoms, 35 (.5) reported the need to increase the analgesic dosage to get the same analgesic effect and 33 (0.2) reported that medication no longer had the same analgesic effect. 8.9 (23 patients) reported reEound headaches when they stopped taking the analgesic as withdrawal symptom TaEle 1. Average scores on the M,DAS disaEility questionnaire was 0. ( 2. and on the Migraine 4uality of Life 4uestionnaire was .6 ( 15.2. The average score in the Zung self-administered scale for depression was 5. ( 9.0 and for anxiety was 3. ( 9.6. The medication most frequently over used was the comEination of acetaminophen, aspirin and caffeine (25.5) Table 1. Prevalence of tolerance, dependence and related symptoms. n (%) 1

Headache Dependence  (93,6) Physical Dependence 3 (91,5) Tolerance 39 (83,0) Larger dose 35 (,5) Effect Loss 33 (0,2) Withdrawal 23 (8,9) Dependence Awareness 2 (89,) Wish to leave Analgesics  (93,6) Attempt to withdraw Analgesics 1 (29,8) Failing Attempts 20 (2,6) Use despite risk 2 (5,) Conclusion: This study suggests that there is and increased prevalence of dependence and tolerance in patients with chronic migraine and medication overuse. Further studies are necessary to con¿rm theses ¿ndings.

ND3H was the least common. A high percentage of patients had history of medication aEuse in Eoth the migraine and CTTH, more so in the former. P14 Family Burden of Chronic Migraine to the Migraineur: Results of the CaMEO (Chronic Migraine Epidemiology & Outcomes) Study Buse, D.C.1; Dodick, D.2; Serrano, D.3; Manack, A.N. 1 The Saul R. Korey Department of Neurology, AlEert Einstein College of Medicine and the Monte¿ore Headache Center, Bronx, NY, USA; 2Department of Neurology, Mayo Clinic, 3hoenix, AZ, USA; 3Vedanta Research, Chapel Hill, NC, USA; Allergan, ,nc., ,rvine, CA, USA. Objectives: To assess the perception among those with chronic migraine (CM) of the nature and extent of migraine Eurden on family activities and relationships. Background: CM is associated with signi¿cant personal disaEility,1 Eut the effect of migraine on the lives of memEers of a migraineur’s family is less well known. Methods: CaMEO recruited persons from a weEEased panel, using quota sampling to oEtain a sample representative of US demography, who completed weEEased surveys over 1 year to characterize migraine. This analysis included data from respondents meeting study CM criteria (modi¿ed ICHD-3b migraine diagnosis + *15 headache >[email protected] daysmo for past 3 mo; ICHD-3b criteria AB for migraine and C for CM not assessed). The proEand’s family Eurden survey (FBS) assessed several domains, including Eut not limited to overall Eurden, family activities missed, relationship impact, activities missed and interactions with partnerchildren, important familylife events, and vacations. Descriptive statistics (count items mean, SD; Einary items numEer, percent endorsing) and sex contrasts (count items rate ratio >[email protected] from negative Einomial regression model; Einary items odds ratio >[email protected] from Einomial logistic regression model) were calculated. Results: Of the 11,518 respondents with valid data for the proEand FBS, 99 (8.6) were classi¿ed as having CM and included in this analysis. 812 (81.) of the CM proEands were women and 182 (18.3) were men. 3roEands experienced reduced enMoyment of family activities and reduced quality time with partner 6.9 and 6.6 days in the prior month, respectively. Most proEands felt that HAs made them easily angryannoyed with their partner (0.2) and made their partner’s life hard (6.1). Many avoided sexual intimacy Eecause of HAs (6.2), felt they would Ee a Eetter partner without HAs (2.5), and felt guilty aEout how their HAs affected their partner (6.). The odds of women reporting interictal stress in romantic relationships were 3 lower than that of men (OR >95 C,@ 0.66 >0.3–[email protected]; P=0.09); similar interictal sex differences were seen in relationships with children (OR >95 C,@ 0.58 >0.35–[email protected]; P=0.0). Respondents reported missing 20 of planned vacations Eecause of HAs (no sex difference; P=0.88). Women cancelled plans 23 less often than men (.09 vs 5.28 timesmo; RR >95 C,@ 0. >0.61–[email protected]; P=0.031).

P13 Clinical Pro¿le of Chronic Daily Headache: Study from a Tertiary Care Referral Centre in India Nandmer, V.K. neurology, Ehu, Varanasi, ,ndia. Objectives: Purpose – Chronic daily headache(CDH) represents a range of disorders characterized Ey the occurrence of long-duration headache of 15 or more days per month. CDH may Ee primary or secondary to an underlying cause.CDH is associated with a signi¿cant disaEility & has an impact on quality of life. We present the clinical pro¿le of CDH patients from a tertiary care referral centre in ,ndia Background: Material and method-All patient with clinical features of CDH attending neurology out patient department and or admitted in the neurology wards from January 2008 to March 2009 were enrolled. 3atient were suEMected to a detailed clinical and neurological examination. Relevant Eiochemical investigation were carried out. Neuroimaging (CT scan or MR,) was done in all. A total of 626 patient were included. 3atients were classi¿ed into various headache suEtypes using the ,CHD2 criteria. Methods: Material and method-All patient with clinical features of CDH attending neurology out patient department and or admitted in the neurology wards from January 2008 to March 2009 were enrolled. 3atient were suEMected to a detailed clinical and neurological examination. Relevant Eiochemical investigation were carried out. Neuroimaging (CT scan or MR,) was done in all. A total of 626 patient were included. 3atients were classi¿ed into various headache suEtypes using the ,CHD-2 criteria. Results: Results- A total of 626 patients were enrolled, out of which 606 were primary headache & 20 were secondary headache types. Male Female ratio was 11.9. Age of presentation ranged from 16 to 65 years and duration of illness varied from 1-20 years. Overall patients were younger and the disease duration was less in the ND3H group. Out of 626 patient 3 had chronic migraine , 222 had CTTH and 10 patients were diagnosed as having ND3H. History of medication aEuse was present in 5 of migraineurs and in 60 of CTTH group Conclusion: Conclusion-Thus chronic migraine and CTTH comprised the maMority of CDH patients while 18

June 2014 ,n the past year, women missed 9 fewer holidays religious events (2.9 vs 5.9; RR >95 C,@ 0.51 >0.32– [email protected]; P=0.003) and 52 fewer weddingsimportant events (2.6 vs 5.09; RR >95 C,@ 0.8 >0.30–0.[email protected]; P=0.00) than men. Conclusion: Most individuals with CM reported that migraine attacks have signi¿cant effects on family relationships and activities. Reduced enMoyment of activities was commonly reported. Women consistently reported lower rates of aEsenteeism Eecause of HA than men across many activities. Reasons for this are unknown. The nature and severity of attacks may Ee qualitatively different Eetween men and women, or women may feel more oEligated to keep commitments despite a migraine attack. Reference: 1. Buse DC, et al. Headache. 2012;52(10)156– 10. Funding: Allergan

(as measured Ey CronEach’s alpha) for Eoth instruments was greater than 0.8 (overall and for each domain). The correlation of concurrent validity was as predicted for the ACM-,. For the ACM-S, the hypothesized correlation was con¿rmed against the MS4 and M,DAS, Eut otherwise tended to Ee lower than predicted against other measures. For known groups validity, the ACM-, performed well, with monotonically increasing scores across the severity groups de¿ned Ey M,DAS, and higher scores in the more severe groups de¿ned Ey frequency of headache days. CFA showed weak support for the hypothesized domain structure of the ACM-, (CF, 0.91, RMSEA 0.11), Eut was Eetter than the one factor CFA (CF, 0.80, RMSEA 0.13). ,nspection of the eigenvalues indicated a very strong one factor solution with the possiEility of up to four factors the ¿rst factor accounted for 85 of the total variance. Conclusion: The domains and overall score of the ACM-, performed well in Easeline psychometric testing. Results of the CFA, along with the good psychometric performance of the overall score, strongly support an overall impact score for the ACM-,. On-going ,RT analyses will aid in item retention decisions. Longitudinal evaluation of the ACM-, (test-retest reliaEility and responsiveness to change) will Ee conducted when follow-up data Eecomes availaEle. The ACM-S needs further testing in a venue that will use data collected in a daily diary format to provide additional support for the scale.

P15 Psychometric Evaluation of the Assessment of Chronic Migraine Impacts (ACM-I) and Assessment of Chronic Migraine Symptoms (ACM-S) Blumenfeld, A.M.5; Rosa, K.2; Evans, C.3; Lai, H.1; Yang, M.1; Gillard, 3.J.1; Aurora, S.K. 1 Allergan ,nc., ,rvine, CA, USA; 2School of Nursing, University of North Carolina, Wilmington, NC, USA; 3 Endpoint Outcomes, Boston, MA, USA; School of Medicine, Stanford University, Stanford, CA, USA; 5The Neurology Center, Encinitas, CA, USA.

P16 Craniocervical Posture Changes in Subjects with Migraine Ferracini, G.N.1; Chaves, T.C.1; Rodrigues, A.B.1; Bevilaqua-Grossi, D.1; Bigal, M.E.2; Dach Eckeli, F.1; Speciali, J.G.1 1 University of Smo 3aulo, RiEeirmo 3reto, Brazil; 2LaErys Biologics, 3hiladelphia, 3A, USA.

Objectives: To evaluate the psychometric properties of the ACM-, and ACM-S among patients diagnosed with chronic migraine (CM). Background: ACM-, and ACM-S were developed to assess the effect Chronic Migraine (CM) has on a patient’s life and to assess CM symptoms, respectively. Both ACM-, and ACM-S were developed in accordance with the FDA guidance on 3ROs and were validated in the COM3EL study an open-laEel, multicenter study of the long-term ef¿cacy, safety and toleraEility of onaEotulinumtoxinA for the prophylaxis of headaches in adult patients with CM. Methods: A sample of participants from COM3EL were included for analysis. 3atients demographic characteristics (e.g., age, gender, race), disease characteristics (e.g., headache), and Easeline descriptive characteristics (e.g., ACM-,, ACM-S, MS4, M,DAS, H,T-6, and SF-36) were collected at Easeline. 3sychometric analyses included item completion, item distriEution (domain Àoor and ceiling effects), inter-item correlation, construct validity, internal consistency reliaEility, concurrent validity, known group validity, con¿rmatory factor analysis (CFA), and item response theory (,RT) analysis. Results: The mean age of patients was 2.5 (SD 11.08) years, most were female (85.3) and Caucasian (86.5). The mean H,T-6 score was 6.8 (SD .2). The ACM-, and ACM-S had missing responses of 1. No ceiling effects were oEserved, while Àoor effects were oEserved for four items of the ACM-,. For some items ( and 5, 11 and 12, 15 and 16 for ACM-,; 3 and 6 for ACM-S), inter-item correlations were >0.80. ,nternal consistency

Objectives: To compare the head and cervical spine alignment, through postural radiographic evaluation Eetween groups of individuals with and without migraine. Background: The association Eetween craniocervical posture and headache has Eeen widely studied and discussed in the literature, Eut the results are still inconclusive. Methods: The sample consisted of 50 suEMects (5 men and 5 women) diagnosed with migraine without aura (migraine group - MG) with a mean age of 3.1 (Standard deviation – SD =10.8) years, and 50 individuals without headache (control group - GC) (5 men and 5 women) with a mean age of 33. (SD=11.3) years. SuEMects were recruited from a tertiary hospital, and the diagnosis of migraine was oEtained Ey a neurologist according to the criteria of the ,CHD - ,,,1. We excluded those with a history of cervical lesions and other comorEidities, such as ¿Eromyalgia, and those who had received physiotherapy treatment in the last year. The radiographic tracing of the cervical spine was performed always Ey the same trained examiner and the following four angles (°) and four distances (mm) were measured, respectively 1) HCA high cervical angle, 2) LCA low cervical angle, 3) A3A atlas plane angle, ) CoEEA CoEE cervical spine angle, 5) C0 C1D distance Eetween the occipital Eone and ¿rst cervical 19

Headache verteEra, 6) ATD anterior translation distance – horizontal distance Eetween second and seventh cervical verteEra, ) TH Triangle measured among points localized on hyoid Eone, Maw and third cervical verteEra, 8) C2-C 3T Angle measured Eetween second and seventh posterior tangent to verteEra Eody wall2. All the angles were measured using the K-3acs® software. For statistical analysis the t test for independent samples and Con¿dence interval (C,) were used. The effect size was calculated using Cohen d coef¿cient3 and were classi¿ed as Small effect size 0.20 (0-0.39) - SES; medium effect size 0.50 (0.-0.9) - MES; large effect size> 0.80 - LEF. The statistical analysis was conducted at a 95 of con¿dence level. Results: ,t was oEserved smaller ATD distance for MG compared to CG >MG 1. (SD=8.0), GC 19.3 (SD=9.6), C, (-8.6  -1.26), p0.01) and effect size of the 0.3, this is, a small effect size. Conclusion: ,ndividuals with migraine demonstrated smaller anterior translation of cervical verteErae, which could suggest a cervical spine recti¿cation in migraine patients. This posture could Ee associated to extensor neck muscle overload. However, the effect size for the difference oEtained was considered only small, suggesting a statistical Eut not clinical difference.

migrainous headache days compared to placeEo. There was no statistically signi¿cant Eene¿t for suEMects in the CBZ group compared to the placeEo group for secondary ef¿cacy variaEles. Both CBZ and placeEo were well-tolerated, with no serious adverse events and no oEMective ¿ndings on physical, neurological, or laEoratory examination. Three CBZ suEMects (20) and four placeEo suEMects (25) noted mild to moderate treatment-emergent adverse events. Discontinuation due to adverse events occurred in 0 (0) of the CBZ group and in 2 (12.5) of the placeEo group. Conclusion: CycloEenzaprine Hydrochloride ExtendedRelease at daily doses of 15mg daily for 12 weeks did not result in statistically signi¿cant reductions in mean monthly migrainemigrainous days compared to placeEo when administered to chronic migraineurs. CBZ was safe and well-tolerated in this group of suEMects. P18 Development and Validation of a Screening Tool for Chronic Migraine (ID-CM) Lipton, R.B.2; Serrano, D.3; Buse, D.C.2; Blumenfeld, A.M.; Dodick, D.W.5; Aurora, S.K.6; Becker, W.; Diener, H.8; Wang, S.9; Vincent, M.B.10; 3avlovic, J.2; Sanderson, J.C.1; Varon, S.F.1; Gillard, 3.J.1; Reed, M.L.11 1 Allergan ,nc., ,rvine, CA, USA; 2AlEert Einstein College of Medicine and Monte¿ore Headache Center, Bronx, NY, USA; 3Vedanta Research and Department of Neurology, AlEert Einstein College of Medicine, Bronx, NY, USA;  The Neurology Center, Encinitas, CA, USA; 5Mayo Clinic, 3hoenix, AZ, USA; 6Stanford University Medical Center, Stanford, CA, USA; University of Calgary, Calgary, AB, Canada; 8Department of Neurology, University of DuisEury-Essen, Essen, Germany; 9Department of Neurology, Neurological ,nstitute, Taipei Veterans General Hospital, Taipei, Taiwan; 10HUCFF-UFRJ, Rio de Janeiro, Brazil; 11Vedanta Research, Chapel Hill, NC, USA.

P17 Ef¿cacy and Safety of Cyclobenzaprine Hydrochloride Extended-Release for the Treatment of Chronic Migraine: A Randomized, Double-Blind, PlaceboControlled Trial Mueller, L. The Headache Center, Kennedy Health Alliance, Cherry Hill, NJ, USA. Objectives: To evaluate the ef¿cacy and safety of cycloEenzaprine HCl extended-release (15mgday) compared to placeEo for the prophylaxis of chronic migraine. Methods: This was a randomized, placeEo-controlled, parallel-group, single center study consisting of 12 weeks of douEle-Elind treatment. SuEMects aged 18 to 65 years meeting ,CHD-,,R chronic migraine criteria (15 or more headache days per month, at least half of which were migrainemigrainous type), were randomized 11 to either cycloEenzaprine HCl ER 15mgday (CBZ) or placeEo. StaEle concomitant preventive migraine treatment was allowed with restrictions. The primary ef¿cacy endpoint was change in mean migrainemigrainous days from pretreatment Easeline ( weeks) compared with last  weeks of study treatment. Assessment of safety and toleraEility included physical and neurological examinations, formal queries at monthly contactsvisits, spontaneous selfreported events, and clinical laEoratory testing (when indicated). Results: Thirty-one suEMects completed Easeline diaries, had no signi¿cant EKG or laEoratory (chemistry panel) aEnormalities, and received study medication (cycloEenzaprine, n= 15; placeEo, n=16). Fourteen (93.3) of the CBZ group and 10 (62.5) of the placeEo group were trial completers. CBZ treatment did not result in a statistically signi¿cant reduction in mean migraine

Objectives: To develop and validate a self-administered screening tool for chronic migraine (CM) amongst individuals with severe headaches. Background: Despite its suEstantial economic and quality of life Eurden, CM remains under-recognized, undertreated and poorly managed. A validated screening tool could improve the identi¿cation of individuals likely to have CM. We previously developed an item pool for ,D-CM Ey reviewing current diagnostic instruments for migraine, gathering expert ideas for candidate questions, modeling previously collected data, conducting Delphi panels with experts, and deErie¿ng interviews in individuals with CM. The draft screening tool had 20 items. Methods: The draft screening tool was administered via internet to severe headache sufferers identi¿ed through an online panel research company (ResearchNow). Exploratory factor analysis was used to determine factor structure. Based on this structure, a two stage screening process was developed. The ¿rst stage was designed to identify migraine Eased on ,CHD-3-Eeta criteria. The second stage partitioned the migraine sample into CM and episodic migraine (EM). ,tem response theory (,RT) models were ¿t to screen for migraine among severe headache suffers and then to identify CM within the 20

June 2014 migraine sample. Analyses were conducted using M-plus version .1. Results: The draft CM screener was administered to 1,562 persons with severe headache. Factor analysis revealed a 3-factor solution which optimally explained the data. Factors corresponded to migraine symptoms (6-items, e.g., pain intensity, nausea), headache-related disaEility (3-items from the M,DAS 4uestionnaire), and disruption of daily activities (3-items, e.g., headache interference with planning). For the ¿rst stage of screening, the symptom factor was used to screen for migraine, with an ,RT model Eased on an optimal suEset of 6 items. These items accounted for 80 of the explained variance differentiating migraine from other severe headache. For the second stage of screening, the disaEility and disruption of daily activities factors were merged into a single disaEility and planning disruption factor to screen for CM in a migraine sample. When the ,RT model was augmented with headache frequency it accounted for 96 of the explained variance differentiating CM from EM, of which 10 was accounted for Ey the disaEility and planning disruption factor. Conclusion: A self-administered tool has Eeen developed to screen for CM. The screening tool accounts for the maMority of the variation in ,CHD-3-Eeta headache case de¿nition in the two disorders they are designed to detect (migraine and CM, respectively). Test-retest reliaEility and validation research is currently underway. Validation testing includes comparing ,D-CM Eased diagnoses with ³gold standard´ physician headache expert clinical diagnosis using semi-structured telephone interviews.

processes that repeatedly occur in CM. Therefore, we hypothesized that alterations in CVH might Ee implicated in the pathophysiology of CM. Methods: We consecutively recruited all migraine patients afferent to our Headache clinic suffering from CM with or without analgesic aEuse (,CHD-,, code 8.2 and 1.5.1) and episodic migraine (EM) with or without aura (,CHD,, code 1.2 and 1.1) and a group of age and sex matched healthy suEMects (HC). CVH was assessed according to a rigorous Elinding procedure, strict operational ultrasound criteria (ZamEoni, 2008) Ey an expert trained operator. By transcranial and extracranial sonography, 5 venous hemodynamic parameters were evaluated 1) ReÀuxEidirectional Àow in the internal Mugular veins (,JVs) andor in the verteEral veins (VVs); 2) ReÀuxEidirectional Àow in the deep cereEral veins (DCVs); 3) B-mode aEnormalities or stenoses in ,JVs; ) AEsence of Doppler-detectaEle Àow in ,JVs and or VVs; 5) Reverted postural control of the main cereEral venous outÀow pathway. When suEMects met at least two criteria we consider this an aEnormality of the CVH. All patients were suEmitted to Erain MR, including arterial and venous MR angiography. Results: We recruited 33 CM patients, 29 EM patients, and 21 HC. CVH alterations were oEserved in 30.3 (n=10) of cases in CM group and in 2 (n=) of EM ones. CVH aEnormalities were not detected in the HC group. The presence of CVH aEnormalities was signi¿cantly higher in CM (p=0.02) and EM (p=0.02) than HC. ,n CM and EM patients, no differences were oEserved for Eoth CVH aEnormalities and for MR morphological changes. ,f we consider the duration of migraine disease (less or more than 10 year of history of migraine), CVH aEnormalities were signi¿cantly more frequent in CM patients with long disease duration (Fisher’s exact test, p=0.03). The occurrence of CVH aEnormalities did not inÀuence the other headache features of Eoth CM and EM patients. Conclusion: Our data support the presence of CVH aEnormalities in migraine. ,n a scenario of a multifactorial disease, CVH aEnormalities might play a role in the mechanisms of chronicization, even without structural venous anomalies.

P19 Cerebral Venous Hemodynamic and Chronic Migraine: Does a Link Exist? Di 3iero, V.1; 3etolicchio, B.1; Viganò2, A.1; D Biase, L.3; Tatulli, D.1; Vicenzini, E.1; 3assarelli, F.2 1 Neurology and 3sychiatry, Sapienza University of Rome, Roma, ,taly; 2Ospedale S. Giovanni CalaEita FateEenefratelli, Roma, ,taly; 3Università Campus Biomedico, Roma, ,taly. Objectives: The aim of the present study was to investigate a possiEle correlation Eetween alterations of cereEral venous hemodynamic (CVH) and chronic migraine (CM). Background: The pathophysiological mechanisms underlying migraine chronicization are still unclear. Among others, an involvement of the Erain venous drainage have Eeen recently suggested an asymmetry of the transverse sinuses was oEserved in 50.6 of a population with chronic headache (Fo¿, 2012) and an idiopathic intracranial hypertension was evidenced in aEout 1 of CM patients, half of whom had Eilateral stenosis of the transverse sinuses (De Simone, 2012). CereEral venous aEnormalities may impact local hemodynamics and overload microcirculation at places distant from the location of the mechanical stenosis (Garaci, 2012). Such a mechanism may lead to capillary hypertension and leakage, consistently contriEuting to the inÀammation processes (Bergan, 2006). ,n addition, an overload of cereEral venous circulation may Ee involved with increased Erain iron deposition as well as representing a kind of facilitator of sterile inÀammatory

P20 Are There Differences in Disability Due to Neck Pain in Migraine and Chronic Migraine Patients? Florencio, L.1; Carvalho, G.1; Gonçalves, M.C.1; Chaves, T.1; Dach Eckeli, F.1; Bigal, M.E.2; Bevilaqua-Grossi, D.1 1 University of Sao 3aulo, RiEeirao 3reto, Brazil; 2LaErys Biologics, San Mateo, CA, USA. Objectives: The aim of this study was to investigate disaEility due to neck pain in episodic migraine (EM) and chronic migraine (CM) patients. Background: Neck pain is a very often comorEid condition of migraine and can inÀuence its prognosis. To the Eest of our knowledge, the disaEility related to neck pain and the contriEution of cervical pain for the overall disaEility of individuals with migraine remains unknown. Methods: The patients were screened from a tertiary headache clinic, 10 patients with M (mean age 36; 21

Headache SD10.) and 65 patients with MC (mean age 38; SD10.2) were assessed Ey a Elind examiner using the Neck DisaEility ,ndex questionnaire (ND,) after consenting to participate. DisaEility is classi¿ed as follows, as a function of ND, score 0- = none; 5-1 = mild; 15-2 = moderate; 25-3 = severe; 35 or higher =complete. Statistical analysis was performed using SAS and 95 con¿dence intervals (95 C,) and two-tailed p values were calculated. Chi-square was applied to compare suEtypes of disaEility Eetween groups and t-student test was applied to compare means of each item score of Eoth groups strati¿ed in function of the presence of neck pain. The study was approved Ey the University Ethics Committee on Research (process n0 11002010). Results: Neck disaEility was present in 69 of M group and in 92 of CM group and the prevalence rates of most severe disaEilities suEtypes were signi¿cantly higher in CM compared to EM (severe disaEility p=0.00; complete disaEility, p=0.003). But, in the presence of neck pain, there are no signi¿cant differences in the magnitude of impairment of ND, items in eight of the nine possiEles comparisions(p0.05), indicating that disaEility is strikingly similar at Eoth groups. Conclusion: DisaEility due to neck pain is very prevalent in migraine independently of its frequency with a noteworthy magnitude. But, as the frequency of attacks gets higher, more activities are impaired provoking most severe overall disaEilities.

Blocking the S3G using local anesthetics relieves pain. Unfortunately, many current interventions are cumEersome, invasive, expensive and some associated with signi¿cant adverse events.. The purpose of this study is to evaluate the ef¿cacy and usaEility of the Tx360, a new nasal applicator device, in the treatment of migraine. Methods: This was a 2 center, randomized, douEleElind, placeEo controlled study consisting of 55 screened suEMects, 18 to 65 years of age, meeting the ,CHD-,, appendix de¿nition of chronic migraine. SuEMects were asked to complete a daily Easeline headache diary for 28 days. Following the Easeline period, 1 suEMects met diagnostic criteria for chronic migraine per diary analysis and were randomized 21 receiving either 0.3 mL of 0.5 Eupivacaine or saline delivered to the mucosal surface of the S3G though each nares with the Tx360® device. The procedure was repeated twice weekly for 6 weeks. Results: There was a reduction in the NRS in suEMects receiving the active treatment compared to the sham procedure at 15 min (3.51 vs 2.53, p 0.0001), 30 min (3.5 vs 2.1, p  0,0001), and 2 hours post treatment (.20 vs 2.85, p  0.001). SuEMects in the treatment group had a reduction in the numEer of headache days per month from Easeline to the end of treatment period while the sham group did not (-3.58 days vs. -0.5 days, p  0.01). Furthermore suEMects receiving active treatment had signi¿cant decreases in 3atients GloEal ,mpression of Change compared to the sham treatment group at 30 min (3.2 vs. 3.00, p  0.001) and 2 hours (3.88 vs 3.08, p  0.001) post treatment. Total acute medication usage was similar Eetween the two groups. However, the average usage of opioids per suEMect during the treatment phase was lower in the treatment group compared to the sham group (8.33 vs. 5.). No serious adverse events were reported and there was no difference in non-serious adverse events Eetween groups. Conclusion: S3G Elocks using the TX360 device provide rapid and sustained migraine relief for a population of patients with chronic migraine. ,mportantly, suEMects in the treatment group experienced a signi¿cant reduction in headache days during the treatment. This study provides evidence for the effectiveness and toleraEility of treating chronic migraine with the TX360 device.

P21 WITHDRAWN BY AUTHOR P22 A Double-Blind, Placebo-Controlled Study of Transnasal Sphenopalatine Ganglion Blockade with TX360 in the Treatment of Chronic Migraine: Evaluation of Clinical Outcomes Cady, R.K.1; Manley, H.R.2; Cady, R.J.2; Tarrasch, J.2; Oh, A.2 1 Headache Care Center, Spring¿eld, MO, USA; 2Clinvest, Spring¿eld, MO, USA. Objectives: 1) Compare Numeric Rating Scale (NRS) score Eetween active and sham treatment groups. 2) Compare the numEer of headache days Eetween active and sham treatment groups 3) Compare 2-hour after procedure 3atient’s GloEal ,mpression of Change (3G,C) score for Eetween active and sham treatments groups. ) Compare acute medications usage Eetween active and sham treatment groups. 5) Compare the adverse events of suEMects receiving S3G Elock with Eupivacaine vs saline Background: The sphenopalatine ganglion (S3G) is a small heart shaped structure that resides deep within the pterygopalatine fossa in close proximity to the sphenopalatine foramen and is implicated in orofacial pain conditions including migraine. ,t is largely innervated Ey the maxillary nerve. Access to this structure can Ee gained via a small area of mucosa Must posterior and superior to the tail of the middle turEinate on the lateral nasal wall.

P23 A Double-Blind, Placebo-Controlled Study of Transnasal Sphenopalatine Ganglion Blockade with TX360 in the Treatment of Chronic Migraine: Evaluation of Patient Reported Outcomes Cady, R.K.1; Cady, R.J.2; Manley, H.R.2; Tarrasch, J.2; Oh, A.2 1 Headache Care Center, Spring¿eld, MO, USA; 2Clinvest, Spring¿eld, MO, USA. Objectives: 1) Compare Modi¿ed Brief 3ain ,nventory Scores Eefore treatment and 2 hours post treatment for TX360 with 0.5 Eupivacaine (Group A) vs. saline (Group B) 2) Compare Easeline and post treatment H,T-6 scores for Group A vs. Group B

22

June 2014 3) Compare patient satisfaction with treatment for Group A vs Group B Background: The sphenopalatine ganglion (S3G) is a small heart shaped structure that resides within the pterygopalatine fossa in close proximity to the sphenopalatine foramen. ,t has Eeen implicated in several orofacial pain conditions including migraine. ,t is largely innervated Ey the maxillary nerve. Access to this structure can Ee gained via a small area of mucosa Must posterior and superior to the tail of the middle turEinate on the lateral nasal wall. Blocking the S3G using local anesthetics may relieve pain associated with chronic migraine. Unfortunately, many current interventions are cumEersome, invasive, and expensive. Some are associated with signi¿cant and sometimes serious adverse events. The purpose of this study is to evaluate the ef¿cacy and usaEility of the Tx360, a new nasal applicator device, utilizing 0.5 Eupivacaine vs. saline in the treatment of chronic migraine. Methods: This was a 2 center, randomized, douEle-Elind, placeEo controlled study consisting of 55 screened suEMects, 18 to 65 years of age, meeting the ,CHD-,, appendix de¿nition of chronic migraine. SuEMects were asked to complete a daily Easeline headache diary for 28 days. Following the Easeline period, 1 suEMects met diagnostic criteria for per diary analysis and were randomized 21 receiving either 0.3 mL of 0.5 Eupivacaine or saline delivered to the mucosal surface of the S3G though each nares with the Tx360 device. The procedure was repeated twice weekly for 6 weeks. Results: SuEMects in Group A reported signi¿cantly lower levels of pain 2 hours after treatment (measured Ey greatest level of pain, least level of pain, average pain and percent relief). There was no signi¿cant change reported Ey suEMects receiving saline as a sham treatment. Group A also reported a signi¿cantly improved aEility to accomplish normal work related tasks and improved sleep. There was no change in these activities for Group B. H,T-6 scores signi¿cantly decreased in Group A, the active treatment group (-.5, p  0.01) from Easeline to after the last treatment (6 weeks) while again there was no signi¿cant change for group B (-1.55 p =0.09). Average treatment satisfaction scores at the end of the treatment period (6 weeks) were signi¿cantly higher for Group A compared with Group B. (3.50 vs. 2.91, p  0.001). Conclusion: Repetitive S3G Elocks utilizing 0.5 Eupivacaine delivered Ey through a TX360 device signi¿cantly reduced pain associated with chronic migraine. Further suEMects reported Eetter sleep and increased function at work over the 6 week time of the study. Additionally suEMects receiving the active treatment had signi¿cant improvement in H,T-6 scores at the end of the treatment period vs. Easeline. These results suggest that repetitive S3G Elockade with 0.5 Eupivacaine administered with the TX360 device may Ee an ef¿cacious treatment and improve clinical outcomes for patients with chronic migraine.

P24 Effects of Demographic and Socioeconomic Characteristics on Barriers to Chronic Migraine Consultation, Diagnosis, and Treatment: Results From the CaMEO (Chronic Migraine Epidemiology & Outcomes) Study Dodick, D.W.1; Lipton, R.B.2; Serrano, D.3; Reed, M.L.3; Fanning, K.M.3; Manack, A.N.; Holden, A. 1 Department of Neurology, Mayo Clinic, 3hoenix, AZ, USA; 2Monte¿ore Headache Center; The Saul R. Korey Department of Neurology, AlEert Einstein College of Medicine, Bronx, NY, USA; 3Vedanta Research, Chapel Hill, NC, USA; Allergan, ,nc., ,rvine, CA, USA. Objectives: To estimate the rate of appropriate treatment among those with chronic migraine (CM) and to determine the effect of demographic, socioeconomic, and headache (HA) variaEles on Earriers to care in persons with CM in a naturalistic setting. Background: Effective medical care for CM, at minimum, requires (1) medical consultation for HA, (2) accurate diagnosis, and (3) an effective treatment plan. Failure at any stage makes acceptaEle patient outcomes unlikely. The American Migraine 3revalence and 3revention study found that only 26.3 of episodic migraineurs received appropriate treatment. Data on Earriers to care for CM would help plan interventions to improve treatment outcomes. Methods: The CaMEO study recruited persons to complete a series of weE-Eased surveys over 1 yr. The weE-panel was constructed to Ee demographically representative of the US. Of 16,89 respondents meeting ICHD-3b criteria for migraine, 1,6 (8.8) met study criteria for CM (modi¿ed ICHD-3b migraine diagnosis + *15 HA daysmo >previous 3-mo [email protected]; ICHD-3b criteria AB for migraine and C for CM not assessed). This analysis included self-reported demographic, socioeconomic, and HA-speci¿c data for respondents who (1) met study CM criteria, (2) had Migraine DisaEility Assessment >M,[email protected] score *2, and (3) reported whether or not they had health insurance. Descriptive statistics were used to assess rates of receiving minimally appropriate treatment and logistic multivariate analyses assessed predictors of consulting patterns. Results: Of those with CM, a M,DAS grade *2, and information on insurance status, only 5121,25 (0.8) respondents reported currently Eeing managed or treated Ey a healthcare professional (HC3) for HAs (current consulters). Of current consulters, 126512 (2.6) reported receiving a diagnosis of CM (or transformed migraine) from an HC3. Of those diagnosed with CM, 56126 (.) received minimally appropriate treatment (acute + preventive therapies). ,n total, .5 (561,25) of the CM population passed all 3 Earriers to care and received minimally appropriate care. The odds of consulting an HC3 increased with age (odds ratio >OR; 95 C,@ 1.02 >1.01–[email protected]), were higher for those with vs without insurance (OR >95 C,@ .61 >3.05–[email protected]), and increased with symptom severity (OR >95 C,@ 1.16 >1.11–[email protected]) and disaEility (M,DAS; OR >95 C,@ 1.02 >1.00–1.0@). Among consulters, the odds 23

Headache of receiving a CM diagnosis from an HC3 were higher for women (OR >95 C,@ 1.93 >1.03–[email protected]), as symptom severity increased (OR >95 C,@ 1.25 >1.1–1.3@), and for those seeing an HA specialist (OR >95 C,@ 2.38 >1.5–[email protected]). 3ossiEly Eecause of small sample size, none of the variaEles predicted receiving appropriate treatment among those diagnosed with CM. Conclusion: Several Earriers must Ee overcome for persons with CM to receive minimally appropriate treatment. Appropriate treatment is more likely with increasing age and among women, those with insurance, and those with greater migraine disaEility and symptom severity, although very few (.5) eligiEle respondents with CM actually received minimally appropriate treatment. 3uElic health efforts should focus on improving consultation, diagnosis, and treatment of CM. Reference: Lipton RB et al. Headache. 2013;5381–92. Funding: Allergan

patients quali¿ed Eased on inclusionexclusion criteria, they were consented and enrolled in a screening period of 28 days during which they entered their headache and treatment data on electronic diaries including frequency, duration, and severity. Those patients that quali¿ed during the screening period Eegan a second 28 day open laEel dose titration period during which they used nasal oxytocin as needed to treat their headaches. During this time, they recorded the severity and timing of each headache. Those that showed a suEstantial reduction in either or Eoth average headache intensity or numEer of headaches, when compared to screeing, were enrolled in a douEle-Elind, placeEo-controlled 28 day period during which they again dosed as needed to treat headaches. Results: 3reliminary results indicate that nasal oxytocin, given 3RN, produces a signi¿cant reduction in the intensity of treated headaches. ,n addition, although dosing was 3RN, patients experienced signi¿cantly fewer headaches over the course of the 28 day period with oxytocin dosing, ,nterestingly, this decrease was progressive on a week-toweek Easis during dosing. Conclusion: Although the study has not Eeen completed, preliminary results provide a strong indiction that nasal oxytocin may Ee a useful addition to the armamentarium of treatments for chronic migraine. These results suggest that 3RN dosing may not only reduce the intensity of headaches, Eut also reduce their frequency.

P25 Therapeutic Effect of Nasal Oxytocin in Chronic Migraine Patients Yeomans, D.C.2; ,zumi, R.3; Mechanic, J.3; AErouk, N.3; Angst, M.S.2; Frey, W.H.1; Yeomans, C.3; Thirucote, R.3; JacoEs, D. 1 Neuroscience, Regions Hospital, St. 3aul, MN, USA; 2 Anesthesia, Stanford University, Stanford, CA, USA; 3 Trigemina, Moraga, CA, USA; Surgery, Kaiser Santa Theresa Hosptial, San Jose, CA, USA.

P26 Spinning Out of Control: The Black Box of Basilar and Hemiplegic Migraine Krel, R.1; Mathew, 3.G.2; Spinner, D.1; Joshi, S.3 1 Neurology, Stony Brook University Hospital, 3ort Jefferson Station, NY, USA; 2Harvard Medical School, Brigham & Women’s Hospital, Department of Neurology, John R. Graham Headache Center, Boston, MA, USA; 3 University of Massachusetts Medical School, New England Regional Headache Center, Worcester, MA, USA.

Objectives: The primary oEMective of this study was to determine whether, and to what extent, nasal application of high concentration oxytocin would attenuate the intensity andor frequency of headaches suffered Ey chronic migraineurs. The secondary oEMective was to determine whether this treatment would attenuate the frequency of nausia and vomiting, photophoEia, or phonophoEia in these patients. The third oEMective was to determine an optimal dose for further development of this treatment. Background: 3revious studies in our laEoratories have demonstrated that many trigeminal neurons that express calcitonin gene related peptide (CGR3) also express oxytocin receptors. We have also shown that the density of these receptors is driven Ey inÀammatory state - response elements for interleukin-6 on the oxytocin receptor gene drive upregulation in the presence of this inÀammatory cytokine - which has Eeen shown to Ee elevated in patients with migraine. We have also shown that nasal application of radioiodinated oxytocin in rats concentrates the hormone neurotransmitter in the trigeminal nerve as well as in the trigeminal nucleus. As a consequence, nasal oxytocin is highly analgesic for trigeminally mediated pain in rats and that inÀammation is critical to that ef¿cacy. These experiments were followed Ey a small single douEle-Elind study in chronic migraineurs, which showed a strong trend toward pain intensity decrease in these patients. The present study sought to extend these ¿ndings Ey examining the effects of chronic dosing in similar patients. ,n this poster, we report preliminary results of this study. Methods: Chronic migraine patients were recruited at 5 sites in Chile and 2 in Australia. After determining that the

Objectives: Evaluating ef¿cacy and toleraEility of triptans in Easilar and hemiplegic migraines. Background: Basilar migraine (BM) is a migraine suE-type with symptoms thought to originate from the Erainstem andor from simultaneous Eihemispheric activation. Hemiplegic migraine (HM) is another migraine suE-type involving episodes of unilateral weakness in the setting of headache. Although triptans have Eeen a mainstay in aEortive treatment of migraine headaches, the FDA mandates that package laEeling state that triptans are contraindicated in BM and HM. Triptans are 5-HT1BD agonists which inhiEit vasoactive peptide release Ey trigeminal nerves, and cause vasoconstriction of dilated cereEral arteries. A proposed mechanism for BM is Easilar artery vasoconstriction, which has not Eeen demonstrated in angiographic studies. HM carries a theoretically elevated risk of stroke compared to migraine with aura, which has not Eeen well elucidated. Despite this lack of data, patients with BM and HM have Eeen excluded from triptan clinical trials. ,n clinical practice, physicians at times prescriEe

2

June 2014 triptans in patients meeting criteria for or have features consistent with BM and HM. Methods: A retrospective chart review was conducted at two tertiary care institutions via electronic searchaEle dataEases from 200-2013. SearchaEle terms included Easilar migraine, vertigo, dysarthria, diplopia, hemiplegia hemiparesis, facial droop, weakness, confusion, altered consciousness, confusion, ataxia, and aphasia, as well as all triptans. Results: The study included thirty-nine patients. Thirty-six were included in the BM suEtype, three in HM. No side effects of stroke or myocardial infarction were reported. Five patients reported adverse effects, including G, upset, rash, neck dystonia, nightmares, and Àushing. Conclusion: ,n this retrospective study, triptans were used effectively with no suEsequent vascular events for the aEortive treatment of migraines with Easilar and hemiplegic features. This data also suggests that Eeta Elockers, tricyclic anti-depressants, anti-convulsants, and Botox inMections have some ef¿cacy in the treatment of migraines with Easilar type and hemiplegic features.

stimulation. Systemic physiologic parameters did not differ Eetween groups. Conclusion: Our data show that acute administration of caffeine enhances CSD susceptiEility as a possiEle mechanism to explain its effectiveness to trigger migraine attacks and promote the migraine chroni¿cation process. P28 Herpes Zoster Ophthalmicus Following OnabotulinumtoxinA for Chronic Migraine Gadient, 3.; Ryan, S.; Smith, J.H. Neurology, University of Kentucky, Lexington, KY, USA. Objectives: To report the ¿rst case of zoster reactivation following onaEotulinumtoxinA (BTX) administration for chronic migraine and review the literature on zoster following minor procedures. Background: Herpes zoster is a painful condition resulting from varicella zoster virus reactivation that typically occurs in elderly and immunocompromised patients. There is a growing Eody of literature documenting local herpes zoster outEreak following procedures. The mechanisms underlying these outEreaks remains elusive. Methods: Chart and literature review. Results: A 2-year-old woman with a 50 year history of chronic migraine had Eeen receiving BTX inMections every 3 months for 3 years without incident. Her history was also notaEle for prior zoster affecting her right lower Eack in 199 with suEsequent post-herpetic neuralgia. ,n August, 2013, she received BTX inMections without immediate complications, Eut Eeginning 8 hours postprocedure developed a suEacute painful rash in the right V1 distriEution consistent with herpes zoster ophthalmicus. BTX administration had Eeen consistent with that given in the 3REEM3T trials. One week later the rash had resolved completely without treatment. She has not resumed suEsequent BTX treatments. ,n our literature review, we identi¿ed 63 cases of zoster reactivation following diverse minor procedures. Based on this literature review, we note that unlike our patient, there is a tendency for cases to Ee reported in young patients without speci¿c risk factors. Further, outEreaks characteristically occur at the level of the exposure, and in response to a spectrum of stimuli (thermal, mechanical, electrical, and radiation). Conclusion: Although local outEreaks of zoster following minor procedures such as BTX administration may Ee coincidental, these may Ee pathophysiologically relevant. Our literature review suggests that local trauma, not speci¿c to the nature of the stimuli (e.g. BTX), may Ee suf¿cient to lead to zoster reactivation. Given the aging epidemiology of our population, similar cases may Eecome more prevalent. ,n patients with zoster risk factors, this potential complication should Ee disclosed as a theoretical risk.

P27 The Migraine Trigger Caffeine Increases Susceptibility to Spreading Depolarization Yalcin, N.; Yu, E.; Atalay, Y.; Ayata, C.; EikermannHaerter, K. Radiology, Massachusetts General Hospital, Charlestown, MA, USA. Objectives: Migraine is an episodic painful headache disease, and the most common neurological disorder in adults affecting 10-20 of the population. To date, many factors that modulate migraine (e.g. sex hormones, migraine prophylactic drugs) have Eeen shown to also modulate in the same direction of cortical spreading depolarization (CSD), a wave of neuroglial depolarization and the electrophysiological event underlying migraine. We here test whether the migraine trigger caffeine enhances CSD susceptiEility in mice as a potential mechanism of action. Methods: C5BL6 mice were treated once acutely or chronically (2xday over 1 week) with caffeine (60mgkg i.p., equivalent to 5 cups of coffee in humans) or vehicle. Withdrawal experiments were performed 2 hours after last administration of chronic caffeine treatment. CSD susceptiEility was assessed Ey measuring the electrical threshold for CSD induction, and Ey analyzing CSD evoked Ey continuous application of KCl (300mM for 30 minutes) onto occipital cortex. Mice were ventilated, and Elood pressure and Elood gas monitored and maintained within normal range. Experiments were done in a Elinded fashion. Results: Here we show that acute caffeine administration decreases the electrical threshold for CSD induction compared to vehicle. A weaker stimulus applied to the occipital cortex was suf¿cient to trigger CSD (p=0.035). CSD parameters upon topical application of KCl (CSD frequency, speed, amplitude and duration) were not affected. Chronic treatment or withdrawal did not inÀuence CSD susceptiEility after topical KCl or electrical

25

Headache P29 Cardiovascular and Hemodynamic Parameters in Women Following Prolonged CGRP Inhibition Using LBR-101, a Monoclonal Antibody Against CGRP Bigal, M.E.1; Walter, S.1; Bronson, M.1; AliEhoy, A.1; Sager, 3.2; Escandon, R.1 1 LaErys Biologics ,nc, Doylestown, 3A, USA; 2 3harmaceuticalDevice Consultant and Chair, Scienti¿c Committee, Cardiac Safety Research Consortium, 3alo Alto, CA, USA.

No statistically signi¿cant differences or clinically relevant aEnormalities were seen when comparing parameters oEtained at Tmax vs.Easeline, or Tmax vs. any other timepoint. Conclusion: 3rolonged inhiEition of CGR3 with LBR101 was not associated with hemodynamic or 12-lead ECG changes in a population at mild-moderately increased age risk for cardiovascular events. The ¿ndings are in alignment with other preclinical and clinical studies and support further development of medications chronically inhiEiting the CGR3 pathway.

Objectives: To assess the effects of sustained CGR3 inhiEition on Elood pressure, heart rate, and ECGs in healthy women *0 years of age. Background: Calcitonin gene-related peptide (CGR3) is relevant to migraine pathophysiology and is a known systemic vasodilator. The vascular effects of acute CGR3 inhiEition are well descriEed, Eut effects of sustained inhiEition in humans warrant further exploration. Methods: ,n this douEle-Elind, placeEo controlled study, 31 women (mean age = 56 years) were randomized to receive placeEo or an anti-GCR3 monoclonal antiEody (mAE) , LBR-101 (T12 a 5 days, Tmax ~ 2 hours after infusion completion) at doses ranging from 300 to 2,000 mg as a 1-hour ,V infusion. 3articipants were con¿ned for seven days and followed after discharge for 168 days. Continuous cardiac telemetry Eegan 2 hours Eefore infusion and continued until 8 hours after infusion completion. Hemodynamic assessments and ECGs were conducted six times during Day 1 (including around Tmax), and periodically for 3 months; 12-Lead ECGs were conducted in triplicate and analyzed Ey a Elinded core laEoratory. Results: No clinically relevant changes in systolic or diastolic Elood pressure, heart rate, or ECG parameters (RR, 3R, 4RS, or 4TcF) were oEserved when comparing Easeline vs. post-dose time-points. Between-group comparisons also yielded no clinically relevant changes in any parameter at any time-point. Using systolic Elood pressure as an example, when all LBR-101 doses are pooled together, the end-of-infusion mean systolic Elood pressure was 11. mmHg (95 C, = 110.3-125.2) for placeEo suEMects and 118.2 mmHg (95 C, = 111.-125.1) for LBR-101 suEMects. Approximately three hours after the start of the infusion, near Tmax, mean SB3 values for the placeEo group were 115. mmHg (95 C, = 110.-121.1) versus 115.9 mmHg (95 C, = 108.9-122.9) for the pooled LBR-101 group. SB3 also remained similar during the ¿rst week of the study and at all later time-points up to Day 168 and a dose response effect was not oEserved. Diastolic Elood pressure end-infusion mean values were 0.5 mmHg (95 C, = 62.9-8.9) for the placeEo group vs. 68.9 mmHg (95 C, = 63.0-.9) for the pooled LBR101 group. Approximately three hours after start of the infusion, mean DB3 values were 0. mmHg (95 C, = 6.-6.) for placeEo and 69.8 (95 C, = 65.5-.1) for LBR-101. Values remained similar Eetween groups across the study period. Strati¿cation Ey LBR-101 dose showed similar ¿ndings. No signi¿cant changes were seen for adMusted 4TcF (Easeline suEtracted ³single delta´, and placeEo and Easeline suEtracted ´douEle delta´).

P30 Ef¿cacy of Greater Occipital Nerve Blocks (ONBs) in the Treatment Of Chronic Daily Headaches (CDH) in Adolescent Females with Fibromyalgia Lacey, D.J. Dayton Children’s Hospital, Dayton, OH, USA. Objectives: The primary oEMective of this study was to asess whether ONBs during outpatient management of CDH in adolescent females with ¿Eromyalgia reduced pain and functionaldisaEility. The secondary oEMective was to see whether giving ONBs during an admission for CDH in these patients shortened the duration of hospitalization. Background: For many Muveniles who have ¿Eromyalgia, headaches are their most trouElesome pain issue. Trials of standard preventive headache medications often do not result in signi¿cant pain and functional disaEility reduction. Although ONBs have Eeen successfully used in adults with CDH, very little has Eeen puElished for children and adolescents. A recent report found that approximately 53 of pediatric patients with cronic headaches Eene¿tted from unilateral ONBs. There are no puElished studies of the use of ONBs on headache patients of any age with ¿Eromyalgia. Methods: Thirty-eight (38) adolescent females with ¿Eromyalgia and CDH (de¿ned Ey currently accepted criteria) were given their ¿rst Eilateral greater ocipital nerve Elock with Eipuvacaine and methylprednisolone. Eight had inMections when admited for CDH, two of these have only had inpatient inMections. The remainder have had inMections Eoth when admitted and later as outpatients. At the time of their initial inMections, only four patients (10.5) had medication overuse (in contrast with 26 of Gelfand et al., 201 ). At 2 weeks and at 2 months following inMection, patients and families were separately asked whether the ONBs made no, some, or maMor improvements in pain and functional quality of life. No changes were made in the medication regimens until after the two-month assessment. Eleven patients have suEsequently had multiple outpatient inMections. Results: For the outpatients, teens recording ³no´, ³some´ or ³maMor´ improvements at 2 weeks were 16, 10 and 12 respectively. At 2 months, the numEers were 9,  and 25. ,nterestingly, although some patients reported limited or no pain reduction, their families reported signi¿cant functional improvement. Anecdotally, some of the outpatients for whom no or only some improvement was present at 2 months, have had less pain and improved quality of life following their second andor third series of 26

June 2014 inMections. Some have had less improvement after multiple inMections. There was an insuf¿cient amount of inpatient data to analyze. Also for these teens, ONBs were typically requested only after multiple intravenous medications were tried and failed. Conclusion: 61 of adolescent females with ¿Eromyalgia and CDH who had Eilateral ONBs showed at least some improvement in pain and function at 2 weeks postinMections; 6 showed improvement at 2 months. Whether ONBs can result in fewer preventive and acute pain medications for these patients will require longer follow-up. Also, whether ONBs can prevent or reduce admissions and their durations for these patients requires further study.

score (p=0.006), Eoth Eeing more prevalent or greater among patients with a two parent history. With regard to the maternal vs. paternal effects, only age of onset of migraine (p=0.0013) met statistical signi¿cance, with an earlier onset noted for patients with a paternal headache history. Conclusion: ,n our cohort, many Easic phenotypic features of migraine (e.g. presence of aura) were not more likely to occur in patients with dual versus single parent headache history. ,nterestingly, an increased likelihood of comorEid psychiatric disorders and headache disaEility were seen in patients with a dual parent history, which may Ee accounted for Ey either neuroEiological andor psychosocial mechanisms. Future studies may prospectively address this question, which has implications for understanding the emerging complex genotype-phenotype relationships in migraine patients.

P31 Migraine Phenotype in Patients with a Dual Versus Single Parent History: A Cohort Study Dimayuga, J.S.2; Gadient, 3.M.2; Smith, V.D.2; Cutrer, F.M.1; Smith, J.H.2 1 Mayo Clinic, Rochester, MN, USA; 2University of Kentucky, Lexington, KY, USA.

P32 Balance Assessment on Stable and Unstable Surface in Migraine with Aura Patients: A Pilot Study Carvalho, G.1; Florencio, L.L.1; Gonçalves, M.1; Chaves, T.1; Dach Eckeli, F.1; Bigal, M.2; Bevilaqua-Grossi, D.1 1 School of Medicine of RiEeirmo 3reto, RiEeirmo 3reto, Brazil; 2LaErys Biologics, San Mateo, CA, USA.

Objectives: To explore the effect of family history of headache on migraine phenotype using retrospective data from the Mayo Clinic Headache registry. Background: The heritaEility of migraine is strongly supported Ey the oEservation of a 3-fold increased risk in relatives of migraineurs, as well as twin studies consistently demonstrating higher concordance among monozygotic twins. Genetic inÀuences are thought to Ee greatest among patients with aura. However, the relationship Eetween family history and migraine phenotype has not Eeen well characterized. We hypothesized that patients with multiple sources of potential genetic susceptiEility (two versus one parental history) would Ee more likely to develop more complex migraine phenotypes. Methods: Retrospective phenotypic data from 1119 patients (91 women, 205 men) diagnosed with migraine according to ,nternational Classi¿cation of Headache Disorders (,CHD) criteria and a family history of recurrent headaches in their mother, father, or Eoth was identi¿ed. 3atients were only included who reported an onset of migraine prior to the age of 16 to intentionally select for a more genetically enriched cohort. 3atients with additional secondary causes of headache (e.g. traumatic Erain inMury) were excluded. 3redetermined covariates included gender, age of onset, presence of aura, headache duration, presence of menstrually-related migraine, and presence of either depression or anxiety comorEidity. Post-hoc exploratory analysis was also performed looking at Migraine DisaEility Assessment Test (M,DAS) score. All analysis was performed using JM3, comparing study variaEles Eetween individuals with a dual versus single parent history of recurrent headaches. Among patients with a single parent history, a secondary analysis was performed comparing study variaEles Eetween patients with a paternal versus maternal history. Results: With regard to the effects of one (1) vs. two (2) parents, two variaEles maintained statistical signi¿cance comorbid depression or anxiety (p=0.010) and MIDAS

Objectives: We aim to identify if there are differences on center of pressure (CO3) oscillation Eetween migraine with aura patients and women without headache on staEle and unstaEle surfaces with eyes open or closed. Background: Migraine has Eeen associated to cereEral microischemias provoked Ey the depression of electrical activity especially on cereEellum, Erainstem and inner ear. ,mpairment of static Ealance has Eeen descriEed in migraine population, especially in those with aura, Eut the inÀuence of surface staEility has not Eeen investigated yet. Methods: We evaluated 10 women with migraine with aura, mean age of 1. (SD .9) and mean BM, of 23.6 (SD.); and 10 women of control group, mean age of 31.9 (SD 8.) and mean BM, of 28.1 (SD.1). Migraine patients were selected from an university-Eased hospital and diagnosed Ey neurologist according to second edition of ,nternational Headache Classi¿cation. Control group was selected among hospital workers and accompanist, without headache for at least one year. The exclusion criteria were oEesity, vestiEulopathies, systemic diseases, other type of headache and use of drugs that may alter the Ealance. A Elind evaluator performed the staEilometry evaluation (using the AMT,-OR6--1000 force platform) with douEle limE support with eyes open or closed during 30 seconds. The unstaEle surface was provided Ey a foam (20x50x50cm; density 0.5kgcm) positioned aEove the platform. The trials were random and each task was repeated three times. The analyzed variaEles were CO3 displacement area of CO3 displacement and displacement velocity of CO3. Statistical analysis was made Ey the mean comparison Ey the Mann-Whitney test using the software Graph3ad 3rism 5. The con¿dence interval adopted was 95 and p values  0.05 were considered signi¿cant.

2

Headache Results: Migraine group demonstrated higher area of CO3 displacement than control group on staEle surface with closed eyes (MA 6.3 SD 9.3; CG 1.22 SD 0.58) and on unstaEle surface with eyes open (MA 9.8 SD 8.99; CG .6 SD 2.59) and closed (MA 29.15 SD 2.5; CG 15.13 SD 6.30) (p0.05). Furthermore, we can highlight that the mean difference Eetween groups is higher as the sensorial disturEance is enhanced. There were no signi¿cant differences Eetween groups in the others variaEles. 3reliminary data indicate that there is impairment on migraine with aura patients’ static Ealance and the maMor difference on the unstaEle surface with closed eyes suggests that static Ealance of these patients receive more contriEution from proprioceptive system. Although it is a pilot study we expect that these oEservations continue when we reached an adequate sample size. Conclusion: These preliminary ¿ndings highlight the presence of postural instaEility, demonstrated Ey higher area of displacement in migraine with aura patients.

,f patients received another potentially prophylactic medication required for the treatment of a comorEid illness such as hypertension or depression, the medication was present at the prior to BT-A treatment Easeline and the dose was unchanged during the period of BT-A treatment and assessment. Results: The presence of migraine aura was associated with a lack of BT-A treatment response, a result which remained signi¿cant in a multivariate analysis (Odds Ratio for aura vs. no Aura 0.1, 95 C, 0.05, 0.55, p = 0.0026). There was no appreciaEle difference noted in treatment outcomes Eased on the time delay to treatment, or the presence of MR, T2-hyperintensities. Conclusion: Our data suggests that the presence of aura is a novel variaEle associted with treatment ef¿cacy of migraine with BT-A. 3atients with aura, whose headaches may at least in part Ee driven Ey the cortical spreading depression-like phenomenon, were less responsive to BT-A treatment in our study. This suggests that in patients without aura, some aspect of the mechanism driving their headaches is more amenaEle to suppression Ey BT-A treatment. One possiEility might Ee that in patients with headaches driven Ey the aura, the primary afferent neurons activated Ey CSD are not assessaEle to BT-A molecule inMected in the muscles of the head, neck and shoulders. ,n those individuals without aura, the headache may Ee driven Ey other factors and the primary afferent neurons activated in the context of the headache without aura may Ee assessaEle to BT-A inMected into muscles . The lack of an association with time to treatment supports current practice standards.

P33 Factors that May Affect the Response of Patients with Chronic Migraine to OnabotulinumtoxinA(BT-A) Treatment: A Retrospective Analysis Ansari, H.1; Cutrer, F.M.2 1 Neuroscience & Neurology Associates (NNA), Akron, OH, USA; 2Neurology, Mayo Clinic, Rochester, MN, USA. Objectives: To assess novel variaEles which might Ee associated with therapeutic responses to BT-A treatment in patients with migraine . ,dentifying these potential variaEle(s), will not only help with selection of patients most likely to experience successful treatment with BT-A Eut also can provide clues to clarifying the precise mechanism that BT-A works in migraine headache. Background: OnaEotulinumtoxinA(BT-A) is an United States Food and Drud Adminstration (FDA) approved treatment for chronic migraine, since OctoEer, 2012 .,t has Eeen in widespread use Ey Headache specialists and some general neurologists due to the fact that BT-A has relatively fewer adverse effects when compared to other medical prophylactic treatments . Different success rates for using this treatment are reported. The precise mechanism that BT-A works in migraine is contravesial and at present, there are no indicators of likely treatment response or non-response to BT-A in migraine patients . Methods: We retrospectively studied 60 consecutive patients with chronic migraine, including 30 responders and 30 non-responders. A power calculation carried out prior to the study suggested that 30 suEMects in each group would allow for the detection of signi¿cant differences in characteristics to Ee assessed. We performed a logistic regression analysis looking at 3 co-variates time from onset of migraine to treatment, the presence or aEsence of white matter change on magnetic resonance imaging, and presence or aEsence of migraine aura.

P34 Quantitative Characterization of Craniofacial Autonomic Function in Migraine Hunter, L.1; 3eterson, J.1; Cortez, M.2; Theriot, J.1; Brennan, K.C.1 1 University of Utah, Salt Lake City, UT, USA; 2Mayo Clinic Arizona, Scottsdale, AZ, USA. Objectives: Use noninvasive optical techniques to characterize craniofacial autonomic function in controls and migraineurs. Methods: SuEMects were recruited into migraine and control groups. For migraine suEMects (diagnosed Ey ,CHD-,, criteria), all measures were taken during an interictal phase. 3upillary measures included photophoEia thresholds, pupil oscillation rate and optically measured pupil diameter. Craniofacial cutaneous measures included mechanical pain threshold using Von Frey ¿laments and reÀectance imaging of hemodynamic changes during stimulation of the trigeminovascular reÀex (inhalation of ammonia vapor). ,mage analysis was performed using ,mageJ. Thirty-one suEMects were examined (1 control; 13 migraineur;  other headache). Results: 3hotophoEia thresholds for migraineurs were signi¿cantly lower compared to control suEMects. 3upil oscillation rates for suEMects with migraine were signi¿cantly slower compared to control suEMects. 3reliminary pupillometry analysis suggests a trend 28

June 2014 toward greater pupil diameter at photophoEia threshold in migraineurs compared to control suEMects. Mechanical pain thresholds (Easeline and post-ammonia inhalation) for migraineurs were signi¿cantly lower compared to normal controls in all regions of interest. 3ain thresholds were further reduced following ammonia stimulation in migraine patients. Hemodynamic oscillation amplitude and frequency in migraineurs were signi¿cantly lower compared to controls Eoth Eefore and after ammoniainduced trigeminovascular reÀex stimulation. Amplitude and duration of ammonia-induced hemodynamic changes did not differ signi¿cantly Eetween groups. Conclusion: Our techniques demonstrate differences in craniofacial autonomic measures Eetween interictal migraine suEMects and non-migraine controls. We also independently con¿rm prior work showing lower photophoEia and mechanical thresholds in migraineurs. ,mportantly, we show that these psychometric differences Eetween groups are accompanied Ey alterations in quanti¿aEle physiological measures. Our optically Eased toolEox may Ee useful to further characterize autonomic dysfunction in migraineurs and aid in the identi¿cation of physiological endophenotypes.

use of headache drugs decreased 63 - from an average of 19.2 drugs per month (per patient), to 8 per month in month 1-3 and .1 per month in month -6 post-surgically. The overall patient satisfaction rate was 90.5. Eighty-¿ve percent of the patients experienced at least a 50 reduction in headache Eurden. ,ndividual analysis showed complete headache resolution in  cases, incomplete in 2 cases and no change in 1 case. Conclusion: Conclusion The ¿ndings of this open-laEeled study suggest that surgical decompression of occipital nerve can alleviate occipital headache in carefully selected patients and thus Mustify the need to continue evaluating the potential Eene¿t of this procedure in the treatment of CDH CM. Mechanistically, we propose that the mechanism Ey which nerve decompression provides pain relief involve reduced mechanical and chemical irritation of the occipital nerve. Reduced mechanical irritation may Ee achieved Ey freeing parts of the nerve that are trapped in the semispinalis capitus muscle of the neck, whereas reduced chemical irritation may Ee achieved Ey removing inÀamed tissue from the perineurium and other tissues that surround the occipital nerve as it makes its way to the periosteum. P36 Complementary and Alternative Medicine (CAM) Use for Migraine Headaches in Hispanic Patients Sahai-Srivastava, S.2; Bernstein, M.2; Lew, D.2; Lane, C.J.1 1 Biostatistics and Bioinformatics Resource Group, CTS,, Los Angeles, CA, USA; 2Neurology, University of Southern California, Los Angeles, CA, USA.

P35 Surgical Decompression of Occipital Nerves for Intractable Headaches 3erry, C.2; Blake, 3.3; Burstein, R.1 1 Department of Anesthesia and Critical Care, Harvard Medical School and Beth ,srael Deaconess Medical Center, Boston, MA, USA; 2River Oaks 3lastic Surgery, Houston, TX, USA; 3Headache Center of Northwest, Houston, TX, USA.

Objectives: The aims of this study are to gain a Easic characterization of CAM usage and assess its prevalence and ef¿cacy in the Hispanic population as it relates to demographic factors and compared to the general population at large. Background: Migraine headaches are one of the most disaEling neurological conditions across the gloEe for which there are few highly effective treatment options. ,n order to successfully treat migraines, many patients are turning to CAM. Although CAM use in the Hispanic population has Eeen documented as low, it is possiEle that CAM use is higher in the Hispanic population when CAM modalities unique to this population are considered as well. Methods: We interviewed 58 (3 Hispanic, 2 NonHispanic) migraineurs in puElic and private treatment settings. We collected demographic data, oEtained detailed headache histories and use of known CAM modalities (38) including those speci¿c to the Hispanic population (6). Results: The maMority of participants in Eoth the Hispanic and Non-Hispanic groups were female (, 83) with average age of 5 in Eoth groups. Within the Non-Hispanic group, a maMority identi¿ed as White (1). The maMority of Hispanic patients (9) fell into the low-income Eracket (30k) while the Non-Hispanic group was fairly evenly dispersed within the income Erackets, with the largest numEer of participants (2) in the middle-income Eracket (30-100k). The maMority of Hispanic patients (85) were seen in a puElic healthcare setting while the maMority of Non-Hispanic patients (83) were seen in a private healthcare setting. ,t was discovered that CAM use

Objectives: OEMectives To assess the therapeutic impact of occipital nerves decompression in intractaEle headache patients. Background: Background The surgical Eene¿t of nerve decompression for the treatment of Chronic Daily Headache (CDH) andor Chronic Migraine (CM) is hotly deEated. Fueling this deEate is the ethical inaEility to design a douEle-Elind placeEo-controlled randomized trials to test the therapeutic ef¿cacy of this procedure. Given ethical limitations, the Eest we can do is to design an open-laEel study that uses the most reliaEle ways to assess ef¿cacy. Methods: Methods Ten patients ful¿lling all required criteria for occipital nerve decompression surgery were asked to ¿ll paper diaries over a period of one month prior to surgery and six month after surgery. Diaries included total numEer of occipital migraine days per month, total numEer of occipital headache days per month, locations of headachesmigraines, daily headache severity, daily headache duration, use of acute and prophylactic headache medications, disaEility scale, and headache impact on quality of life. Results: Results Average numEer of occipital headache days per month decreased Ey 85 - from 28.5 dm prior to surgery, to . dm in post-surgery month 1-3, and to .3 dm in post-surgery month -6. Average headache severity decreased Ey 5 - from aEout 10 (visual analogue scale) prior to surgery to aEout 210 after surgery. The 29

Headache was statistically signi¿cant (p=0.05) with the prevalence of CAM in Hispanics at  vs. 96 in Non-Hispanic participants. This similar pattern was found for CAM use for migraines with 68 of Hispanics reporting CAM for migraines compared to 83 of Non-Hispanics. While not statistically signi¿cant, the use of traditional Hispanic CAM was reported Ey 15 of Hispanics, Eut only 1 () of Non-Hispanics. Conclusion: We found that Hispanics are signi¿cantly less likely to use CAM than Non-Hispanics. Still, it is notaEle that a maMority within the Hispanic group does report use of CAM modalities in general and for migraines. Although more Hispanic compared to Non-Hispanic participants use traditional Hispanic CAM, the maMority of Eoth groups do not use these remedies. The continued assessment of CAM use for migraine relief in the Hispanic population will help healthcare providers more completely understand the prevalence and types of CAM speci¿cally used in this population and allow them to achieve a higher level of patient-centered, safe, and effective care.

3reventive (RF3) 59 to 8, Emotional Function (EF) 61 to 0) compared to usual care (MS4Lv2 RFR 28 to 32, RF3 5 to 0.8, EF 23 to 28.8). H,T-6 scores for LY group showed a mild improvement at 8 weeks (6 to 60.), compared to usual care group (6.3 to 68.3). Fatigue scores showed a trend towards improvement in Eoth groups LY group (6.9 to 1.), usual care (55.5 and 9). The LY group showed greater improvement in depression at 8 weeks (12.5 to 6.5) compared to the usual care group (1.5 to 1.5). Given the small sample size of this pilot study, no results were statistically signi¿cant. Study limitations include sample size and a high drop out rate. Conclusion: Addition of Laughter Yoga therapy to usual medical therapy is feasiEle low risk treatment that may improve quality of life and depression in chronic migraineurs while also decreasing headache impact on daily life. Laughter Yoga therapy may also cause a mild decrease in headache frequency. P38 A Randomized, Placebo-Controlled, Double-Blind, Parallel Group Study Assessing the Relative Safety and Tolerability of Two Different Doses of LBR-101 Given Subcutaneously Bigal, M.E.; Bronson, M.; Walter, S.; Escandon, R. LaErys Biologics ,nc, Doylestown, 3A, USA.

P37 Pilot Study of Laughter Yoga Therapy in Treatment of Chronic Migraine Sahai-Srivastava, S.; Joyce, A.; Christie, C.C.; Ugurlu, C.; Manh, C.; KimElin Licht, H. Neurology, University of Southern California, Los Angeles, CA, USA.

Objectives: To evaluate the safety and toleraEility of two distinct doses of LBR-101 when administered suEcutaneously to healthy male and female volunteers. Background: LBR-101 is a fully humanized monoclonal antiEody (mAE) that potently and selectively Einds to Eoth isoforms (_ and `) of CGR3, Elocking its Einding to the CGR3 receptors. LBR-101 is speci¿c for CGR3 and does not Eind to the closely related family memEers amylin, calcitonin or adrenomedullin peptides. Across the 3hase 1 program, 5 separate douEle-Elind, placeEo-controlled trials have Eeen completed testing LBR-101 via the intravenous (,V) route of administration with 9 healthy suEMects receiving LBR-101 and 5 suEMects receiving placeEo. Treatment-related adverse events occurred in 21.2 of suEMects receiving LBR-101, compared to 1. of those receiving placeEo. LBR-101 was not associated with any clinically relevant patterns of change in vital signs, ECG parameters, or laEoratory ¿ndings. Herein we report the results of a study conducted to assess the safety and toleraEility pro¿le of LBR-101 given suEcutaneously, conducted in preparation for 3hase 2 studies. Methods: This was a randomized, placeEo-controlled, douEle-Elind, douEle-dummy study assessing 6 cohorts of 6 patients each. 3articipants received a single administration (either ,V or SC) of LBR-101 or placeEo given at two different dose levels. SuEMects were con¿ned in a clinical research unit for  days after dosing, and were followed periodically for additional outpatient visits up to study Day 90. The study is ongoing and will Ee ¿nalized at the time of the meeting presentation. Treatment-emergent adverse events (related or not to drug administration), treatmentrelated adverse events, laEoratory ¿ndings and ECG ¿ndings will Ee contrasted Ey formulation (,V and SC), Ey study arm (LBR-101 vs. placeEo), and Ey dose.

Objectives: To study effects of laughter yoga in chronic migraine patients in addition to usual treatment. Background: Chronic migraine is a disaEling headache disorder that affects 1.–2.2 of the US population. Traditional yoga postures and exercises have Eeen shown to decrease migraine frequency and severity. Laughter yoga is a less well known technique that includes mimicking facial movements of laughter to induce a state of mirthfulness. Laughter is natural human emotion which may improve stress levels and muscle relaxation Ey decreasing levels of cortisol, dopamine, epinephrine, and growth hormone. The effects of laughter yoga without the use of traditional postures have not Eeen formally studied for chronic migraine. Methods: Randomized case-control study of 19 chronic migraineurs. 3atients were randomized to usual care including medical treatment or usual care in addition to Laughter Yoga (LY) therapy once a week for an hour with a live instructor in group sessions, followed Ey daily practice at home (LY group). We collected data that included demographics, vital signs and validated survey instruments; the Migraine Speci¿c 4uality of Life 4uestionnaire (MS4Lv2.1), Headache ,mpact Test (H,T-6), Fatigues Severity Scale (FSS), and 3atient Health4uestionnaires (3H4-9). Data was collected at Easeline, at week  and 8. Results: 19 total cases and controls enrolled and 1 completed the study. They were all female with an average age of 2 years. The LY group had average headaches (13.85month) at Easeline which did not decrease signi¿cantly (13.5month) at week 8. 4uality of life scores at 8 weeks improved in in the LY group (MS4Lv2 Role Function Restrictive (RFR) 2 to 65, Role Function 30

June 2014 Results: The study is ongoing and full data will Ee presented at the meeting. Authors are presently Elinded to the treatment arms. During the ¿rst 5 days of the study, only mild treatment-related adverse events were reported. Clinically relevant laEoratory or ECG aEnormalities have not Eeen oEserved. Conclusion: Up to this point, results of 3hase 1 suggest that LBR-101 is well tolerated when delivered either ,V or SC. Overt safety concerns have not emerged. Updated assessment will Ee presented at the time of the meeting.

P40 The Place of Corticosteroids in Migraine Management: Systematic Review and Critical Appraisal Woldeamanuel, Y.; Cowan, R. Neurology, Stanford Headache 3rogram, Stanford University, Stanford, CA, USA. Objectives: To determine the role of corticosteroids in the management of migraine. Background: ,ncomplete pain relief, repeated emergency department (ED) visits, and lost productivity contriEute signi¿cantly to migraine-related economic Eurden. Headaches recur in up to 8 of migraine patients visiting ED, making ED recidivism a management challenge. Lower headache recurrence is a primary goal according to patients. Corticosteroids have long Eeen used to optimize migraine management, even prior to current evidence demonstrating the signi¿cance of sterile neurogenic inÀammation in migraine pathophysiology. Methods: We conducted systematic review of clinical studies on corticosteroids for migraine from 1980 till date. 3uEMed search was employed for Clinical Studies Categories and Systematic Reviews on 3uEMed Clinical 4ueries tool comEining the terms ‘migraine’ and ‘corticosteroids’. References were searched to extract related puElished clinical studies. Results: Twenty clinical studies and  systematic reviews were included. Eighty percent of the studies were randomized controlled trials conducted in ED settings. Migraine diagnosis was met Ey employing the ,nternational Classi¿cation of Headache Disorders criteria in 65 of the studies. Ninety percent of the studies indicated oEserved outcome differences favoring Eene¿ts of corticosteroids. Mean aEsolute risk reduction (ARR) was 2.6 (range 6-8.2; median 30) and 18.6 (range 6-8.6; median 11) for 2-hour and 2-hour headache recurrence, respectively. 3arenteral dexamethasone was the most commonly (65) used corticosteroid. Dexamethasone was administered with average single dose of 12.8mg (range -2mg; median 10; mode 8, 10mg) in 0 of the studies. All systematic reviews and meta-analyses revealed importance of adMuvant corticosteroids to various aEortive medications – indicating generalizaEility of results. Three meta-analyses showed that a single dose of adMuvant parenteral dexamethasone was associated with 11.1 ARR, numEer needed to treat of 9, and 26 relative risk reduction for 2-hour headache recurrence. The fourth meta-analysis indicated that parenteral dexamethasone delivered highest ef¿cacy. Adverse effects were toleraEle. Higher disaEility, prolonged migraines, status migrainosus, incomplete pain relief, and headache recurrence were the settings where corticosteroids were Eene¿cial. AEortive medications which were ineffective prior to dexamethasone Eecame effective suEsequently. Conclusion: The use of corticosteroids in Migraine is inconsistent and controversial. Our literature review suggests that with corticosteroids, recurrent headaches Eecome milder than pretreated headaches and later respond to nonsteroidal therapy. ,ntravenous dexamethasone provides reasonaEle option for the treatment of resistant, severe, or prolonged migraines. Dexamethasone restores

P39 LBR-101 is not Associated with Signs of Liver Toxicity in Healthy Volunteers: Results of the Phase 1 Program Bigal, M.E.; Escandon, R.; Walter, S.; Bronson, M. LaErys Biologics ,nc, Doylestown, 3A, USA. Objectives: To characterize the hepatic effects of LBR101, a monoclonal antiEody against CGR3, Ey presenting the pooled results from the 3hase 1 program. Background: The potential role of CGR3 in migraine pathophysiology was suggested more than 20 years ago and since then our knowledge of the peptide and its role in the pathophysiology of migraine has increased suEstantially, leading to a roEust interest in targeting CGR3 to treat migraine. Clinical proof-of-ef¿cacy for the acute treatment of migraine has Eeen oEtained with several small molecule CGR3 receptor antagonists, Eut their development has Eeen complicated Ey signs of liver toxicity associated with frequent use. The utility of monoclonal antiEodies as therapeutics includes target-speci¿city, as well as reduced potential for hepatotoxicity and drug-drug interactions. Methods: Herein we report the pooled results of the 3hase 1 program for LBR-101, which consisted of ¿ve studies testing intravenous (,V) administration, and one study testing including suEcutaneous (SC) administration. All studies were douEle-Elind, placeEo-controlled trials enrolling healthy volunteers. Doses ranged from 0.2 mg to 2,000 mg given once, or up to 300 mg given twice (Day 1 and Day 1). The half-life of the drug is approximately 5 days. LBR-101 was given to 118 healthy suEMects, while 5 suEMects received placeEo. 3articipants were con¿ned in research units for at least  days, and followed for at least 90 days after drug administration. LaEoratory tests included serum chemistries, hematology, and urinalysis. Hematology, chemistry, coagulation, and urine safety laEoratory tests were performed at multiple study times. Results: Clinical laEoratory ¿ndings were similar across placeEo and LBR-101. ,n particular, liver function aEnormalities, de¿ned as any post-dose value outside the normal test range, were not oEserved in suEMects receiving any of the studied doses of LBR-101 within the following tests aspartate aminotransferase (AST), alanine aminotransferase (ALT), total EiliruEin, alkaline phosphatase, and gamma-glutamyl transferase (GGT) . Limited effects on liver function tests were seen in three patients receiving placeEo. Clinically signi¿cant aEnormalities were not seen for any other laEoratory test. Conclusion: LBR-101 does not seem to Ee associated with any signs of liver toxicity or with relevant changes in other laEoratory ¿ndings. 31

Headache sensitivity to other aEortive agents. Recommendations include 6-8 dexamethasone administrations per year with follow up of adverse effects. By virtue of having a halflife of 36-2 hours and Eeing potent anti-inÀammatory with negligiEle mineralocorticoid effect, dexamethasone suppresses inÀammation during the period when patients are most likely to experience headache recurrence, potentially making it ideal for a one-time administration Eefore ED discharge.

32 of the CBT+A group had ) 3 headache days at 20 weeks (HE+A = 16; p 0.05); 61 of the CBT+A group had ) 3 headache days at the 12-month follow-up (HE+A = 0; p  0.05). Conclusion: Cognitive Behavioral Therapy plus Amitriptyline was not only superior to Headache Education plus Amitriptyline on * 50 reduction in headache days along with disaEility reduction to the mild to none range (JAMA, 2013), Eut also led to more participants falling Eelow the clinically relevant ³Need for 3revention´ of ) 5 and ) 3 days per month. From a clinical perspective, reduction of headache frequency from a chronic level to less than one per week is a maMor improvement. Our results demonstrate that CBT+A lowers headache frequency to a level that preventive medication is no longer needed as part of a multidisciplinary treatment plan. Next steps are to ¿nd effective ways to disseminate this high-impact treatment and to examine the traMectory of this improvement into early adulthood. Funded Ey R01NS050536, R01NS050536-S1, UL1TR0000, and T32DK063929 from the N,H. clinicaltrials.gov identi¿er NCT00389038

P41 Cognitive Behavioral Therapy Plus Amitriptyline Improves Headache Frequency to ) 3 Per Month in Children and Adolescents with Chronic Migraine 3owers, S.W.; Kashikar-Zuck, S.M.; Slater, S.; Zafar, M.; Allen, J.R.; LeCates, S.L.; KaEEouche, M.; O’Brien, H.; Kacperski, J.; Shenk, C.; Rausch, J.; Hershey, A.D. 3ediatrics, Cincinnati Children’s Headache Center, Cincinnati, OH, USA. Objectives: Determine if cognitive Eehavioral therapy plus amitriptyline (CBT+A) compared to headache education plus amitriptyline (HE+A) for chronic migraine leads to improvement in headache frequency to ) 5 and ) 3 per 28 days. Background: How much impact an intervention for chronic migraine has can Ee measured Ey the degree of change in headache frequency. ,deally for patients, treatment would reduce headache days to very few to zero occurences with no side effects. ,n a randomized clinical trial for children and adolescents with chronic migraine, CBT+A was superior to HE+A on reduction in the numEer of days per month with headache and migraine-related disaEility at the 20-week endpoint and 12-month followup (3owers et al., JAMA, 2013;3102622-2630). CBT+A was also superior on the metric of a * 50 reduction in headache days. More pronounced change can Ee measured Ey headache frequency that meets criteria for the initiation of preventive medication (i.e., ³Need for 3revention´). ³Need for 3revention´ has Eeen de¿ned (when Eased solely on frequency) as 3revention medication should Ee offered * 6 per month; Medication should Ee considered  or 5 per month; Medication not indicated ) 3 per month (Lipton et al., Neurology, 200;6833-39). ,n our pediatric Headache Center, the clinical guideline is to suggest preventive medication if headache frequency is  or more per month. Thus, a Eenchmark of _ 3 per month would indicate suEstantial improvement. Methods: Randomized clinical trial of CBT+A vs HE+A with treatment effects measured at Easeline, 20 weeks (post-treatment), and follow-up (12 months post-treatment as ¿nal assessment). Headache days measured Ey 28-day, prospective diary. Analyses were conducted with Chisquare test for independence. Results: 3articipants had 21 ( 5 headache days per month at Easeline; all 135 had * 15 per month. 53 of the CBT+A group had ) 5 headache days at 20 weeks (HE+A = 23; p 0.001); 5 of the CBT+A group had ) 5 headache days at 12-month follow-up (HE+A = 55; p  0.05).

P42 Breath-Powered™ Nasal Delivery of Powdered Sumatriptan (AVP-825): Migraine Disability and Functional Outcome in a Phase 3 Study (TARGET) McAllister, 3.6; Cady, R.K.1; Spierings, E.L.3; Messina, J.; Carothers, J.; DMupesland, 3.G.5; Mahmoud, R.A. 1 Headache Care Center, Spring¿eld, MO, USA; 2Associated Neurologists of Southern Connecticut, 3C, Fair¿eld, CT, USA; 3MedVadis Research Corporation, Watertown, MA, USA; OptiNose US ,nc., Yardley, 3A, USA; 5OptiNose AS, Oslo, Norway; 6New England ,nstitute for Neurology and Headache, Stamford, CT, USA. Objectives: Migraine is associated with suEstantial disaEility; early treatment is critical to improving patient outcomes. AV3-825 is a ¿rst-in-class treatment for migraine, using a novel closed-palate Breath 3owered™ device to deliver low-dose sumatriptan powder deep into the nasal cavity Eeyond the nasal valve²an area extensively innervated Ey the 1st and 2nd Eranches of the trigeminal nerve²where it can Ee rapidly and ef¿ciently aEsorEed. ,n a 3hase 3 trial (TARGET), 2 of patients using AV3825 vs. 2 placeEo reported headache relief Ey 30 min (P=.03), with 68 vs. 5 reporting headache relief at 2 h (P=.0016; primary outcome) and minimal triptan-related adverse effects. Here, key secondary outcomes from the AV3-825 TARGET study are reported to provide a clinical picture of migraine disaEility and associated functional improvement in these patients. Methods: The TARGET study was a randomized, douEleElind, placeEo-controlled trial evaluating AV3-825 for the acute treatment of moderate or severe migraine headache. 3atients were instructed to treat the ¿rst migraine headache following randomization as soon as headache reached moderate to severe intensity. Ef¿cacy assessments were made immediately Eefore dosing and at multiple time points up to 2 h after administration. The Headache ,mpact Test (H,T-6; a measure of disaEility) was assessed at Easeline. 32

June 2014 Results reported here include meaningful pain relief over time and change in clinical disaEility score. Results: A total of 212 patients (n=108 AV3-825, n=10 placeEo) experienced a qualifying migraine headache and comprised the full ef¿cacy analysis set. Baseline values for the H,T-6 demonstrate suEstantial headache-associated disaEility within the study population. Median time to meaningful headache relief was .5 min for AV3-825, and not achieved within the 120 min time period for placeEo (P.01). Mean clinical disaEility scores showed progressive improvement, with Eetween group differences reaching statistical signi¿cance Ey 5 min. At 2 h post-dose 2 of AV3-825-treated patients reported a clinical disaEility score of ³0´ (no disaEility) vs. 2 for placeEo (Easeline values were 2 and  respectively). The percentage of patients reporting moderate to severe disaEility at Easeline (5 vs 55 for AV3-825 and placeEo, respectively) was reduced to 19 for AV3-825 vs. 35 for placeEo (P.05). Conclusion: Low-dose sumatriptan powder delivered through the innovative system of AV3-825 offers potential for rapid headache relief with minimal triptan effects as well as signi¿cant reduction in migraine-associated clinical disaEility and improved function.

h are reported for these two suEgroups. 3ain freedom and meaningful relief were also assessed. Results: A total of 223 patients were treated. Ten patients took study medication prior to completing Easeline assessments, and one did not complete post Easeline assessments resulting in 212 patients who were analyzed for ef¿cacy; 16 (n=90 AV3-825, n=86 placeEo) reported moderate headache at Easeline and 36 (n=18 in each group) reported severe Easeline headache. Overall, no maMor differences were noted Eetween the moderate and severe suEgroups with respect to demographic characteristics, prior average numEer of attacks per month or prior use of intranasal medication. For the severe headache suEgroup, 56 of AV3-825 patients and 22 of placeEo patients reported headache relief at 2 h endpoint compared with 0 and 50 in the moderate suEgroup. Complete pain relief was achieved Ey 1 vs. 0 (AV3-825 vs. placeEo) of patients in the severe group and 38 vs. 21 in the moderate group at 2 h. Meaningful relief was reported Ey 6 vs 28 in the severe group and 1 vs. 9 in the moderate group. For the severe suEgroup, the proportion of patients with sustained pain relief at 2 and 8 h was 33 vs. 11 and 28 vs. 6 (AV3-825 vs. placeEo), respectively. Within the moderate suEgroup,  vs. 2 and 36 vs. 23 achieved sustained pain relief at 2 and 8 h, respectively. Conclusion: The inÀuence of Easeline headache intensity on placeEo response and, hence, on signal detection should Ee further evaluated. Although data comparisons are limited Ey the small sample size of the severe suEgroup, this exploratory analysis suggests placeEo response is notaEly lower, and the delta notaEly higher, when Easeline headache intensity is severe. Regardless of Easeline headache intensity, treatment with AV3-825 demonstrated notaEle ef¿cacy with good response rates and suEstantial differences in pain relief at 2 and 8 h.

P43 Breath Powered™ Nasal Delivery of Sumatriptan Powder (AVP-825): An Exploratory Analysis of Response in Migraine Patients Grouped by Baseline Headache Intensity from the Phase 3 TARGET Study Cady, R.K.1; McAllister, 3.6; Spierings, E.L.2; Messina, J.3; Carothers, J.3; DMupesland, 3.G.; Mahmoud, R.A.3 1 Headache Care Center, Spring¿eld, MO, USA; 2MedVadis Research Corporation, Watertown, MA, USA; 3OptiNose US ,nc., Yardley, 3A, USA; OptiNose AS, Oslo, Norway; 5 Associated Neurologists of Southern Connecticut, 3C, Fair¿eld, CT, USA; 6New England ,nstitute for Neurology and Headache, Stamford, CT, USA.

P44 Randomized Controlled Trial of Behavioral Insomnia Treatment for Chronic Migraine with Comorbid Insomnia: Preliminary Results of a Sham-Controlled Pilot Study Smitherman, T.A.1; Walters, A.1; AmErose, C.E.1; Davis, R.E.1; Roland, M.2; Houle, T.T.; Rains, J.3 1 3sychology, University of Mississippi, University, MS, USA; 2Oxford Neurology Clinic, Oxford, MS, USA; 3 Center for Sleep Evaluation, Elliot Hospital, Manchester, NH, USA; Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC, USA.

Objectives: A previously presented 3hase 3 trial (TARGET) demonstrated the safety and ef¿cacy of AV3825 (a ¿rst-in-class treatment which delivers low-dose sumatriptan powder intranasally using a novel, closedpalate Breath 3owered™ device) compared with placeEo for the acute treatment of migraine. This exploratory analysis evaluated ef¿cacy outcomes, including pain relief and pain freedom, in TARGET migraine patients according to Easeline headache intensity. Methods: The TARGET study was a randomized, douEleElind, placeEo-controlled trial evaluating AV3-825 for the acute treatment of moderate or severe migraine headache. 3atients were instructed to treat the ¿rst migraine headache following randomization as soon as the headache reached moderate or severe intensity. Ef¿cacy assessments were made immediately Eefore dosing (Easeline) and at multiple time points up to 2 h after administration and at 2 and 8 h. For this exploratory analysis, the patients were grouped Eased on Easeline headache intensity (moderate >grade [email protected] or severe >grade [email protected]). 3ain relief (de¿ned as a reduction in headache intensity from moderate or severe to mild or none) at 2 h as well as sustained pain relief at 2 and 8

Objectives: To pilot-test the feasiEility, crediEility, and impact on headache frequency of a 3-session Eehavioral insomnia intervention for adults with chronic migraine (CM) and insomnia. Background: ,nsomnia is associated with more frequent and severe migraine and has Eeen reported as an independent risk factor for headache chroni¿cation. The prevalence of insomnia increases proportionally with headache frequency, such that up to 85 of those with chronic migraine merit a diagnosis of insomnia (Calhoun & Ford, 200; Sancisi et al. 2010). Sleep hygiene is often 33

Headache recommended for headache patients, Eut it is unknown if treatment of insomnia improves headache. Calhoun and Ford (200) puElished an RCT demonstrating signi¿cant improvement in CM after a Eehavioral sleep regulation intervention; although these patients reported a high incidence of sleep complaints, they were not diagnosed with insomnia. To our knowledge, this is the ¿rst RCT evaluating a validated Eehavioral treatment for comorEid insomnia on headache. Methods: Thirty-one adults with chronic migraine (M age = 30.8 years; M = 21.5 headache daysmonth; 90 female) participated in this trial supported Ey the Migraine Research Foundation. Sixteen were randomly assigned to 3 Eiweekly sessions of Eehavioral sleep management (SM; consisting of 5 stimulus control and sleep restriction techniques), and 15 were assigned to a sham control group that included 3-session instruction in modifying general lifestyle haEits putatively unrelated to migraine (lifestyle modi¿cation, LM; cf Calhoun & Ford, 200). 3articipants kept daily headache diaries throughout the 2-month study and during a 2-week posttreatment and 6-week follow-up assessment. Repeated measures ANOVA and generalized linear models were used to quantify treatment effects. Results: Both interventions were rated as equally crediEle and yielded signi¿cant reductions in headache frequency. Among the 2 participants who completed the trial, headache frequency in the SM group (n = 1) decreased 28 at posttreatment and 9 at 6-week follow-up, compared to reductions of 38 and 2 at posttreatment and follow-up, respectively, among the LM group (n = 10). A main effect for time, Eut not group, was oEserved, such that frequency reductions were larger later in the trial (partial eta2 = 0.6); the group x time interaction approached signi¿cance (]2 = 8.5 >[email protected], p = .1). Frequency reductions were similar when analyzed using last oEservation carried forward among the 31 participants providing at least complete Easeline data. Headache-related disaEility improved suEstantially across Eoth groups. Higher levels of pretreatment sleepiness were associated with larger reductions in headache frequency (p = .002). Conclusion: This pilot trial demonstrates the feasiEility and acceptaEility of a Erief Eehavioral insomnia intervention and its positive effects on migraine frequency. The predicted group x time interaction that trended toward signi¿cance suggests that the effects of the Eehavioral sleep intervention were perhaps more enduring over time, although future larger trials are needed to estaElish superiority over a crediEle pseudotherapy control. ,mplications for migraine management and the high placeEo response rate will Ee discussed.

Background: The ,,HTT is a multicenter, randomized, douEle-masked, placeEo controlled trial comparing acetazolamide to matching placeEo in individuals with mild visual ¿eld loss from ,,H. A low-sodium diet weight loss program was offered to all suEMects. 165 participants (161 women,  men) were enrolled. Methods: Headache characteristics were queried at Easeline and throughout the duration of the study during structured interviews. Descriptive statistics, Spearman and 3earson correlation coef¿cients were applied. Results: Headache was the most common symptom of ,,H (n=139, 8) and was the initial symptom in 35. The average severity on a 1-10 scale was 6.3 + 1.9 with 9 participants reporting a severity of 10. 32 of enrollees with headache descriEed constant pain. Those with intermittent headache experienced a median of 12 headache days monthly (range 1-30). The pain was characterized as pressure (), throEEingpounding (2), staEEing (5), exploding (2) or other (), and 2 experienced nocturnal awakening. The location of head pain was frontal (68), gloEal (36), posterior (39), unilateral (30), ocular () and extended to the neck in . Associated symptoms included photophoEia (0 ), phonophoEia (52), nausea (), vomiting (1), and aggravation Ey routine physical activity (50). 1 of participants reported a history of migraine (18 with aura, 58 without aura, 2 Eoth). The average H,T-6 score was 59. + 9.0 (severe disaEility). There was no correlation Eetween the H,T-6 score and papilledema grade, perimetric mean deviation, lumEar puncture opening pressure or Eody mass index (BM,). Conclusion: The headache pain of ,,H in this cohort was variaEle in quality and location, and many suEMects had associated symptoms that are typical of migraine. The headaches were severe, disaEling and not related to visual status, BM,, lumEar puncture opening pressure or papilledema grade. P46 Treatment of Hemicrania Continua in Patients Intolerant to Indomethacin Musonza, T.1; Garza, ,.2; RoEertson, C.E.2 1 College of Medicine, Mayo Clinic, Rochester, MN, USA; 2 Headache Neurology, Mayo Clinic, Rochester, MN, USA. Objectives: To ¿nd safe and comparaEle alternative treatments for HC in patients intolerant to indomethacin. Background: Hemicrania continua (HC) is a primary headache disorder which responds aEsolutely to therapeutic doses of indomethacin. Unfortunately, approximately a fourth of patients develop adverse effects leading to discontinuation of the drug, and no other treatments have Eeen proven to Ee consistently effective. Methods: The Mayo Clinic’s medical index dataEase was queried to include the period from January 200 to NovemEer 2013. Following ,nstitutional Review Board approval, we performed a retrospective medical record review of HC patients seen Ey headache suEspecialists at our institution. 3atients who discontinued indomethacin due to intolerance were identi¿ed. Alternatives tried were recorded for response rate, ef¿cacy, and side effect pro¿le

P45 Headache Characteristics at Baseline in the Idiopathic Intracranial Hypertension Treatment Trial Friedman, D.,. Neurology & Neurotherapeutics and Ophthalmology, UT Southwestern Medical Center, Dallas, TX, USA. Objectives: To report the headache features of suEMects enrolled in the ,diopathic ,ntracranial Hypertension Treatment Trial (,,HTT) 3

June 2014 as documented in suEsequent visits and communications with headache suEspecialists. Results: Two hundred and ninety one patients with a possiEle diagnosis of HC were identi¿ed; 1 were diagnosed with HC according to the ,nternational Classi¿cation of Headache Disorders 2nd edition (,CHD-,,) Ey a headache specialist at our institution. Twelve patients discontinued ,ndomethacin; 11 (26.8) due to adverse outcomes, and one (2.) due to a diagnosis of non-alcoholic fatty liver disease (NAFLD). The commonly reported adverse effects were gastrointestinal (63.6), and elevated creatinine (18). Alternatives tried after the discontinuation of indomethacin include gaEapentin, melatonin, verapamil, topiramate, celecoxiE, and onaEotulinumtoxinA. 3rophylactic treatment resulted in a partial decrease of headache severity Eut not frequency in 33 cases with gaEapentin and 25 with Eoth celecoxiE and verapamil respectively. No therapeutic response was reported with topiramate or melatonin. Adverse effects were reported in 66. cases with gaEapentin, 25 with celecoxiE, and 28.6 with topiramate. No adverse outcomes were reported with verapamil or melatonin. Six patients received onaEotulinumtoxinA after alternative treatments had Eeen tried and failed. FavoraEle response was reported in 5 cases (83); two Eecame headache free, one reported a headache frequency decrease Ey 66 while the other two reported an unquanti¿ed Eut meaningful decrease in headache severity Eut not in frequency. One patient (16.6) reported no Eene¿t. No adverse outcomes were reported with onaEotulinumtoxinA. Conclusion: ,ndomethacin is the most effective treatment for HC. Adverse effects and comorEidities which preclude the use of indomethacin often make the treatment of HC challenging. ,n clinical practice, alternative treatments have not Eeen consistently effective or tolerated. ,n our series, onaEotulinumtoxinA was well tolerated and superior to other alternatives commonly used in HC when indomethacin is not tolerated. Our ¿ndings suggest onaEotulinumtoxinA may have an important role managing HC patients in whom indomethacin needs to Ee discontinued. ,n some cases, onaEotulinumtoxinA may have comparaEle ef¿cacy to indomethacin with a favoraEle side effect pro¿le. Larger studies are needed to con¿rm our ¿ndings.

Background: ,CHD-3 Beta de¿nes TAC as lateralizing headaches which are differentiated from other headache disorders Ey the presence of prominent autonomic features ipsilateral to the headache. ,n the literature there are rare reports of cluster-like unilateral headaches in the setting of herpes zoster ophthalmicus. There are no reports of prolonged TAC with underlying suE-clinical Herpes infection. Methods: Our patient was 36 when he presented with right-sided unilateral throEEing headache with conMunctival inMection and lacrimation. 3rior headache history included childhood migraine. ,ndomethacin was tried Eut not tolerated. He was started on verapamil with minimal improvement. At 3 months his pain suddenly and drastically escalated. Relief was eventually oEtained with a single dose of high-dose (1 Gram) methylprednisolone ,V. Unfortunately, 8 hours later symptoms returned and were now associated with Bell ’s 3alsy and periauricular vesicles ipsilateral to headache. He underwent lumEar puncture with lymphocytosis and mild protein elevation; All CSF herpes studies and serum H,V studies were normal. Serum ,gM levels for HSV-1 and VZV were elevated. MR, Brain did not show meningeal thickening. He was placed on high dose anti-viral therapy and prednisone taper with full symptom resolution. Results: We present an unusual case of a patient with symptoms initially suggestive of TAC. After extensive non-diagnostic evaluation, clinical therapeutic response most suggested a diagnosis of a herpes reactivation syndrome despite non-speci¿c CSF & ,maging ¿ndings. There have Eeen rare reports in the literature of VZV producing symptoms of unilateral headache with Zoster ophthalmicusoticus, and it is possiEle the HSV-1 was an opportunistic response. However, such a prolonged time course has not Eeen previously reported. Additionally atypical in our case was the aEsence of vesicular ¿ndings until after our patient received high dose steroids raising the possiEility of suEclinical herpes reactivation in an immunocompetent individual. Conclusion: There is literature to support that VZV reactivation manifestations can involve multiple ganglion sites as seen in zoster ophthalmicus and oticus with a predilection for autonomic ganglion. Our patient provides an example of a multiple ganglion presentation including involvement of autonomic ganglion resulting in his initial TAC diagnosis. As imaging and CSF 3CR were unrevealing except for non-speci¿c lymphocytosis it is unclear how Eest to approach patients with suspicion of HerpesVZV involvement as few index cases have Eeen puElished. We would conclude Ey suggesting that our literature review and experience with our own patient have demonstrated this to Ee a signi¿cant potential suEtype of TAC and that in patients resistant to conventional therapies this should Ee investigated further and on a larger scale.

P47 Herpes Masquerading as Trigeminal Autonomic Cephalalgia; Are We Missing An Important Headache Type? Mutgi, S.A.; Oas, J.G. Neurology, OSUMC, ColumEus, OH, USA. Objectives: We present a case of a young immunocompetent male diagnosed as Trigeminal Autonomic Cephalalgia (TAC) whom after 3 months ¿nally declared an underlying suEclinical VZVHSV-1 associated headache. Through reviewing our case and availaEle literature we will demonstrate that in patients with chronic headaches with autonomic features, suE-clinical herpes reactivation should Ee considered as a potential etiology.

35

Headache P48 Hemicrania Continua: A Single Entity or a Clinical Situation? Considerations from a Case Series Report Monzillo, 3.H.1; Haziot, M.E.1; Nemoto, 3.H.1; Silva, G.S.2 1 Neurology, Santa Casa de Smo 3aulo, Smo 3aulo, Brazil; 2 Neurology, Hospital ,sraelita AlEert Einstein, Smo 3aulo, Brazil.

P49 Indomethacin-Induced Migraine in Hemicrania Continua Chou, D.E. Neurology, ColumEia University Medical Center, New York, NY, USA. Objectives: 1) To descriEe the frequency of co-morEid migraine (with or without aura) among patients diagnosed with Hemicrania Continua. 2) To characterize the effect of indomethacin on headache in patients diagnosed with Hemicrania Continua, with or without a prior history of migraine. Background: Hemicrania Continua (HC) is a chronic, lateralized headache disorder with associated cranial autonomic features that is de¿ned Ey a complete response to indomethacin, a non-selective COX inhiEitor. However, it has Eeen reported that indomethacin may induce a ³de novo´ headache in HC.1 The present study further explores this phenomenon and offers an explanation as it pertains to the relationship Eetween HC and co-morEid migraine. Methods: This is a retrospective review of all cases of Hemicrania Continua seen Ey the author from SeptemEer 15, 2012 to FeEruary 1, 201 at the ColumEia University Headache Center. Results: Thirty-one patients were identi¿ed who met ,CHD-,, criteria for Hemicrania Continua. Of these, twenty-one (68) also had a prior history of episodic migraine with or without aura. Nine of these patients (3) reported recurrence or signi¿cant worsening of their migraines on indomethacin, Eut de¿nite improvement or remission of HC. Onset of migraine exacerEation occurred after an average of 11 weeks on indomethacin and at higher doses of indomethacin (ranging 150-225mgd, mean of 208mgd). ,n all cases of indomethacin-induced headache, pain was characterized as severe, Eilateral and throEEing, with Eilateral phonophoEia or photophoEia and nausea. Headache attacks were responsive to either triptan or phenothiazine treatment, and frequency of migraine attacks promptly diminished in all cases following cessation of indomethacin or dose reduction; however, HC symptoms recurred upon weaning of indomethacin. ,n the suEset of patients with a prior history of migraine who did not experience worsening on indomethacin (n=12), mean duration of treatment was 6 weeks and maximum indomethacin dose averaged 1mgday. None of the ten patients with HC, without a prior history of migraine, reported ³de novo´ headaches while on indomethacin for a mean duration of 10 weeks. Conclusion: This study highlights the overlapping comorEidity Eetween migraine and HC, and furthermore suggests that indomethacin-induced headache in HC is not a ³de novo´ phenomenon Eut may rather represent triggering of pre-existing migraine. Risk of migraine worsening on indomethacin appears to correlate with higher doses and longer duration of treatment. These ¿ndings demonstrate the importance of ascertaining a prior history of migraine (even if remote) among patients who present with HC, and Eearing caution with regards to indomethacin dose and duration in such cases. Future studies exploring the

Objectives: Evaluate the clinical and epidemiological features of patients with hemicrania continua (HC) followed in a neurology department, well as the natural evolution of their headaches. Background: HC is an uncommon primary headache disorder, mainly when diagnosed according to ,nternational Headache Society (,HS) criteria, Eecause in clinical practice these criteria seem too restrictive and many HC-like headaches remain unclassi¿ed. These controversies aEout diagnostic criteria also extend to HC pathophysiology. Thus this series especially highlighted the aEsolute response to indomethacin criteria requirement and the HC interface with other primary headache disorders, a neglected HC clinical feature discussed. Methods: We retrospectively reviewed 1063 patients’ medical records, Eetween January 2005 and May 2012 seen in our neurology department. Among these, were selected 12 patients with HC possiEle diagnosis (moderate pain, strictly unilateral, continuous for a period higher than 3 months and ipsilateral trigeminal-autonomic activation) according to the data in these records. All of then were invited for a neurological revaluation, with the aim of validating medical records data used for selection. Results: A total of 58 patients (5.3) were enrolled, (6 patients not returned for reevaluation and 9 of them were excluded for not meeting the proposed criteria). Between then, 28 (9.1) ful¿lled ,HS-,,, criteria for HC and 30 (52.6) did not responded to indomethacin test. HC was preceded Ey another primary headache in 3 (58.6); migraine was the most prevalent, followed Ey paroxysmal hemicrania. ,t was possiEle determine a primary headache that followed HC in 22 (38), and migraine was also the most frequently. Conclusion: The aEsolute therapeutic response to indomethacin as required criteria is the most restrictive aspect of HC in our opinion, which is corroEorated Ey the clinical data in this series even as previous similar studies. A patient with any other primary headache, that sometime change his prior clinical characteristics, to a spectrum of manifestations such as HC, is a reasonaEle concept. The signi¿cant percentage of patients in this sample with a primary headache that preceded or succeeded the HC diagnosis, reinforces this concept, and suggests her as a self-limited clinical situation, although the sample size does not allow de¿nitive conclusions, Eut the analysis of our results, shared Ey other authors, seem to move to this statement.

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June 2014 mechanism Eehind indomethacin-induced migraine may also help elucidate its therapeutic role in HC. References 1. Jurgens T3 et al. Cephalalgia 2013 Oct;33(1)1203-5.

P51 Sphenopalatine Ganglion (SPG) for Chronic Cluster Headache (CH) Treatment – Change in Preventive Medication (PM) Use at 1 Year in the Pathway CH-1 Study Caparso, A.1; Lainez, J.3; Jensen, R.; Schoenen, J.5; Gaul, C.6; Lantéri-Minet, M.2; Goodman, A.8; May, A. 1 Research and Development, Autonomic Technologies, Redwood City, CA, USA; 2Department Evaluation and Treatment of 3ain, H{pital Cimiez, Centre Hospitalier Universitaire de Nice, Nice, France; 3Department of Neurology, University of Valencia, Valencia, Spain;  Danish Headache Center, Glostrup Hospital, University of Copenhagen, Copenhagen, Denmark; 5CHR de la Citadelle, Liège University, Liège, Belgium; 6Department of Neurology and Headache Centre, University DuisEurg-Essen, Essen, Germany; ,nstitute for Systems Neuroscience, University Medical Center HamEurgEppendorf, HamEurg, Germany; 8Clinical, Autonomic Technologies, Redwood City, CA, USA.

P50 Effectiveness of Occipital Nerve Block for the Treatment of Acute Exacerbation of Cluster Headache Elchami, Z.; ,ssa, M.; MiramEel, A.; Diaz, E.; Massoud, R.; Magayano, D. 3ain & Headache Management Center of Excellence, ,nternational Medical Center, Jeddah, Saudi AraEia. Objectives: The oEMective of the study is to evaluate the effectiveness of occipital nerve Elock applied to the occipital region in the management of acute exacerEation of cluster headache. Background: An occipital nerve Elock is an inMection of a steroid or other medication around the greater and lesser occipital nerves that are located on the Eack of the head Must aEove the neck area. Cluster headaches, on the other hand, occur in cyclical patterns or clusters, which gives the condition its name. Cluster headache is one of the most painful types of headache. Methods: 30 patients were evaluated according to the ,nternational Headache Society (,HS) classi¿cation of secondary headaches. 3atients were allocated to receive either occipital nerve Elock or ,V infusion, as per patients’ preference. Trial was conducted over a -year period at the 3ain & Headache Center, ,MC, Jeddah, K.S.A. ,nclusive criteria 28 males, 2 females; ages Eetween 20-50 years, with a mean of 35. Exclusive criteria pediatric patients; patients older than 50, with uncontrolled diaEetes, Elood pressure, and other neurological de¿cits. Results: Average improvement of 85, according to numeric pain scale, was appreciated Ey patients within 10 minutes of occipital nerve Elock and lasted for an average of 2 hrs as patients continued to improve with initiation of preventative therapy. However, an average improvement of only 60 was appreciated within 30 minutes of ,V infusion and lasted for only 2hrs as patients continued to improve as per aEove. Conclusion: 3atients who received occipital nerve Elock showed more rapid, signi¿cant, and sustained improvement compared to patients who received the ,V infusion.

Objectives: S3G stimulation has Eeen shown in CCH patients to provide acute pain relief and reduction in the use of acute medications. ,n addition, a reduction in the numEer of cluster attacks was also oEserved. This post-hoc analysis was undertaken to assess if a corresponding change in preventive headache medications (3M) also occurred and to characterize such changes at one year following implantation of an on-demand S3G neurostimulator. Methods: 3atients met the ,CHD-2 criteria for CCH with a minimum of  attacksweek. 3atients were implanted with a miniaturized neurostimulator which, along with a controller, provides S3G stimulation. 3M data for this analysis were collected at Easeline prior to implant and at the 1 year follow-up visit (38 days, range 31- 31). At each time point, each patient’s current prescriEed 3M were collected via case report forms. 3atients were required to keep their 3M unchanged through completion of the randomized, controlled experimental period (168 days from time of implant, range 62-38); changes were permitted when patients entered open laEel. 3M changes were characterized as stopped all 3M, decreased dose and or stopped some 3M, remained off 3M (no 3M at Easeline), no change from Easeline, increased dose andor added 3M, not evaluaEle (changed 3M andor increased dose of some decreased dose of others). Results: 3 patients were enrolled, 36 (8) provided 3M data Eoth at Easeline and 1 year. Of the 36 patients,  (19) did not use any 3M at Easeline, 18 (50) used verapamil, 6 (1) used Eoth verapamil and topiramate, 1 (3) used topiramate, and  (11) used other 3Ms. Average attack frequency at Easeline was 18.2 attacksweek (range -0). At the 1 year following the implant procedure, 1 () patients had a reduction in overall attack frequency, average over the last four weeks prior to the one year visit (38 days, range 31-31) compared to Easeline, of at least 50, with the average cluster headache reduction Eeing 5. At 1 year following the implant procedure, 11 (31) patients Eene¿tted Ey either stopping all 3M (N=6) or decreasing dose andor stopping some 3M (N=5). ,n addition, 6 of the  patients who used no 3M at Easeline remained off 3

Headache of 3M at 1 year. Of the remaining 19 patients, 6 (1) had no change in 3M from Easeline,  increased dose and or added 3M (11) and 9 (25) were not evaluaEle as patients either changed 3M or increased the dose of some and decreased the dose of others medications. Conclusion: Acute, on-demand S3G stimulation using the AT, Neurostimulation System is associated with attack frequency reduction in  of patients and an improvement in preventive medication use in many patients.

P53 SUNCT & SUNA Presenting with Aura, Sensory Loss, & Interictal Pain Halker, R.B.; Dodick, D. Neurology, Mayo Clinic, Scottsdale, AZ, USA. Objectives: We descriEe 3 patients with Short-lasting Unilateral Neuralgiform Headache with ConMunctival ,nMection and Tearing (SUNCT) and Short-lasting Unilateral Neuralgiform Headache with Cranial Autonomic Features (SUNA) with the unique features of aura, continuous Eackground pain, and sensory loss. Methods: case descriptions of 3 patients Results: 3atient 1 is a 1-year-old man with adult-onset Alexander disease and a 12-year history of SUNCT. He had 12-15 attacks daily of severe right periorEital pain, lasting 30-5 seconds, with ipsilateral lacrimation and rhinorrhea. 3rior to each attack, he experiences paresthesias around the right eye and cheek for 15-20 minutes. He is painfree Eetween attacks. He denies a history of migraine or other headache disorders, or any cutaneous triggers for his attacks. MR, Erain, including high-resolution coronal images of the pituitary gland and F,ESTA imaging of the trigeminal nerves, was signi¿cant for chronic Eifrontal white matter patchy T2 hyperintensities with associated signal aEnormalities in the Erainstem extending into the cervical spine, consistent with Alexander disease. His pituitary gland and trigeminal nerves appeared normal. An EEG, extensive serology, and an MRA of the Erain were normal. CSF exam showed normal opening and closing pressures, and normal CSF contents with the exception of a slightly elevated protein at 62. Topiramate 200 mg B,D, carEamazepine 100 mg B,D, and duloxetine 30 mg B,D reduced his attacks to 3- per day. 3atient 2 is a -year-old man with a 36-year history of SUNCT, presenting with 50-100 daily attacks of severe retroorEital and temporal pain lasting 60-90 seconds. 80 of his attacks are heralded Ey the sequential occurrence of a visual and somatosensory aura preceding the pain Ey 15-30 seconds. The aura Eegins with ³Elack Eugs´ in his right visual ¿eld and is followed Ey ipsilateral right facial and right upper extremity paresthesias. ,n addition to ipsilateral rhinorrhea and lacrimation, during attacks he also experiences loss of sensation and paresthesias over the right face and arm. ,nterictal quantitative sensory testing found thermal anesthesia in the right V1 distriEution. 3atient 3 is a 3-year-old man with 2 cycles of ³sawtooth´ SUNA separated Ey 2 years. The active phase of each cycle features dozens of daily attacks, lasts months, and is accompanied Ey a moderately severe Eackground continuous pain and sensory loss over the ipsilateral (left) face. Facial nerve conduction studies, Elink reÀexes, and needle exam of the left masseter were normal. 3atients 2 and 3 had normal Erain MR, and normal serology, including pituitary hormone levels. ,ntravenous lidocaine led to cessation of SUNCT and SUNA attacks in Eoth patients, and also resolution of aura in patient 2 and interictal pain and sensory loss in patient 3. Conclusion: Each patient presented with attacks meeting ,CHD-3 criteria for SUNCT or SUNA, yet had unique

P52 Rare Presentation of Cluster Headaches in Multiple Sclerosis Patient Sahai-Srivastava, S.; Khan, K.J. Neurology, University of Southern California, Los Angeles, CA, USA. Objectives: To descriEe a rare presentation of cluster headache in multiple sclerosis patient. Background: Multiple sclerosis (MS) is a chronic neurological disease where primary headache pain is a frequent and disaEling symptom. Migraine and tension headaches are the most frequently reported primary headaches in the setting of MS. Cluster headache, an uncommon autonomic headache disorder, with a male predominance, and a prevalence of 0.–0.6 in the normal population has rarely Eeen descriEed in Multiple sclerosis patient. Only three male patients with multiple sclerosis and cluster headaches have Eeen ever descriEed in 3 different case reports from Germany and ,taly. Methods: This is a case report and review of literature. Results: We are reporting the case of a 3 year old female teacher, who presented with two weeks of severe right sided retro-orEital pain radiating to the right temple. The headache occurred once or twice a day, each lasting for 0-5 minutes and was associated with right eye tearing, ptosis and redness. 3ast medical history was signi¿cant for a recent diagnosis of Multiple sclerosis, for which she had not yet Eegun treatment. Neurological examination and routine Elood testing was unremarkaEle. MR, Erain showed demyelinating lesions consistent with her diagnosis of Multiple sclerosis, Eut did not show any hypothalamic lesions. She was given a trial of indomethacin, Eut didnot respond to it, thus excluding the diagnosis of 3aroxysmal Hemicrania which is an autonomic cephalalgia that is more prevalent in women. She responded equivocally to indomethacin. A diagnosis of cluster headache was made and she was treated with Oxygen in the clinic, since she had an attack while there. Her attack resolved with this treatment. She was treated with oral steroids and preventative treatment with Verapamil and has not had a cluster attack in several weeks. Conclusion: Cluster headaches, an unusual primary headache disorder can Ee seen in the setting of Multiple Sclerosis. Further research needs to Ee done as to whether the demyelinating lesions of Multiple sclerosis have any relationship to the onset of cluster.

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June 2014 features associated with their attacks, including visual and somatosentory aura, sensory loss, and continuous Eackground pain, which also responded to treatment. Given the aEsence of structural aEnormalities, a trigeminal neuropathy, or other concomitant primary or secondary headache disorders, these unusual ¿ndings are likely intrinsic features of SUNCT and SUNA.

approximately 6-12 months after the education. Data collection for these measures is Eeing ¿nalized. Results: Data analysis is currently underway. Descriptive statistics will Ee used to descriEe headache patients at the time of education and their satisfaction with the HEAD program. 3aired t-tests will Ee used to compare pre-andpost differences in M,DAS, lifestyle Eehaviours and selfef¿cacy. Conclusion: Findings regarding patient disaEility and presence of co-morEid depressionanxiety at presentation, patient perception of the value of the HEAD program, and the clinical impact will Ee shared. The implications of integrating education into clinical practice will also Ee highlighted.

P54 Headache Education Active Waiting Directive (HEAD): A Program to Enhance Well-Being During Long Referral Wait Times Lawler, V.; Lay, C.; Lagman-Bartolome, A. Centre for Headache, Women’s College Hospital, Toronto, ON, Canada.

P55 A Live Patient Simulation Model to Effectively Manage Dif¿cult Headache Patients 3irmohamed, F.; Vota, S. Neurology, VCU, Henrico, VA, USA.

Objectives: 1. To evaluate the clinical impact of a headache education program for newly referred patients. 2. To assess patient disaEility, co-morEid depression anxiety at presentation as well as patient perception of the value of the program. 3. To assess sustainaEility of implementing the program as standard of practice. Background: 3atients referred to a university Eased academic headache program (Centre for Headache in Toronto, Canada), face > 15 month wait, delaying diagnosis and appropriate management. The HEAD program was designed to advance patient knowledge and impart self-care skills to newly referred patients. Educating patients aEout headache, including common treatment mistakes (medication overuse, treating late) could lead to improved self-ef¿cacy and contriEute to a solid foundation for a successful patientprovider partnership. Since a pilot HEAD program in 2011 showed reduced headache pain and associated disaEility and patients found it valuaEle, HEAD was integrated as a standard of practice in 2012. Methods: Study design: This study is a prospective cohort study for which approval was oEtained from the hospital Research Ethics Board. Participants: New patients referred to the Centre for Headache who met eligiEility criteria were required to attend HEAD. 3articipation in research was voluntary. Between May and DecemEer 2012, 182 patients were recruited. Pre-intervention measures: Measures collected prior to education included M,DAS, 3H4 9, GAD , self ef¿cacy scores, demographic and self-reported lifestyle haEits. Intervention: HEAD included didactic 3ower3oint presentations led Ey an Advanced 3ractice Nurse (A3N) with expertise in headache management. Topics included headache types, triggers, treatment options, lifestyle modi¿cations, medication overuse, and appropriate goal setting. Written educational materials, headache and sleep diaries were provided as well as a Headache Action 3lan to assist with goal setting and a time for open discussion. A standardized satisfaction questionnaire was also completed. Telephone contact Ey an A3N was carried out 3 months later. Post-intervention measures: Collected from participants at their consultation appointment with the neurologist

Objectives: To improve medical knowledge and interpersonal and communication skills in treating dif¿cult headache patients. Background: Treating dif¿cult headache patients is common for neurologists. There are certain characteristics of medication overuse, management non-adherence and demanding manipulative patient Eehavior that may lead to challenging patient encounters. 3atient dissatisfaction may lead to frustration and emotional Eurn-out in physicians. The lack of appropriate training in order to effectively manage dif¿cult headache patients has Eeen recognized. Methods: A curriculum was designed for postgraduate (3GY 2-5) neurology residents and fellows to improve their communication skills and treatment strategies when treating dif¿cult headache patients. The curriculum included didactic lectures and independent Mournal reviews. Topics included headache management, factors which may contriEute to dif¿cult patient encounters, and strategies to improve physicianpatient relationships. Residents then participated in a clinical encounter at the VCU Human Simulation Center where they implemented these treatment strategies. The standardized patient and supervising physician provided initial deErie¿ng. ,ndependent review of the recorded encounter was then availaEle. 3articipant’s feedEack was oEtained through a computerized survey. Results: All participants felt that this educational curriculum was valuaEle and clinically relevant. 92.3 found the deErie¿ng to Ee useful and 6.9  found the initial curriculum on headache management and improving challenging patient encounters as valuaEle. Upon self reÀection, residents felt this program helped with improving communication strategies as well as decrease frustration, stress, and anxiety when dealing with dif¿cult headache patients. All participants also felt this curriculum would Ee valuaEle early in one’s educational career to improve con¿dence when treating these challenging patients. Conclusion: Educational didactics paired with simulated patient encounter can Ee a valuaEle educational tool in improving medical knowledge and communication skills

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Headache for neurology residents when caring for challenging headache patients.

P57 Asthma is a Risk Factor the for Transformation of Episodic to Chronic Migraine: Results from the American Migraine Prevalence and Prevention (AMPP) Study Martin, V.T.1; Buse, D.C.2; Fanning, K.3; Serrano, D.3; Reed, M.L.3; Lipton, R.B.2 1 ,nternal Medicine, University of Cincinnati, Cincinnati, OH, USA; 2Neurology, AlEert Einstein College of Medicine, New York, NY, USA; 3Vedanta Research, Raleigh, NC, USA.

P56 Nurse Practitioner/Physician Assistant Roles in Headache Centers Moriarty, M. N33A Special ,nterest Section of AHSGeorgetown University School of Nursing and Health Studies; Georgetown University Hospital, Washington, DC, USA. Objectives: ,dentify roles and responsiEilities of American Headache Society nurse practitioner and physician assistant memEers in headache practices. Background: Although roles of nurse practitioners and physician assistants are well descriEed in the literature, little is written aEout responsiEilities of these professionals in specialty care practices. ,nvolvement of nurse practitioners and physician assistants in headache practices Eegan 30 years ago. During a nurse practitionerphysician assistant American Headache Society Special ,nterest Group meeting in June 2012 attendees shared their clinical, educational and research responsiEilities, practice settings, reimEursement strategies and compensation. VariaEility in response comEined with scant puElished information regarding these roles in headache practices identi¿ed a knowledge gap. A survey focusing in the aforementioned areas was distriEuted to all nurse practitioner and physician assistant memEers. Methods: A 33 item mixed ¿xed choiceopen ended questionnaire was sent electronically to all nurse practitionerphysician assistant and physician memEers of the American Headache Society. The latter group was instructed to forward the survey to any nurse practitioner physician assistant provider af¿liated with their practice. 4uestions included credentialing, practice setting, clinical, educational and research roles, reimEursement strategies, compensation and views on interprofessional practice. Respondents had two weeks to complete this 20-minute survey. Descriptive data was reported in each category. Results: The maMority of 2 respondents were nurse practitioners. Most respondents were Master’s prepared practicing for 2-5 years in amEulatory headache settings. Clinically, the maMority saw new and follow up patients and performed procedures such as toxin inMection, peripheral Elocks and trigger point inMections. Most Eilled third party payers for services and modal salary range was 5,000 to 100,000 dollars. 3hysician collaEoration was positively viewed, enhancing patient satisfaction and care. Conclusion: This descriptive survey identi¿es nurse practitioner and physician assistant roles in headache practices. Disseminating this information raises awareness of previously hidden though effective roles. Future steps include expansion of respondent Ease to non American Headache Society memEer nurse practitioners and physician assistants in neurology practices. Role overlap Eetween physician, nurse practitioner andor physician assistant, when caring for headache patients highlights interprofessional educational opportunities and estaElishes a guide for collaEorative practice.

Objectives: To test the hypothesis that in persons with episodic migraine (EM), asthma is a risk factor for the new onset of chronic migraine (CM). Background: Migraine and asthma are comorEid chronic disorders with episodic attacks thought to involve inÀammatory mechanisms. Herein, we assess the inÀuence of asthma on the clinical course of EM. Methods: This study included persons who completed the 2008 AM33 Study survey, a prospective, longitudinal, US population Eased study, and in that year met modi¿ed ,CHD-3 Eeta criteria for EM and completed the validated six-item asthma questionnaire from the European Community Respiratory Health Survey (ECRHS). Using the ECRHS we de¿ned asthma as a dichotomous variaEle using a prede¿ned cut-score and developed a Respiratory Symptom Severity (RSS) score Eased on the numEer of positive responses (none= 0, mild=1-2, moderate= 3-, severe= 5-6 positive responses). New onset chronic migraine in 2009 was the primary outcome measure and was de¿ned using SilEerstein-Lipton criteria. . We used logistic regression in separate models to assess the inÀuence of asthma as a Einary variaEle (Model 1) and RSS score categories (Model 2 using ³none´ as the reference) on CM onset adMusting for sociodemographic factors, Eody mass index, cutaneous allodynia (ASC-12; de¿ned dichotomously with cut-score of 10), headache frequency, headache-related disaEility (M,DAS), depression (3H4-9; de¿ned dichotomously with a cut-score of 10), migraine preventive medication use and medication overuse (de¿ned dichotomously Ey modi¿ed ,CHD-3 Eeta criteria). Results: The eligiEle sample for this study included ,532 individuals with EM in 2008 of whom 1 had asthma. This group had a mean age of 50 and was 81 female. ,n 2009, CM developed in 3 of the 2008 cohort including 5.5 of the asthma group and 2.5 of non-asthma suEgroup. Model 1 demonstrated an adMusted odds ratio (aOR) for CM onset of 1.9 (1.1, 3.1; 95 C,) for the asthma as compared to the non-asthma group. Model 2 showed an increase in the aORs in those with mild, moderate and severe RSS scores, Eut only those with a severe RSS grade showed a statistically signi¿cant increase in the risk of CM onset as compared to those with no respiratory symptoms (aOR 2.8; 95 C, 1., 5.5). Conclusion: Asthma is associated with an increased risk for transformation from EM to CM with the highest risk Eeing amongst those with the most severe respiratory symptoms. The exact mechanisms underlying this association are unknown. We suggest mast cell degranulation, autonomic

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June 2014 dysfunction or the treatment of asthma as possiEle mechanisms.

Conclusion: This study is one of the few population Eased incidence and course studies world-wide. Migraine prevalence is quite similar to the previous study. However, TTH prevalence is higher. On the other hand, high interchange Eetween TTH and migraine to each other strongly supports the headache spectrum theory. Our results con¿rmed again that headache incidence is very high in the general population. Therefore, policies for management and follow-up of headaches, strategies for policy makers should Ee Euilt on this Easis.

P58 Incidence and Course of Migraine and TTH in a 5-year, Population Based, Validated Survey in Turkey Karli, N.1; Ertas, M.3; ZarfoÄlu, M.2; Kocasoy Orhan, E.; Siva, A.5; Saip, S.5; Baykan, B.; Turkish Headache study group, T.6 1 Neurology, University of Uludag, School of Medicine, Bursa, Turkey; 2Neurology, University of Uludag, School of Medicine, Bursa, Turkey; 3Neurology, Liv Hospital, ,stanEul, Turkey; Neurology, University of ,stanEul, ,stanEul school of Medicine, ,stanEul, Turkey; 5Neurology, University of ,stanEul, Cerrahpasa School of Medicine, ,stanEul, Turkey; 6Turkish Neurological Association, Ankara, Turkey.

P59 Headache Disorders Are a Risk Factor for the Development of New Onset Hypothyroidism Martin, V.T.1; Martin, A.T.1; 3inney, S.M.2; Xie, C.2 1 ,nternal Medicine, University of Cincinnati, Cincinnati, OH, USA; 2Department of Environmental Health, University of Cincinnati, Cincinnati, OH, USA.

Objectives: To estimate the incidence of migraine and tension-type headache (TTH) and to oEserve their course and spectrum in a population Eased validated telephone study design Background: Although headache is a very frequent disorder in the general population, incidence and course studies are very limited. Both TTH and migraine incidence and course have not Eeen studied in Turkey Eefore. Methods: The ¿rst Turkish headache prevalence study, accomplished in 2008, was a nationwide, homeEased, face-to-face study done Ey educated general practitioners. ,n 2013, a second study was planned and 5323 suEMects who were included in the ¿rst study was phoned and interviewed according to a structured questionnaire. ,CHD-,, was used as the diagnostic criteria. 3re-validation and post-validation studies were done in two different university headache centers. CronEach’s alpha value for pre-validation was 0.911 and 0.06 for post-validation. 2563 migraine free suEMects in the ¿rst study were included into the incidence calculation and availaEle 3001 suEMects included into the headache course – spectrum analysis. Results: 3001 (56.) suEMects (ages Eetween 23 and 9) could Ee interviewed again. Headache prevalence was 5.3 in 2013 study compared to .6 in 2008. Migraine prevalence was found to Ee 16. and TTH 22.3. Chronic migraine prevalence was 2.9. Headache, migraine, chronic migraine and TTH incidences were 8.6, 3.2 (de¿nite + proEaEle migraine), 0.56 and 6.51 (de¿nite + proEaEle TTH) respectively. De¿nite migraine incidence is found to Ee 2.. Only 2.9 of de¿nite migraineurs in 2008 received the same diagnosis in 2013, 23.3 was diagnosed as de¿nite TTH, 11.6 evolved into proEaEle TTH, 6. changed to proEaEle migraine and 15.8 of the sufferers were headache free. Moreover, 32.3 of de¿nite TTH sufferers’ diagnosis in 2008 remained the same, 1. was diagnosed as proEaEle TTH, 1. de¿nite migraine, 6. proEaEle migraine and 28.9 was headache free. 6.2 of those who received CM diagnosis in 2008 were now headache free and 38.5 was now suffering from de¿nite episodic migraine. 6. of migraineurs was also suffering from medication overuse headache at the time of the study period. The rate of preventive medication usage for all headaches increased from .9 to 9.2 in 5 years.

Objectives: To determine if headache disorders are a risk factor for the development of new onset hypothyroidism Background: 3ast epidemiologic studies have reported associations Eetween headache disorders and hypothyroidism, Eut most have Eeen cross sectional analyses and the directionality of the associations is unknown. Methods: This was a longitudinal prospective cohort study using data from the Fernald Medical Monitoring 3rogram (FMM3), which was a medical surveillance program of 9,82 residents that lived around the Fernald uranium processing plant near Cincinnati, Ohio from 1990-2008. Residents received physical examinations and thyroid function testing upon entrance into the program and every 2-3 years thereafter. ,n addition, a list of all medications and new medical diagnoses were recorded at each visit. At the time of their ¿rst examination they completed a health questionnaire that included a question querying them as to the presence or aEsence of ³frequent headaches´. Exclusion criteria for this study included any evidence of past thyroid disease (hypothyroidism, hyperthyroidism or thyroid cancer) or aEnormal thyroid function tests recorded during the ¿rst of¿ce visit. A diagnosis of a headache disorder was con¿rmed Ey any of the following 1) an af¿rmative answer to the question regarding ³frequent headache´ during the ¿rst of¿ce visit, 2) use of any headache-speci¿c medications (triptans, ergots, EutalEital- and isometheptane-containing medications) recorded during any of¿ce visit or 3) received a new diagnosis of a headache disorder during any of the of¿ce visits. The primary outcome measure was new onset hypothyroidism, which was de¿ned as 1) initiation of thyroid replacement therapy prior to an of¿ce visit with no past evidence of hyperthyroidism or 2) TSH was >  in the aEsence of thyroid medication. Since our collection of data was linked to the date of the of¿ce visit we were aEle to determine if exposure to the independent variaEles preceded the development of new onset hypothyroidism, which allowed us to use Cox survival analysis for the analysis. Headache disorders, Eody mass index, smoking, narcotic use and hypothyroidism producing meds (eg. lithium, interferon, amiodarone) were included in the

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Headache models as time dependent variaEles while sex and age de¿ned at Easeline were non-time dependent variaEles. Results: Data from 8,12 residents enrolled in the FMM3 was used in the current study. The average age of the residents was 5 and 5 of the participants were female. Headache disorders were present in 25 of the residents and new onset hypothyroidism developed in . The hazard ratio for the development of new onset hypothyroidism was 1.21 (95 C, = 1.001, 1.62) for those with headache disorders. Conclusion: To our knowledge this is the ¿rst report that headache disorders are associated with an increased risk for the development of new onset hypothyroidism. The mechanisms underlying this association are unknown, Eut we hypothesize that the release of stress hormones encountered in those with frequent headache might impair the synthesis andor release of thyroid hormones. Shared immunologic or genetic factors Eetween these disorders is also possiEle.

P61 Differences in Sleep Patterns and Sleep Disturbances in Episodic and Chronic Migraine: Results from Korean Sleep-Headache Study Chu, M.1; 3ark, J.6; Yun, C.2; Yang, K.3; Kim, B.; Kim, W.5 1 Hallym University, Anyang, Democratic 3eople’s RepuElic of Korea; 2Neurology, Seoul National University Bundang Hospital, Seongnam, RepuElic of Korea; 3Neurology, Soonchunhyang University College of Medicine, Cheonan Hospital, Cheonan, RepuElic of Korea; Neurology, EulMi University School of Medicine, Seoul, RepuElic of Korea; 5Neurology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, RepuElic of Korea; 6 Neurology, UiMeongEu St. Mary’s Hospital, The Catholic University of Korea, UiMeongEu, RepuElic of Korea. Objectives: To estimate and to compare sleep patterns and disturEances of episodic and chronic migraine (CM) in a Korean population-Eased sample. Background: Compared with patients with episodic migraine (EM), those with CM have reduced healthrelated quality of life, increased headache-related Eurden, and greater psychiatric and medical comorEidities. Sleep disturEance is a common complaint among individuals with migraine. Sleep patterns were closely associated with sleep disturEances. However, the sleep patterns and disturEances of CM in comparison with EM were not reported yet. Methods: We selected a strati¿ed random population sample of Koreans aged 19-65 and evaluated them with a 60-item semi-structured interview designed to identify headache type, sleep duration and sleep disturEances. We assessed sleep durations and sleep onset time for sleep patterns. We investigated sleep disturEances such as daytime sleepiness, insomnia, sleep apnea using Epworth sleepiness scale (ESS), insomnia severity index (,S,), Berlin questionnaire (B4), respectively. We de¿ned a CM suEMects if a suEMect reported experiencing headache with migrainous features more than 15 days per month for more than 3 months during the previous year. Compared with patients with episodic migraine (EM), those with CM have reduced health-related quality of life, increased headacherelated Eurden, and greater psychiatric and medical comorEidities. Sleep disturEance is a common complaint among individuals with migraine. Sleep patterns were closely associated with sleep disturEances. However, the sleep patterns and disturEances of CM in comparison with EM were not reported yet. Results: Of 262 participants, the 1-year prevalence of CM and EM were 1.0 >95 con¿dence interval (C,) =0.8-1.6@ and 5.0 (95 C,=.2-5.), respectively. Although sleep duration (6.(1. hours vs. .1(1. hours, p=0.189) and sleep onset time (23.9(1. 3M vs. 0.1(1. AM, p=0.961) were not signi¿cantly different Eetween CM and EM groups, CM group showed more )5 hour sleep duration compared to EM group (21.1 vs. 8.8, p=0.021). CM group showed higher ,S, score (9.1(. vs. 6.8(5.6, p=0.00) and higher 3S4, score (6.8(2.8 vs. 5.5(2., p=0.005) compared to EM group. However, ESS score and B4 score were not signi¿cantly different Eetween 2 groups.

P60 Increased Risk of Bell’s Palsy in Patients with Migraine: A Nationwide Population-Based Study 3eng, K.2; Fuh, J.1; Wang, S.1 1 Neurology, Neurological ,nstitute, Taipei Veterans General Hospital, Taipei, Taiwan; 2Medicine, Taipei Veterans General Hospital, Taoyuan Branch, Taoyuan, Taiwan. Objectives: To evaluate the association Eetween migraine and Bell’s palsy and to examine the effects of age, sex, migraine suEtype, and comorEid risk factors for Bell’s palsy. Methods: This population-Eased cohort study was conducted using data from the Taiwan National Health ,nsurance Research DataEase. SuEMects aged *18 years with neurologist-diagnosed migraine from 2005 to 2009 were included. A non-headache age-, sex-, and propensity score–matched control cohort was selected for comparison. All suEMects were followed until the end of 2010, death, or the occurrence of a Bell’s palsy event. Cox proportional hazards regression was used to calculate the adMusted hazard ratios (aHRs) and 95 con¿dence intervals (C,s) to compare to the risk of Bell’s palsy Eetween groups. Results: Both cohorts (n = 136,0 each) were followed for a mean of 3.2 years. During the follow-up period, 61 patients (2,32 person-years) in the migraine cohort and 365 matched control suEMects (38,6 person-years) were newly diagnosed with Bell’s palsy (incidence rates, 158.1 and 83.2100,000 person-years, respectively). The aHR for Bell’s palsy was 1.91 (95 C,, 1.68–2.1; p  0.001). The association Eetween migraine and Bell’s palsy remained signi¿cant in sensitivity analyses, and tests of interaction failed to reach signi¿cance in all suEgroup analyses. Conclusion: Migraine is a previously unidenti¿ed risk factor for Bell’s palsy. The association Eetween these two conditions suggests a linked disease mechanism, which is worthy of further exploration.

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June 2014 Conclusion: ,ndividuals with CM showed more in )5 hours sleep duration, insomnia and sleep disurEance compared to those in individuals with EM.

than the accurate estimate group. The same pattern was seen when comparing days with migraine per month. Conclusion: H,T-6 scores were not a strong predictor of overall monthly disaEility calculated via daily assessment. Further evaluation indicated that individuals whose H,T6 underestimated disaEility had more headache days per month. This suggests that although the H,T-6 has demonstrated clinical utility, assessing the disaEling impact of headache on a daily Easis may provide additional clinical utility. Moreover, the current ¿ndings suggest that the impact of headache on those with chronic migraine may Ee even greater than currently understood.

P62 The Relationship Between the Headache Impact Test6 (HIT-6) and Disability Assessed Daily Varies as a Function of Monthly Headache Frequency Nicholson, R.A.; Slayton, R.M.; Yount, B.; Smith, T.R. Mercy Health, St. Louis, MO, USA. Objectives: 1. Evaluate the relationship Eetween H,T-6 scores and disaEility assessed daily among patients with migraine. 2. Determine what factors are related to variations Eetween H,T-6 scores and a daily measure of disaEling impact. Background: The H,T-6 is a gold standard for assessing the disaEling impact of migraine and other headaches over a month. However, little research has evaluated the relationship Eetween the H,T-6 and a measure of the disaEling impact of headache assessed daily or what factors inÀuence the accuracy of the H,T-6 score. The current research looked to compare H,T-6 scores to disaEility assessed daily among adults with primary migraine. Methods: A total of 252 adults (91 female, mean age = 2.8+- 11.25, mean headache days per month 11.1+6.0) completed Easeline questionnaires (demographic, clinical, cognitive) followed Ey 30 days of daily headache diaries completed via a weE-Eased patient portal utilizing patient-response driven algorithmic Eranching logic questionnaire optimization. As part of the diary, individuals completed the Migraine DisaEility ,ndex (M,D,, score of 0 >no [email protected] -10 >total [email protected]) on headache days. Monthly disaEility was then calculated (days with headache per month X mean M,D, score per headache day; mean = 2.06+-29.0). After 30 days, individuals completed the H,T-6 (mean = 61.09 +- 6.09). Kendall’s tau compared the rank of the H,T-6 and monthly disaEility score. The rank difference Eetween the H,T-6 and monthly disaEility was then calculated. ,ndividuals were then classi¿ed into a group Eased on quartile ranking differences 1) H,T-6 overestimated monthly disaEility (n=63), 2) H,T6 accurately estimated monthly disaEility (n=12), 3) H,T-6 underestimated disaEility (n=65). ,ndependent sample Kruskal-Wallis and Chi-square tests compared the groups for signi¿cant differences (Bonferroni adMusted) on demographic, clinical, and cognitive characteristics. Results: Kendall’s tau indicated that the correlation Eetween H,T-6 and monthly disaEility was signi¿cant Eut not strong (tau = .18, p  .001). Comparisons of the rank difference groups showed no signi¿cant differences for demographic, clinical, or cognitive characteristics. Headache frequency was signi¿cantly different such that those whose H,T-6 score overestimated disaEility had signi¿cantly fewer headache days (mean days = 6.92 +- 3.05) than those whose H,T-6 score accurately estimated disaEility (mean days = 10..9 +- 5.59) or H,T6 underestimated disaEility (mean days = 15.56 +- .38) (Kruskal-Wallis >[email protected] = 63.23, p  .001). Similarly, the H,T-6 underestimate group had signi¿cantly more headache days

P63 Anxiety and Depression in Migraine Patients and Their Relation with Headache-Related Disability Zandifar, A.1; Haghdoost, F.1; Zandifar, S.3; Manouchehri, N.2; Saadatnia, M. 1 3hysiology Research Center and Medical Student Research Center, ,sfahan University of Medical Sciences, ,sfahan, ,slamic RepuElic of ,ran; 2Medical Student Research Center, ,sfahan University of Medical Sciences, ,sfahan, ,slamic RepuElic of ,ran; 33hysiology Research Center, ,sfahan University of Medical Sciences, ,sfahan, ,slamic RepuElic of ,ran; ,sfahan University of Medical Sciences, Department of Neurology and ,sfahan Neurosciences Research Center, ,sfahan, ,slamic RepuElic of ,ran. Objectives: The oEMectives of the present study were to determine the prevalence of anxiety and depression in migraine patients and to assess the relation of headacherelated disaEility with depression and anxiety. Background: Anxiety and depression are more prevalent among patients with headache than normal population. M,DAS is valid and reliaEle questionnaire for evaluating headache-related disaEility. Hospital Anxiety and Depression Scale (HADS) is a valid and reliaEle scale for screening the psychological disorders. Methods: ,n this cross-sectional study we included migraine patients Eased on ,CHD-2 criteria from four clinics in ,sfahan, ,ran. HADS, M,DAS and a symptom questionnaire were ful¿lled Ey the patients. Level of patients’ disaEility categorized in four grades Eased on M,DAS total scores; grade ,, minimal or infrequent disaEility; grade ,,, mild or infrequent disaEility; grade ,,,, moderate disaEility and grade ,V, severe disaEility. Regards to odd questions summation of HADS scores’ we determined depression score (patients with sores more than  were assumed as depressed) and we calculated anxiety score Ey summing the even questions of HADS scores (patients with sores more than  were assumed as anxious). The student T test was used to compare the mean scores Eetween two groups. ANOVA was used to compare the mean scores Eetween groups. Results: We included 126 migraine patients with mean ((SD) age of 32. (9.9 and 65.1 female gender. Of the participants, 100 (9.) and 56 (.) had anxiety and depression according to the HADS questionnaire respectively. Female patients had signi¿cantly more anxiety than male suEMects (8.8 vs. 63.6, 3=002). But there was no signi¿cant difference Eetween two gender for 3

Headache depression (3=0.559). 3atients with higher M,DAS grade got signi¿cantly higher depression score (3=0.01) Eut there was no such difference for anxiety score Eetween four groups of disaEility (3=0.152). Conclusion: Result of this study showed high prevalence of anxiety (9.) and depression (.) in migraine patients. Also we found a signi¿cant relation Eetween level of disaEility and depression score whereas there is no signi¿cant relation Eetween anxiety and headache-related disaEility.

P65 An Innovative Model Care in a Headache Unit in Colombia: Clinical Results from a Pilot Phase Volcy Gomez, M.; Velez, A.L.; Rangel, N.; Lanau, S.; Montoya, L.; Arango, J.; Martinez, O.D.; Massaro, M.M. HEADACHE UN,T, ,NST,TUTO NEUROLOG,CO DE COLOMB,A, Medellin, ColomEia. Objectives: To evaluate the initial results of a new model of patient care with 3rimary Headaches -3H-at the Neurological ,nstitute of ColomEia Headache Unit, which will make possiEle to increase the amount of attentions and minimize the progression and chroni¿cation risks. Background: 3H are considered a high prevalence disease with high impact on puElic health in ColomEia and in the world. ColomEian Studies from the nineties reported 3H prevalence of 10.6 to 19.9 . Emergence of headache centers has Eeen given as a response to the growing numEer of patients, which suffer chroni¿cation and progression processes, taking into attention the low percentage of clinical regression to episodic pattern (26.1 ) or total clinical remission  10 for every 100 personsyear. Methods: Study of a pilot phase from a three months headache consultation model implementation, carried out Ey neurologist-headache specialist, assisted Ey two general practitioners, nursing staff, functional neurosurgeon, neuropsychologist, psychiatrist, psychologist and pharmaceutical chemist. DescriEes the patient care path and the model strategic components. The analysis compared clinical outcomes and the program impact program in the short term using non-parametric tests. Results: There have Eeen 90 amEulatory attentions and 3 patients in a three months period. The current study presents the results from 86 patients with at least two consultations. The average age was 3 (SD 1.5 ); 82.6  were women. Headache Eegan in average at age 23 (SD 13.), average headache evolution time was 19 years (SD 15.1 ). According to ,HCD-Beta 3, 3H were classi¿ed as Migraine 93 (chronic 91.3), New daily persistent headache 11.6 , tension type headache . , hemicrania continua 2.3 , cranial neuropathy 3.6 . 58.1  had medication overuse headache and 6.5  referred mood changes; 60.5  had cranial allodynia and 22.1  extracranial. 81.  had M,DAS score in the moderately to severely disaEility. The initial therapeutic plan included 9.  pharmacologic management, 23.3  cranial nerve Elocks, 9.3  Eotulinum toxin type A inMetion, 3.2  non-pharmacological management. There was improvement in emergency room visits (5 vs 32  ) and hospitalization (13 vs 1  ). 95 of patients showed adherence to medical recommendations, although 9 reported having any side effects. 20 of patients were not taking medications as ordered; 6 of them related to health insurer authorizations. ,n a short-term follow-up (comparison of measured >,[email protected] Easeline vs.follow-up) showed ,ncreased headache free hoursday (0 > [email protected] vs1 > [email protected], p-value 0.001 ), headache-free daysweek (0 > [email protected] vs 3 > [email protected], p-value  0.0001 ); allodynia reduction ( > [email protected] vs 6 > [email protected], p-value 0.0 ). DisaEility scores improvement, H,T-6 (6 > 59-[email protected] vs60 > [email protected], p-value  0.0001 ) and M,DAS (59 > 19-1[email protected] vs 16 > [email protected], p-value  0.0001 ).

P64 Integration of Primary and Subspecialty Academic Headache Care 3ippitt, K.; Baggaley, S.; Brennan, K.C.; Copsey, C.; Digre, K. University of Utah, Salt Lake City, UT, USA. Objectives: ,mprove access, diagnosis, and treatment of headache in a resource-challenged health care system. Background: Chronic headache is a puElic health proElem. New solutions are needed to provide care to the millions who need it. University of Utah is a UCNS academic certi¿ed headache center serving a  state catchment area (average referrals of 00month) with 1.5 full time equivalent (FTE) headache providers. Ten University community clinics sharing the same EMR contriEute 25 of the headache referrals (~100 referrals month), providing an opportunity to test new approaches. Methods: We have emEedded referral queue within shared EMR that has diagnostic and decision support integrated into referral pathway. A primary care provider in headache clinic at 0.1 FTE sees headache referrals from primary care and works with specialists to design treatment strategy. ,RB was approved for continuous data gathering and quality improvement. Results: -provider who comes from the ³culture´ of the referring pool will Eetter understand needs, serve as more effective amEassador Eetween primary and suEspecialty care -leveraging resources of primary care system will allow system-wide changes – e.g. patient and provider education on migraine diagnosis, discouragement of opiate use, etc. -integration of primary care approaches to suEspecialty care, and vice versa, will generate unforeseen ideas, ef¿ciencies, solutions -integration of primary and suEspecialty teams anticipates the reality of accountaEle care – care delivery as well as revenue models Conclusion: ,f successful our model is scalaEle, allowing the dissemination of suEspecialty headache care to the entire delivery system.



June 2014 Conclusion: This pilot phase demonstrate the impact of the model care focused on patients with 3H throughout an interdisciplinary intervention, which in the medium term, will translate into greater ef¿ciency (optimisation in resources), effectiveness (improvement of clinical outcomes and quality of life for the patient and his family) and therefore, reduction of the overall care costs.

P67 Treatment of Chronic Migraine Using OnabotulinumtoxinA May be Less Effective in Pediatric Patients with History of Depression or Anxiety O’Brien, H.; KaEEouche, M.; Kacperski, J.; Hershey, A.D.; Horn, 3.; Vaughan, 3.; Slater, S.; Wood, B. CCHMC, Cincinnati, OH, USA.

P66 Migraines, PFO’s, and Scuba Diving: Do the Same Rules Apply? Ali, A.; Rothner, A. Cleveland Clinic, Cleveland, OH, USA.

Objectives: To determine whether treatment of chronic migraine with onaEotulinumtoxinA is more effective in patients with depression or anxiety compared to patients without a mood diagnosis. Background: Studies have shown that patients using Eotulinum toxin to treat glaEellar frown lines may have a positive impact on maMor depressive symptoms (Wollmer et al, 2012, Finzi & Rosenthal, 2013). 3atients receiving onaEotulinumtoxinA for chronic migraine have shown improvement in disaEility scores which translates to improvement in functioning and less psychological stress (Aurora et al, 2010, KaEEouche, 2012). This underlying mechanism is unclear Eut one Eelief is that facial expression may regulate mood and Ey inhiEiting muscles of facial expression that involve frown lines, resulting in positive effects on mood. Depression and anxiety are common among migraineurs and medications are often used to treat Eoth pain and mood conditions. OnaEotulinumtoxinA is a non-oral medication indicated for chronic migraine treatment in adults. There are limited studies puElished that addresses this population’s response to such treatment. Methods: Retrospective data on children ) 18 years referred with chronic migraine who failed at least 2 conventional oral treatments and received treatment with onaEotulinumtoxinA was reviewed. Standardized forms and semi-structured interview were used to collect information on headache characteristics including headache frequency, disaEility score and previous diagnosis of depression at initial and follow-up visits. Results: A total of  patients were analyzed. The average time frame Eetween initial and return treatment with onaEotulinumtoxinA was 100 days. The prevalence of depression was 3. There was no signi¿cant difference in change in headache days Eetween depressed and nondepressed patients. On average, the depressed patients reported a decrease in headache frequency of 3.8 days. Those without depression showed an improvement of 1. days (p = 0.). There was no difference in disaEility scores Eetween these two groups (p = 0.1). The prevalence of anxiety among those receiving onaEotulinumtoxinA was 26. These patients reported an improvement of headache days compared to those without anxiety, Eut this was not signi¿cantly different, 0.9 days and 5.1 days, respectively (p = 0.25). There was no difference in disaEility scores (0.39). Conclusion: There was no difference in outcomes Eetween patients with depression or anxiety compared to those without when treated with onaEotulinumtoxinA for chronic migraine within the ¿rst 3 months. Further studies are needed to determine whether patients with an underlying mood diagnosis treated with onaEotulinumtoxinA have similar Eene¿t as those without depression or anxiety.

Objectives: To report a pediatric patient who developed migraine with aura after scuEa diving and to discuss the signi¿cance of patent foramen ovale (3FO) in this patient population. Background: While neurologic complications of decompression sickness have Eeen oEserved and investigated for over half of a century, little is known aEout the risk of diving in patients that suffer from MWA. Additionally, studies have shown an increased prevalence of 3FO in patients with MWA. ,s there a greater risk in divers that suffer from MWA that also have a 3FO" Methods: We report the case of a pediatric patient with a history of migraine without aura who develops symptoms of migraine with aura after a scuEa diving lesson. Results: A 12 year old female with a history of migraine without aura was taking scuEa diving lessons. After 20 minutes at 15 feet depth, she ascended at normal velocity. After clearing the surface, she developed a headache which progressively worsened as she developed tunneled vision and disorientation. She then experienced right hand clumsiness, and written responses on an in-class assignment suggested impaired dexterity. She went home, took Naproxen, and went to sleep, and awoke 3 hours later with a residual headache. After 12 hours, her symptoms resolved. Work-up as outpatient revealed a 3FO on echocardiogram. Conclusion: Despite the increased prevalence of 3FO in patients with MWA, routine closure is presently not recommended. ,t is unclear, however, if this applies to the scuEa diving population, as it is the recommendation of some experts that MWA is a relative contraindication to scuEa diving. Recent evidence suggests consideration for 3FO closure in divers with neurologic complications of decompression sickness, and many Eelieve there is a link Eetween MWA and decompression sickness. Additionally, as in the aEove case, in scuEa divers with a pre-existing history of migraine without aura, one must Ee cautious aEout the development of a new MWA during and following ascension. Symptoms such as confusion and visual loss may Ee mistaken for decompression sickness when indeed it is a new form of migraine for the patient.

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Headache P68 Co-Morbid Mood Disorders Identi¿ed in Adolescent and Young Adult Patients Presenting to a Headache Specialty Clinic O’Brien, H.; Vaughan, 3.; KaEEouche, M.; Kacperski, J.; Hershey, A.D.; Slater, S. CCHMC, Cincinnati, OH, USA.

Nonetheless, recognition of these patient characteristics should prompt further investigation and early treatment of headaches and co-morEid mood symptoms as warranted. P69 New Investigator and Trainee Telementoring Seminars in Headache Medicine: A Novel Model for Mentorship Monteith, T.1; Minen, M.T.; Joshi, S.3; Seng, E.2 1 Neurology, University of Miami School of Medicine, Miami, FL, USA; 2Neurology, Yeshiva University, Bronx, NY, USA; 3Headache, New England Regional Headache, Worcester, MA, USA; Neurology, Brigham and Women’s Faulkner Hospital, Graham Headache Center, Boston, MA, USA.

Objectives: To determine the prevalence of co-morEid mood disorders in adolescents and young adults with intractaEle headache presenting to an outpatient clinic for specialty headache treatment. Background: The prevalence of migraine increases as an individual develops from childhood into adolescence. Young adults represent an underserved population whose needs are unique and challenging for providers in solely a pediatric or adult setting. An adolescent and young adult clinic was developed to meet the unique needs of this group while they transition to adulthood. Co-morEid conditions, such as anxiety and depression, are often associated with intractaEle headache. Reports of anxiety and depression in adolescents are lower than what has Eeen reported in adults. ,dentifying the prevalence of co-morEid mood disorders in the young adult population may help explain the difference in mood co-morEidities Eetween pediatric and adult headache patients and inform treatment options for this understudied developmental group. Methods: A retrospective review was performed on 353 patients (ages 15-26) presenting to a headache specialty clinic. Each patient received a multidisciplinary evaluation utilizing a semi-structured interview process, a comprehensive neurological and headache examination, and treatment plan for a headache disorder, Ey a team comprised of a Eoard certi¿ed Neurologist and Headache Medicine specialist, pain psychologist, nurse practitioner and registered nurse. Standardized questionnaires were completed Ey each patient providing information aEout the headache and health history, as well as information pertinent to con¿rm headache diagnosis Eased on the ,nternational Criteria for Headache Disorders 3rd edition. Results: The female to male ratio was 31, 88 were Caucasian and  were African American. The mean age on evaluation was 16.9 ( 2.5 years old. The maMority of patients met criteria for migraine without aura (96). Episodic migraine (15 headache daysmonth) occurred in 31.2 of the patients evaluated. Chronic Migraine (>15 headachesmonth) was seen in 68 of the patients treated. At initial visit, a co-morEid diagnosis of depression was already estaElished in 18 of patients while 1 carried a diagnosis of anxiety. Self-reports of sleep dif¿culty (), feelings of worrying (), feeling anxious (29), feeling depressed (26) and having low self-esteem (19) were noted. Conclusion: Mood disorders and symptoms are common in adolescents and young adults with intractaEle headaches. The maMority of this patient population is likely to present with chronic headaches that are primarily migraine without aura. Co-morEid mood disorders are diagnosed in only 16 of patients, Eut symptoms are present in nearly 12 of patients. These symptoms may Ee the result of the current state of their headaches, especially when chronic.

Objectives: To report the ¿ndings of the mentoring needs assessment and descriEe the 1-year American Headache Society’s (AHS) New ,nvestigator and Trainee telementoring seminar experience. Background: Career development depends on the estaElishment of mentorship relationships. Novel models of mentorship are necessary to provide a high quality curriculum to improve professional development in headache medicine. Methods: A pilot survey was sent to a suEset of the AHS memEership (New ,nvestigator and Trainee section memEers, program directors, fellowship directors and trainees). 3articipants (n=1) responded from 15 different institutions. The response rate was 1. Results were taEulated descriptively. Results: The maMority of respondents had a mentor (N=1, 82) and were satis¿ed or very satis¿ed with their mentorship experience (N=15, 88). Research interests were clinical only (N=1, 82), comEined Easictranslational and clinical interests (N=9, 53), and translational interests only (N=2, 1). The maMority of respondents said that they would participate (N=11, 65) or would proEaEly participate (N=5, 29). Respondents were most interested in mentorship on early career development, developing a research proMect and the puElication process. The optimal frequency for the phone seminars was Eetween 2-3 months. Over a one year period, seminars were held for one hour, approximately every 3 months; participation ranged Eetween 10-20 callers. Conclusion: Novel approaches for mentoring are desired in headache medicine. Telementoring seminars appear to Ee a feasiEle approach for standardized mentoring in early headache medicine careers. Future research can examine the effectiveness of this novel form of mentoring as well as other novel mentoring techniques.

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June 2014 P70 Combined Concordant Peripheral Neurostimulation for Chronic/Refractory Migraine Headaches: A Retrospective Analysis of 188 Consecutive Patients Reed, K.2; Conidi, F.1; Will, K.2; Bulger, R.2; Datta, S.2 1 Florida Center for Headache & Sports Neurology_ x000D_, 3ort Saint Lucie, FL, USA; 2Reed Migraine, Dallas, TX, USA.

Conclusion: 3eripheral neurostimulation provides effective therapy for some patients with intractaEle chronic migraine headaches. The degree of responsiveness reported here was markedly improved over that reported Ey most studies evaluating ONS alone, including the large multicenter (Medtronic, St. Jude) study groups2. The data strongly supports the clinical approach of seeking concordant stimulation (most commonly comEined SONSONS) to ONS alone when evaluating these patients for 3NS therapy.

Objectives: To demonstrate that peripheral neurostimulation is an effective treament for Chronic Refractory Migraine Background: ,n 1999 we introduced occipital nerve stimulation (ONS) as a novel treatment for occipital neuralgia1. Others extended the methodology to migraine headaches with the results suggesting a lower response rate than that for occipital head pain2. Hypothesizing that the addition of supraorEital stimulation (SONS) may improve the results for chronic migraine, we developed the associated procedure and in 2010 reported positive results in a series of  patients treated Ey comEined ONSON stim.3 To date we have implanted comEined systems in over 00 patients suffering from chronic migraine. Here we report the results of a retrospective analysis of 188 consecutive patients from ¿ve implanting specialists across three different centers. Methods: Between May 1, 2009 and May 15, 2012 our group implanted peripheral neurostimulation systems in 188 patients. The numEer and location of the leads were determined Ey the anatomic location of the perceived pain, thereEy seeking a concordant paresthesia (paresthesia covers area of perceived pain) e.g. comEined occipital and supraorEital leads for pain perceived over the distriEutions of the occipital and supraorEital nerves. Following a review of the medical record, each patient received a survey request. ,ncluded were scores for the Migraine DisaEility Assessment (M,DAS) and a set of clinical parameters, including headache frequency and severity, medication usage, overall patient satisfaction, and patient preference for either the comEined or single modality therapy (ONSONS vs. ONS). Results: 93 of patients required at least SON and ON leads, with 5 ONS only, and 2 frontal only. Other implanted regions included temple & parietal (15 pts), infraorEital (6), mandiEular (2), vertex (), and cervical (). 85 of patients had  leads implanted; 6 ; and 9 >  (range 5-8). 163 patients (129 F; 3 M) responded to the survey. 2 were adolescents, ages 1 to 19. All suffered from chronic migraine that had failed to respond to conservative management. The average time since permanent implant was 1 mo. 85 of patients reported over 50 improvement in HA frequency (HA daysmo) andor severity (VAS 0-10). The average HA daysmo decreased Ey 3 (2 to ), and the average severity of the headaches, when they occurred, improved Ey 59 (9 to ). 50 saw virtually complete resolution of headaches (0-1mo). 1 of patients decreased medication usage Ey > 50, and 38 were aEle to completely discontinue all routine headache medications. The M,DAS score improved Ey 6 (avg 208 -> 50). 8 felt the treatment to have Eeen successful, and 93 would recommend it to others.

P71 Therapeutic Effectiveness of Sphenopalatine Ganglion (SPG) Stimulation in Cluster Headache after an ATI Neurostimulator Revision Procedure Caparso, A.6; Rostgaard, J.2; Hillerup, S.2; Assaf, A.; 3uche, M.5; Müller, O.3; Jürgens, T.; Jensen, R.1 1 Danish Headache Center, Glostrup Hospital, University of Copenhagen, Copenhagen, Denmark; 2Department of Dental, Oral and Maxillofacial Surgery, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; 3 Department of Neurosurgery, University Hospital Essen, Essen, Germany; Department of Oral and Maxillofacial Surgery, University Medical Center HamEurg-Eppendorf, HamEurg, Germany; 5University of Valencia, Valencia, Spain; 6Research and Development, Autonomic Technologies, Redwood City, CA, USA; Department of Systems Neuroscience, University Medical Center HamEurg-Eppendorf, HamEurg, Germany. Objectives: The AT, Neurostimulator, powered using a handheld remote controller, is designed to electrically stimulate the S3G as a treatment for cluster headache attacks. S3G stimulation has Eeen shown to provide acute headache pain relief and oEserved to reduce the frequency of cluster headaches. This analysis aims to characterize the occurrence, purposes and effectiveness of AT, Neurostimulator revision procedures. Methods: All patients were implanted with a miniaturized neurostimulator, called the AT, Neurostimulator, using a minimally invasive trans-oral technique. The AT, Neurostimulator is designed to Ee implanted in the mid face, with the integrated lead and electrodes extending into the pterygopalatine fossa (33F). The AT, Neurostimulator is also designed to Ee safely and easily explanted. During the initial experience with this new implant procedure, a minority of patients required a suEsequent procedure to reposition the stimulating electrodes within the 33F in order to provide adequate S3G stimulation. ,n each of these patients, the original position of the stimulating electrodes within the 33F was characterized, the revision procedure was planned and executed and the therapeutic effectiveness after revision was evaluated. Effectiveness was de¿ned as achieving effective therapy (pain relief from moderate or greater pain or pain freedom from mild pain) in *50 of all acute cluster attacks stimulated or a *50 reduction in cluster attack frequency compared to Easeline. Results: Ninety-two (92) cluster headache patients have Eeen implanted with the AT, Neurostimulator at the time of this analysis; 11 of the 92 (12) patients required a revision procedure. Average time from the original implant 

Headache to the revision procedure was 2 days (range 1 – 966 days). The original lead placement was characterized as Eeing superior and lateral in  patients (6), inferior in 1 patient (9) within the 33F or placed within the maxillary sinus in 3 patients (2). Revision procedures resulted in improved lead placement in 9 patients (82) and therapeutic effectiveness was achieved in 8 patients (3). The effectiveness achieved in patients undergoing a revision procedure is slightly improved over the response rate from the initial 3athway CH-1 study and 3athway CH-1 LTFU study at 18 months post implant, in which 68 and 6 of patients achieve effective therapy, respectively. Conclusion: The early experience with the AT, Neurostimulator implant procedure required a minority of patients to have revision procedures in order to achieve adequate lead placement. Revision procedures are associated with resulting therapeutic effectiveness for cluster headache patients.

experience episodic migraine and exacerEations of leftsided hemicrania continua. 3atient 2 is a 9-year-old Caucasian female with a history of RS hemicrania continua, EM without aura and hypothyroidism. ,n 2011 she underwent right sided occipital and supraorEital stimulator placement and reported complete headache relief immediately after the procedure. Fourteen months after the procedure, she developed an identical new daily and continuous leftsided indomethacin-responsive headache associated with superimposed exacerEations of more severe pain and ipsilateral autonomic features starting at the site where the supraorEital stimulator ended. Currently she continues to experience episodic migraine and exacerEations of leftsided hemicrania continua. Conclusion: Although prior studies have suggested that placement of occipital nerve stimulation in patients with hemicrania continua can Ee an effective treatment for patients with intoleraEility or contraindications to indomethacin, our two patients’ experience suggest that additional placement of supraorEital nerve leads can cause migration of the patient’s hemicrania continua to the opposite side. While causality cannot Ee determined in this oEservational study, these ¿ndings suggest a pattern of outcomes. Future work to determine a mechanism would Ee helpful in understanding the underlying pathophysiology. To the Eest of our knowledge, these are the ¿rst case reports demonstrating this phenomenon.

P72 Contralateral Pain Migration after Placement of Supraorbital and Occipital Nerve Stimulators in Two Patients with Hemicrania Continua: A Surprising Clinical Development Kuruvilla, D.E.; Buse, D.C.; GrosEerg, B. Neurology, The AlEert Einstein College of Medicine and the Monte¿ore headache center, Bronx, NY, USA. Objectives: To descriEe two cases of headache pain reduction followed Ey contralateral pain migration after placement of unilateral supraorEital and occipital nerve stimulators for hemicrania continua. Background: Hemicrania continua is characterized Ey a continuous strictly unilateral headache associated with superimposed exacerEations of more severe pain and ipsilateral cranial autonomic features. ,t responds aEsolutely to therapeutic doses of indomethacin. Though the vast maMority of patients have side-locked pain, rare cases of hemicrania continua alternating sides have Eeen reported. ,n patients where indomethacin is contraindicated or poorly tolerated, occipital nerve stimulation has Eeen shown to Ee an effective treatment. Methods: We treated two patients at a tertiary headache center with chronic (duration > 2 years) right sided (RS) hemicrania continua. Both patients responded to indomethacin Eut could not tolerate treatment due to gastrointestinal (G,) distress. These patients were referred to a neurosurgeon for right occipital and supraorEital stimulator placement. Consent to puElish data was oEtained from patients. Results: 3atient 1 is a 51-year-old Caucasian female with a history of RS hemicrania continua, episodic migraine (EM) without aura, anxiety, oEsessive compulsive disorder, depression, and Crohn’s Disease. ,n 2011, she underwent right-sided occipital and supraorEital stimulator placement and reported 0 headache relief immediately after the procedure. Six months after placement, she developed an identical new daily and continuous leftsided indomethacin-responsive headache associated with superimposed exacerEations of more severe pain and ipsilateral autonomic features. Currently she continues to

P73 Resolution of Status Migrainosis by Sphenopalatine Ganglia Blockade via Intranasal Catheter in a Pregnant Patient Cooper, W. Neurology and Anesthesiology, University of Michigan, Ann ArEor, M,, USA. Objectives: To report a novel approach to treatment of status migrainosis in pregnancy. Background: The sphenopalatine ganglion (S3G) is a key structure to facial pain and migraine. ,t is located in the pterygopalatine fossa lateral to the sphenopalatine foramen. The S3G includes pathways of the cranial autonomics that when activated result in increased cereEral EloodÀow. The S3G has trigeminal nerve inputs from the maxillary Eranch Must distal to the middle meningeal nerve which contriEutes to the nociception of the periorEital dura and middle cranial fossa. The use of S3G Elockade with local anesthestic has Eeen reported to Ee effective in several types of headache, including migraine, cluster headache, and various trigeminal autonomic cephalgias. S3G Elockade Ey infrazygomatic long needle approach may Ee challenging due to patient discomfort, need for Àouroscopy, and limited medial spread of anesthestic. ,ntranasal approach with rigid applicator (4-tip) may Ee challenging due to anatomical constraints of the nasal passages and limited delivery of the anesthestic to the intended target. A ÀexiEle intranasal articulating catheter may Ee used to deploy liquid anesthetic to the sphenopalatine foramen which aEsorEs through the mucous memErane to achieve S3G Elockade. 8

June 2014 Treatment options are limited in pregnant patients due to concerns for fetal health. Lidocaine is classi¿ed Ey the FDA as 3regnancy Category B. Methods: Chart review and Case Report Results: A 32 yo pregnant woman with a longstanding history of episodic migraine without aura and generalized anxiety disorder presented with 10 days of severe headache descriEed as throEEing and with associated photophoEia, phonophoEia and nausea ful¿lling the ,CHD 3rd ed. Eeta criteria for status migrainosus. She was 11 weeks pregnant without complications. She descriEed her headache as similar to previous migraine attacks, and refractory to acute therapy. Her neurological examination was normal including normal fundoscopy. ,maging was deferred. The patient was then placed in supine with her head extended. The right nostril was atomized with one half cc of 2 lidocaine without epinephrine. An intranasal articulating catheter was inserted in the right nostril Must past the middle turEinate with the tip extended to target the sphenopalatine foramen. Approximately 1.5cc of 2 lidocaine was deployed towards the sphenopalatine foramen, and the catheter was removed. The procedure was repeated on the left side. She experienced tearing ipsilaterally within seconds of each procedure with suEMective warming of the cheeks. She remained in supine position for 10 minutes. At 10 minutes she noted a reduction of pain from 810 to 310. At 2 hours she noted her pain at 110 with complete resolution of photophoEia, phonophoEia, and nausea. At 2 hours she was headache free. She remained headache free for  weeks, followed Ey a return of episodic migraine. Conclusion: Sphenopalatine ganglia Elockade with local anesthetic via intranasal catheter resulted in effective treatment of status migrainosis in a pregnant patient within 2 hours. The procedure was well tolerated, and utilized only medications classi¿ed as category B Ey the FDA. The patient remained headache free for  weeks.

(E) 3atients who suffer from staEEing pain as a chief complaint (c) Without other organic causes. Results: These patients consisted of 18 females and 132 males aged 12 to 86 years (mean age = 51.5 1.08). The pain was more frequently localized extratrigeminal area (1.8), less frequently in the trigeminal area (3.2), or Eoth (2). Regarding other headache history, 32. suffered from other types of headache (migraine 9.1, tension type headache 23.9). NoEody had the associated autonomic features. ,n most patients (2.8), the paroxysms lasted only 1-2s. The maximal frequency of attacks during one day was variaEle, ranging from several tens to hundreds. StaEEing headache was lasted from 1 to 3 days (mean 9( days, median  days). Conclusion: These results show that the clinical features of 3SH are somewhat different from previous studies. 3SH is more commonly occurred in patients with tension type headache than migraine and attack frequency is generally high, with more than several tens per day. P75 No Laughing Matter: A Case of Gelastic Migraine Mathew, 3.G.1; RoEertson, C.E.2 1 Harvard Medical School, Brigham & Women’s Hospital, Department of Neurology, John R. Graham Headache Center, Boston, MA, USA; 2Department of Neurology, Mayo Clinic, Rochester, MN, USA. Objectives: To demonstrate a case of migraine with aura, which involves a gelastic prodromeaura. Background: Gelastic epilepsy is a disorder that involves ictal laughter as a primary manifestation. Gelastic epilepsy can Ee further categorized Ey the presence or aEsence of mirth. Mirth refers to the pleasant or euphoric sensation that can Ee associated with pathologic laughter. This seizure type has a strong association with hypothalamic hamartomas, Eut cortical foci have Eeen noted. Based on EEG recording and electrocortical stimulation, it is suspected that the mesiallateral aspects of the superior frontal gyrus, the cingulate gyrus, and the orEitofrontal gyrus play a role in the semiology of gelastic seizures. Surgical excision has Eeen an effective treatment for gelastic epilepsy. The uncontrollaEle laughter that is seen in gelastic epilepsy has not Eeen reported with any migrainous aura or prodrome to the Eest of our knowledge in the literature. Methods: A 3 year old woman presented with headaches that Eegan around the age of 1. The headaches are hemicranial, start in the Eack of the head, and the pain remains ipsilateral during individual attacks with a right side predominance. The headache pain quality is pressurelike with superimposed throEEing with an average intensity of 610. The headaches involve nausea, photophoEia, phonophoEia, and osmophoEia. She denies any autonomic features. She has approximately 6 headaches per month with a duration of  hours to 2 days. When questioned aEout aura, she notes that in the early phase of the headache, she has episodes of word ¿nding dif¿culties that can last a half hour. She clari¿es that she is unaEle to retrieve simple words. Her aphasia terminates Eefore the headache Eegins to reach maximum intensity.

P74 Clinical Characteristics of Primary Stabbing Headache Kim, B.1; Kim, J.2 1 EulMi Hospital, Seoul, RepuElic of Korea; 2Neurology, Hanyang University, Seoul, RepuElic of Korea. Objectives: To clarify clinical characteristics of primary staEEing headache Background: 3rimary staEEing headache (3SH) is characterized Ey transient, ultrashort staEs of pain on head. The ,nternational classi¿cation of Headache disorder 3rd edition (,CHD-3) emphasize that 3SH is more commonly occurred in patients with migraine and attack frequency is generally low, with one or a few per day. However 3SH seems to occur more frequently in patients with TTH and staEs usually occur more than dozens of times per day and repetitively over days. Methods: To de¿ne clinical features of 3rimary staEEing headache more clearly, we investigated patients presented with staEEing headache. 316 patients suffering from staEEing headache were examined in our headache clinics. ,nclusion criteria were (a) Recurrent staEEing head pain occurring spontaneously as a single staE or series of staE. 9

Headache The patient also descriEes an uncontrollaEle urge to laugh that precedes some of her migraines. Conversely, all laughter episodes have Eeen followed Ey a migraine headache. The laughter starts out as a giggle, and Eecomes true laughter typically lasting 5-10 minutes. During these episodes she is not thinking of anything funny, and was not in an entertaining situation. She denies any visual, sensory, or motor aura. She denies any loss of consciousness, convulsive activity, urinary incontinence, or tongue Eiting. Results: She had an EEG, and there was no evidence of epileptiform activity. MR, of the Erain was an unremarkaEle study. She started a titration of verapmail, and a dose of 80mg twice a day provided a reduction of 1-2 headache days per month. Conclusion: The patient’s headaches meet criteria for episodic migraine with aura. Her episodes of uncontrollaEle laughter without mirth that occur exclusively Eefore a headache are likely a migrainous phenomenon. ,t is unclear whether this laughter is a form of aura or a prodrome. To the Eest our knowledge, this is the ¿rst reported case of gelastic migraine. ,n addition to demonstrating this potential migraine suE-type, this case also demonstrates that despite the American Academy of Neurology and the American Headache Society’s evidence-Eased guideline U rating (agent has evidence that is conÀicting or inadequate to support or refute its use) of verapamil, it is a preventative medication that has demonstrated some ef¿cacy in clinical practice.

Eased on a self-administered questionnaire. Those who eventually underwent surgery were re-questioned at the time of follow-up. Exclusion criteria included only patient non acceptance. Because the purpose of the study was to characterize the headache pattern at or close to presentation for management of the pituitary lesion, no assumptions were made as to the types of headache that would Ee encountered. The questionnaire thus included a wide array of questions of interest to Eoth the surgical staff involved and to the headache neurologist. No known validated questionnaires exist for studying this population. Results: 133 suEMects completed the survey. Of these, 8 (3) suEMects reported regularly occurring or recurrent headache at the time of evaluation. Compared to those suEMects without headache at presentation, the group with headache showed an almost 21 female predominance (5 vs. 6), a younger age (.5 vs. 55.9 yrs.), and a higher proportion of suEMects with a prior headache diagnosis ( vs 10). Of those with a prior headache diagnosis 33 had carried the diagnosis over 10 years. 56 however reported having a headache diagnosis for less than 5 years prior to presentation (20  less than one year). Headache location, frequency, severity and pain quality were assessed along with associated and triggering features. 1.9 of suEMects reported headache localized to the anterior half of the head, a ¿nding noted in prior studies. Details of headache managment are discussed. Medication overuse was not assessed. Conclusion: The patient presenting with headache and suspected pituitary pathology is more likely to Ee female, younger (mid 0s) and have a prior headache diagnosis. Headache was triggered Ey moving or Eending and noise. Associated features most often reported included photophonophoEia, nausea, dizziness and Elurred vision. As with prior studies, the headache is more often localized to the anterior half of the head. As seen in studies of all intracanial tumors, headache in pituitary tumor may often resemEle the patient’s primary headache pattern. 3ossiEle modi¿cations to the ,CHD classi¿cation of pituitary headache are discussed.

P76 The Characterization of Headache Associated with the Presentation of Pituitary Lesions: A Case Series and Review of the Literature Rizzoli, 3.2; ,uliano, S.1; WeizenEaum, E.2; Laws, E.R.1 1 Neurosurgery, Brigham & Women’s Hospital, Boston, MA, USA; 2Neurology, Brigham and Women’s Faulkner Hospital, Boston, MA, USA. Objectives: Characterize headache in suEMects at the time of presentation for management of a suspected pituitary lesion. Assess the response of headache in those undergoing surgical management of the pituitary lesion Assess the validity of current ,CHD criteria for pituitary headache Background: Half of patients with any intracranial neoplasm will present with headache. With pituitary tumor, headache is even more frequent, estimated at 3-0 . The headache is incompletely characterized and current ,CHD criteria seem of limited discriminatory value. The role for surgery in the management of headache is unclear. The purpose of this study was to further de¿ne the presenting headache characteristics in these suEMects and assess whether these features could Ee helpful in diagnosis and management. Methods: We collected data from consecutive patients referred, over a 6 month period, to a multidisciplinary 3ituitaryNeuroendocrine Clinic. Criteria for clinic referral included the suspicion, Eased on signs, symptoms and, in some, imaging, that the patient had a pituitary disorder, most commonly a pituitary tumor. Headache was characterized

P77 Comorbidities and Predictive Factors in NDPH Hindiyeh, N.; Boykoff, N.; Barad, M.; Barch, C.; Cowan, R.; Aurora, S. Stanford University, Stanford, CA, USA. Objectives: As a rare clinical primary headache disorder of unclear etiology, New Daily 3ersistent Headache (ND3H) remains dif¿cult to treat with a guarded prognosis. De¿ned Ey the most recent ,CHD ,,,-Eeta criteria as a persistent headache, daily from its onset, two suEforms have Eeen descriEed; one that is self-limiting, and another, refractory, resisting aggressive treatment regimens. No signi¿cantly effective treatment has Eeen reported to date for ND3H and thus we analyzed patients for possiEle predictive responses. Methods: A search of Stanford’s electronic medical record for the ,CD9 diagnosis code corresponding to ND3H was performed with date ranges from 2010 -1201. The proMect 50

June 2014 was supported Ey an N,H CTSA award numEer UL1 RR025. Of the 85 patients coded to have ND3H in our electronic dataEase, 36 who met ,CHD ,,,-Eeta diagnostic criteria were included. Results: All of the 36 patients who met diagnostic criteria for ND3H had tried medications for the headache. Fourteen of the 36 (39) reported improvement in headaches after treatment, 2 were signi¿cant. Fifty percent reported improvement after tricyclic antidepressants, most commonly nortriptyline while 21 found topiramate Eene¿cial, 1 improved with either gaEapentin or duloxetine and other Eene¿cial treatments included doxycycline, venlafaxine and onaEotulinumtoxinA each in . Thirteen out of the 1 (93) treatment responders reported an inciting event prior to the headache onset with 61 (3) recalling an infectious process immediately preceding or coinciding with the headache, 3 reported head trauma, 2 reported stressful life events (SLE), 1 reporting a post-surgical headache and 1 post vaccination. ,n contrast, 1522 (68) non-responders reported an inciting event. The maMority, 53, were post-infectious, 0 post-surgical and 1 () had an SLE. ,n terms of comorEidities, 121 (86) treatment responders reported any past medical history (3MH), 25 psychiatric, 33 infectious or autoimmune, 1 with thyroid disease, 1 with a history of prior ND3H and 1 with any prior surgical history. Eighteen of 22 non-responders reported 3MH; with 22 psychiatric, 22 thyroid disease, 11 autoimmune or infectious, 61  with any surgical history, 36 of these having central of peripheral nervous system surgeries. Sixty-two percent of treatment responders and 55 of non-responders reported poor sleep. Conclusion: Ninety-three percent of treatment responders reported an inciting event coinciding with or preceding the onset of headache, 3 infectious, 23 traumatic, and only 8 post-surgical. Whereas of the of 68 of non-responders reporting an inciting event, 53 report infection, and 0 report post-surgical headache and none reporting preceding trauma. The frequency of infection suggests an inÀammatory process underlying ND3H. The difference in response may Ee most related to post-surgical headache as well as history of surgery. Further studies are needed to investigate underlying inÀammatory Eiomarkers in ND3H.

Background: The most commonly prescriEed medications for migraines are analgesics, triptans, and ergotamines. Due to varying molecular structures within drug classes, there is reason to Eelieve that some drugs may Ee less likely than others in their class to elicit MOH. Methods: A comprehensive systematic literature was undertaken to identify studies of varying designs that reported on MOH within the considered treatment classes. Since no causative comparative design studies were identi¿ed, data from prevalence studies and surveys were retrieved. Data from studies and dataEases on medication use were retrieved. For each study, the reported prevalence of medication overuse was adMusted Ey the medication use frequency in the country or region where the study was conducted. SuEsequently, adMusted medication overuse prevalence estimates were pooled in a meta-analysis of proportions, and from the pooled proportions crude relative risk estimates of MOH risk were oEtained Eetween treatment classes, analgesics, triptans, and ergotamines. Results: A total of ¿fty studies informed the relative risk Eetween treatment classes. The relative risk Eetween triptans and analgesics was 0.65, suggesting a 35 smaller risk of MOH with triptans. The relative risk of triptans and ergotamines was 1.00, suggesting no difference in risk of MOH Eetween the two. The relative risk Eetween ergotamines and analgesics was 0.55, suggesting a 5 reduction in risk of MOH with ergotamines versus analgesics. Some heterogeneity was oEserved Eetween study relative risk estimates. Conclusion: Our study suggests that in patients with frequent migraines, analgesics are associated with a higher risk of developing medication overuse headache than Eoth triptans and ergotamines. These ¿ndings provide incentive for Eetter monitoring of use of analgesics for treating migraine episodes. P79 Naproxen Effects on Spontaneous (Non-Evoked) Behavioral Orofacial Pain Responses Valenti, J.2; Akerman, S.1; Romero Reyes, M.2 1 Neurology, UCSF, San Francisco, CA, USA; 2Oral & Maxillofacial 3athology, Radiology & Medicine, NYU College of Dentistry, New York, NY, USA. Objectives: To examine the effects of naproxen, a common non-steroidal anti-inÀammatory used in temporomandiEular disorders (TMD), on spontaneous (non-evoked) nociceptive Eehavioral responses and neuronal activation in an estaElished mouse model of orofacial pain. Background: ,t is known that headache and orofacial pain disorders, such as TMD, are highly prevalent conditions in the general population. TMD involve the masticatory musculature, the temporomandiEular Moint or Eoth. Current Eehavioral models are signi¿cantly limited Ey the fact that they measure responses to evoked sensory modalities, (mechanical or thermal stimuli) and animals have control over the duration of these stimuli. ,n patients, spontaneous (non-evoked) pain responses provide a more accurate representation of the pain experience, yet this Eehavior

P78 Risk of Medication Overuse Headache Across Classes of Treatment for Migraine Thorlund, K.1; Kanters, S.2; Druyts, E.3; Eapen, S.3; EErahim, S.; BhamEri, R.5; Ramos, E.5; Mills, E. 1 Stanford University, Stanford, CA, USA; 2School of 3opulation and 3uElic Health, University of British ColumEia, Vancouver, BC, Canada; 3Faculty of Health Sciences, University of Ottawa, Ottawa, ON, Canada;  Stanford 3revention Research Center, Stanford University, Stanford, CA, USA; 5Targeted GloEal Brands, 3¿zer ,nc, New York, NY, USA. Objectives: The aim of this study was to determine whether certain medications for migraine are more likely to elicit MOH than others. 51

Headache is not Eeing measured routinely in animal models of headache, neuropathic or inÀammatory pain. Methods: C5BL6 mice received either a suEcutaneous inMection of naproxen or vehicle, followed Ey an inMection of complete Freund’s adMuvant (CFA) or 0.9 saline solution in their right masseter muscle. Animals were video recorded for one hour. The duration of different facial nociceptive grooming patterns (including fore-paw ruEEing and lowerlip-skincheek ruEEing) were analyzed. After 2 hrs, mice were euthanized, perfused and the Erainstem was removed. The area of the trigeminal nucleus caudalis (TNC) was tested for Fos expression to verify neuronal activation. Results: Naproxen pre-treated mice receiving CFA masseteric inMection, spent signi¿cantly less time exhiEiting nociceptive Eehaviors compared to those that received vehicle and CFA, and also presented with lower levels of Fos immunoreactivity in the TNC (3  0.05). Conclusion: ,ncorporating models that measure spontaneous pain may provide a signi¿cant translational tool for a Eetter understanding of the pain neuroEiology in the craniofacial region. Naproxen decreased spontaneous Eehaviors and their correlated cellular responses triggered Ey acute masseteric inÀammation in the TNC. Clinical comorEidity Eetween primary headaches and TMD has Eeen estaElished and since Eoth disorders rely on nociceptive inputs in the TNC, an ongoing TMD disorder should Ee addressed to prevent further sensitization. Some of this work has Eeen presented in the ,ADR Session. Seattle, Wash; USA. March 23rd, 2013

Results: Twelve of 20 patients with migraine descriEed allodynia. Our ¿ndings showed Eilateral hyperexcitaEility of cortical and trigeminal structures in the allodynic group compared to the migraineurs without allodynia, which reached statistical signi¿cance on the contralateral side without headache for the ,CF (p=0.002) and on the headache side for Elink reÀex excitaEility at 800ms ,S, (p=0.039). Allodynic patients had also signi¿cantly increased motor cortex excitaEility on the headache side and Eilateral hyperexcitaEility at the Erainstem at different ,S,s, in comparison to healthy suEMects. Conclusion: Our ¿ndings suggested that migraineurs with allodynia had Eilateral hyperexcitaEility at Eoth cortical and trigeminal levels which should Ee taken into account in the management of allodynic patients P81 The Migraine Aura Open Access Database, and Its Applications VanvalkenEurgh, 3. CSULB, Long Beach, CA, USA. Objectives: To ¿ll an unrecognized gap in migraine knowledge. 3recisely where on the cortex do migraines Eegin" The goal was to add to the cursory documentation started Ey others, Eut more precisely, longer, and on one suEMect. Background: ,t would seem impossiEle to identify where migraines Eegin, while there is disagreement as to exactly what they are. However, in many cases, auras (commonly assumed to Ee due to Cortical Spreading Depression, or CSD, which is oEservaEle with fMR,) seem to Ee reliaEle precursors. And yet, fMR, is dif¿cult to coordinate with auras, and it has a resolution of only aEout 5 mm, compared to aEout 0.5 mm visual resolution of CSD on the cortex (0.01 visual degrees at the fovea), which is 10 times more precise. Unfortunately, there has Eeen a lack of supporting real-time aura data from migraineurs, possiEly due to their preoccupation with the impending pain. Methods: All map drawings of auras are oEMective tracings of proven real events taking place in real time on the cortex, not in the suEMective mind, and therefore minimally inÀuenced Ey interpretation or memory. Recording techniques have Eeen consistent throughout, and accurately timed with a stopwatch, noting effects of variaEles such as an NSA,D, stress, meals, weather (Ey date), and aging, Ey aura type, laterality, direction, and duration, as noted in the dataEase columns. Details of recording procedures, including a YoutuEe video, are given. Results: More than 1,00 auras over 19 years are listed on the display Eackground, and are continually updated with almost 15 new episodes every month ² the Eiggest collection of migraine aura data ever recorded. The suEMect and data have already Eeen used in studies at UCLA and Harvard, and to develop a proposed theory, and have led to new aura discoveries, such as de¿nite origin focal clusters, progression paths, and discontinuities, which repeat almost identically, year after year, plus V1-V2 distinction and MR, correlations. One example application previously shown on an ,HS2013 poster will Ee presented. The data can also

P80 Excitability Changes Related to Allodynia at Brainstem and Cortical Levels in Patients with Migraine Ekizoglu, E.; Sozer-Topcular, N.; Baykan, B.; Oge, A. Department of Neurology, ,stanEul University, ,stanEul Faculty of Medicine, ,stanEul, Turkey. Objectives: Allodynia, recognized as a result of central sensitization, is a frequently reported clinical phenomenon in patients experiencing migraine. Transcranial magnetic stimulation and Elink reÀex studies allow analysis of the excitaEility changes in the cortex and trigeminal structures, respectively. Hence these studies could Ee used to evaluate the unknown electrophysiological changes underlying central sensitization. Our aim was to assess the interictal excitaEility of motor cortex and trigeminal structures in migraineurs with allodynia. Methods: Twelve patients with migraine without aura and 8 migraineurs with aura, diagnosed according to the criteria of ,nternational Headache Society (200) and having lateralized headaches, were included in this study after their consent. 12-,tem Allodynia Symptom Checklist was used to detect allodynia. 3aired pulse transcranial magnetic stimulation was delivered Eilaterally on primary motor cortex to assess short intracortical inhiEition and intracortical facilitation (,CF) periods of cortical excitaEility. Moreover, Elink reÀex recovery was studied at 200, 300, 500 and 800ms interstimulus intervals (,S,s) Eilaterally to investigate the excitaEility of trigeminal structures in the patient groups and 16 age and sex matched control suEMects. 52

June 2014 Ee used to match to MR, images, identify corresponding suspicious cortical areas, and con¿rm CSD size constancy. Conclusion: Until now, a scienti¿c investigation into exactly where on the cortex that migraine auras Eegin seems to have Eeen essentially overlooked, making explanations or theories aEout how and why somewhat speculative. Migraine theories that do not explain this real data may Ee descriEing some other form of migraine unrelated to CSD. This set of aura data suggests looking for pinch points in sulci (especially the calcarine) on otherwise ³unremarkaEle´ MR,s. And ¿nally, applications of this powerful tool may also motivate others to record and compare aura data, and look for other causative speci¿cs of cortical anatomy.

images could Ee helpful for the prediction of stoke in the patients with RLS. P83 Repeated Infusion of Prostaglandin E2 on the Dura is Suf¿cient to Induce Chronic Trigeminal Sensitivity via TRPA1 Receptor Oshinsky, M.L.; Fried, N.T.; Cooper, M.E. Neurology, Thomas Jefferson University, 3hildelphia, 3A, USA. Objectives: To investigate the role of each component of the widely used inÀammatory soup in the transition to chronic trigeminal sensitivity. Background: Numerous models of migraine have relied on the infusion of an inÀammatory soup (,S) containing histamine, serotonin, Eradykinin, and prostaglandin E2 at low pH onto the dura of rats in an attempt to mimic the endogenously released inÀammatory mediators and extracellular environment on the dura that occurs during the onset of migraine. A single application of the ,S induces peripheral and central sensitization of the trigeminal system for hours while repeated infusions 3x wk for 10 infusions induces chronic sensitization which outlasts the ¿nal infusion for months. To Eetter understand the contriEution of the individual components of the ,S to the chroni¿cation of trigeminal pain, we tested the aEility of each soup component to cause the transition to chronic trigeminal sensitivity in rats. Methods: ,S or the individual soup components were infused onto the dura of awake rats through a cannula 3xwk for a total of 10 infusions. To assess sensitization Eehaviorally, periorEital nociceptive pressure thresholds were determined Ey applying a range of von Frey mono¿laments to the periorEital region. Rats that had transitioned to chronic periorEital sensitivity had thresholds of )2g, whereas naive rats had a threshold of 8-10g. To assess sensitization neuropharmacologically, microdialysis and H3LC was used to measure release of extracellular glutamate as a marker for pain at the trigeminal nucleus caudalis in response to chemical headache trigger GTN (0.1mgkg, i.p.). 3eriorEital thresholds in sensitized rats were also tested in response GTN. Results: ,nfusion of an ,S with physiological pH (.), not low pH, was suf¿cient to produce chronic trigeminal sensitivity Eehaviorally and neuropharmacologically. ,nfusion of 3GE2 alone produced similar transition to trigeminal hypersensitivity. Both ,S and 3GE2-infused rats showed Eehavioral sensitivity to GTN treatment. ,nfusion of Eradykinin, serotonin, or histamine alone did not produce trigeminal hypersensitivity. Concurrent infusion of 0.05mM HC-030031, a TR3A1 receptor antagonist on to the dura, with 3GE2 prevented Eehavioral sensitization. ,nfusion of 0.1mM 3GA2, another form of prostaglandin that is formed Ey the dehydration of 3GE2 and contains an electrophilic moiety that increases it’s af¿nity for TR3A1 channels, also produced the transition to chronic trigeminal hypersensitivity. Conclusion: Acidic ,S was found not to Ee necessary for the induction of chronic trigeminal sensitivity. The only ,S component that produced trigeminal von Frey and GTN

P82 Current Smoking and Silent Brain Infarct Are Associated with Stroke Occurrence in the Migrainers with Right to Left Shunt 3ark, H.1; Ko, S.2 1 Neurology, ,nha University Hospital, ,ncheon, RepuElic of Korea; 2Seoul National University Hospital, Seoul, RepuElic of Korea. Objectives: sought to determine the prevalence of risk factors in two groups and to ¿nd the radiological predictors for stroke. Background: Right-to-left shunt (RLS) is known to Ee associated with cryptogenic cereEral infarction and migraine. However, it has not Eeen elucidated, which factors affect the stroke occurrence in the patients with RLS. Methods: We performed a retrospective review of the medical records and Erain MR image of patients with RLS, who visited our hospital for treatment of migraine or cryptogenic infarction from January, 2008 to June, 2012. 3atients with potential risk factors for cardioemEolism like aortic atheroma(>mm) and atrial ¿Erillation were excluded. RLS was de¿ned as *11 microemEolic signals(MESs) on the agitated saline test, using Transcranial Doppler sonography. We de¿ned white matter hyperintensities(WMHs), as the Fazekas score*2, and assessed the prevalence of each risk factors and radiological ¿ndings in stroke and migraine group. Results: A total of 89 patients were included in this study(stroke; 55.(11.0, N=25 vs migraine; 56.0(10.5, N=232). On univariate analysis, the patients with stroke had the higher ratio of men, hypertension, diaEetes, dyslipidemia and current smoking than the migrainers. On multivariate Einary regression test, the odds ratio of current smoking was highest(OR=10.08, 95 C,; .38~23.1). The stroke group had the high frequency of silent Erain infarct(28.3 vs 5.2 , 30.01) and WMHs(13.1 vs 6.9), compared to those with migraine. There was no difference in age, intraextracranial stenosis, microemEolic signal numEer or microEleeds Eetween two groups. Conclusion: Some cardiovascular risk factors, especially silent Erain infarct and smoking history were associated with stroke occurrence in the patients with RLS. These results suggest that the evaluation of risk factors and Erain

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Headache sensitivity, was 3GE2, which has Eeen shown to activate TR3A1 channels on peripheral nociceptors. 3GE2’s effect is Elocked with concurrent infusion of a TR3A1 antagonist, suggesting that 3GE2’s action is via TR3A1 channels. 3GA2 is similar in structure to 3GE2, Eut has greater af¿nity for TR3A1 channels, also produced chronic trigeminal sensitivity further suggesting a role of TR3A1 in the induction of chronic trigeminal hypersensitivity.

P85 Psychophysical Relationships Between Pain Intensity and Throbbing Quality in an Experimental Model of Acute Pain Ahn, A.H.1; Holt, J.1; Jordan, M.1; King, C.D.2; Fillingim, R.B.2 1 University of Florida College of Medicine, Gainesville, FL, USA; 2University of Florida College of Dentistry, Gainesville, FL, USA.

P84 Operant Pain-Related Decisions and Disability in a Mouse Model of Migraine-Related Hypersensitivity Ahn, A.H.1; Holt, J.1; Curta, A.1; NeuEert, J.2; Caudle, R.M.2 1 University of Florida College of Medicine, Gainesville, FL, USA; 2University of Florida College of Dentistry, Gainesville, FL, USA.

Objectives: The purpose of this study was to determine the psychophysical relationships Eetween pain intensity and throEEing quality Background: 3atients report that a throEEing quality accompanies their most severe and intense migraine attacks. However, even prospective methods to determine the relationships Eetween migraine pain intensity and throEEing quality are suEMect to selective Eias. Moreover, the neural mechanisms linking migraine to its throEEing qualities remain elusive, though they have the potential to provide critical clues to the pathophysiological mechanisms underlying migraine. Methods: Here we examined the psychophysical relationships Eetween pain intensity and throEEing quality in an experimental model of acute pain. SuEMects previously identi¿ed as experiencing a throEEing quality in the cold pressor pain model returned to the laEoratory to record the timing and intensity of throEEing pain associated with the cold pressor at a range of temperatures, from 2 (room temperature) to  degrees Celsius. The cold pressor stimulus was repeated at a predetermined sequence of -degree intervals. 3ain intensity and pain qualities were recorded Ey their responses to the McGill 3ain 4uestionnaire (SF-M34-2) and the timing and rhythm of throEEing qualities (latency to onset, duration of throEEing, and throEEing rate) were reported Ey the suEMect using a push Eutton digital event recorder. Results: 3ain intensity elicited Ey immersion of the hand in cold water increased Eriskly as a function of decreasing temperature. ,nterestingly, a throEEing quality was detected at even modestly cold temperatures, from 16 degrees, associated with only modest – if any – pain. ,n addition, further decreases in stimulus temperatures were associated with a parallel rise in throEEing intensity, and with modest increases in the duration and throEEing rate, as well as decreasing latencies to the onset of the throEEing quality. Conclusion: Our experimental model of throEEing pain indicates dynamic relationships Eetween pain intensity and all of the measured psychophysical features of the throEEing quality. Further work is required to determine the neural systems engaged Ey peripheral stimuli to produce this perceptual quality, and to determine their relationship to migraine pain.

Objectives: We tested the hypothesis that nitroglycerininduced hypersensitivity could Ee demonstrated in an operant Eehavioral paradigm that models clinically relevant pain-related decisions and disaEility in migraine. Background: Nitroglycerin (NTG) is a medication known to trigger migraine-like attacks, and has proved useful as a model of migraine in humans and experimental animals. We have shown previously - using acute nociceptive Eehaviors - that NTG induces Eoth thermal and mechanical hypersensitivity in mice that is reversiEle with sumatriptan. Here we wanted to extend the NTG model in mice to model the perceptual decisions that are more clinically related to disaEility, such as engaging in work or socially rewarding Eehaviors. Methods: We trained SKH1 hairless immunocompetent mice to press their face against a thermal or mechanical contact stimulus to receive a food reward, while an automated system recorded task-related events. ,n this operant paradigm, freely moving animals voluntarily perform a learned Eehavior for a reward; Ey varying the contact temperature and contact pressure required for the reward, the measured Eehaviors reÀect a choice Eetween performing the learned Eehavior and avoiding a potentially aversive stimulus. On the test day, trained animals received an inMection of NTG or saline and were presented the operant task at one of a range of conditions, and at varied time points after the inMection. Results: We found that NTG suppressed operant Eehaviors in Eoth neutral and noxious thermal and mechanical stimulus conditions, likely reÀecting an overall increased sensitivity. The time course of this suppression, which peaks at 30 minutes and declines to normal Eehavior at 90 minutes following inMection, is overall shorter in duration than we previously reported in a different strain of mouse. The chronic administration of NTG, at a rate of three inMections per week, did not appreciaEly affect operant Eehaviors in this strain of mouse. Conclusion: Our ¿ndings support the conclusion that NTG induces a trigeminal hyperalgesia that affects clinically relevant operant Eehaviors. Future studies are directed toward determining whether this model can Ee exploited as a model of migraine pain predictive of responses to aEortive therapies.

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June 2014 P86 Cardiovascular Parameters in Monkeys Following Administration of LBR-101, a Monoclonal Antibody Against CGRP Walter, S.; Escandon, R.; AliEhoy, A.; Bronson, M.; Bigal, M.E. LaErys Biologics ,nc, Doylestown, 3A, USA.

ECG Findings There were no statistically signi¿cant changes in 4Tc interval or in any other ECG parameter at any time point, relative to vehicle treatment in the single or multiple dose studies. Conclusion: ,nhiEition of CGR3 with very high doses of LBR-101 was associated with no clinically signi¿cant changes in the diastolic Elood pressure and heart rate, nor with any detectaEle changes in systolic Elood pressure or ECG in cynomolgous monkeys.

Objectives: To study the cardiovascular effects of single and multiple administrations of an anti-CGR3 monoclonal antiEody (LBR-101) on hemodynamic and electrocardiographic parameters in cynomolgus monkeys. Background: Most studies on the vascular consequences of inhiEiting CGR3 have Eeen conducted in shortduration exposure paradigms using medications with short half-lives. Since monoclonal antiEodies typically have relatively longer half-lives, it is important to understand and characterize hemodynamic and cardiovascular effects after long-term inhiEition of CGR3. LBR-101 is a mAE directed against CGR3 Eeing developed for the preventive treatment of episodic and chronic migraine. Methods: Two independent studies were conducted. ,n a single-dose study, 8 adult males were surgically telemetered. Vehicle was administered ¿rst and telemetry data were collected from 1 hour pre-dose through 22 hours post-dose. Animals were then dosed with LBR-101 (100 mgkg, ,V), and monitored periodically for two weeks. The multiple-dose safety study included 8 adult, gendermatched naïve animals that received vehicle or LBR-101 once weekly for 1 weeks at doses up to 300 mgkg (1,200 mgkgmonth). As a matter of comparison, the highest dose given to humans in 3hase 2 is approximately 25 mg kgmonth. ECG and Elood pressure measurements were recorded and contrasted. Results: Effects on Blood Pressure and Heart Rate Single dose – Telemetry Study Systolic Elood pressure (SB3) was remarkaEly similar Eefore and after treatment with LBR-101 during the ¿rst day after dosing as well as on suEsequent days. At the time interval of 1- hours post-dosing (LBR-101 Elood concentrations at maximal levels), mean SB3 was 111 mm Hg versus 113 mm Hg following vehicle administration. SB3 data were similar at all other time points. A slight decrease (of approximately 3 mm Hg ) in diastolic Elood pressure (DB3) was oEserved in LBR-101-treated animals versus vehicle (Hours 1-). From Hours 5-22, the group means for the vehicle and LBR-101 groups were similar. The same trend was seen on other days. Similar to DB3, minor decreases in heart rate were detected during the ¿rst assessment (Hours 1-), versus vehicle. Differences were undetectaEle during the intermediate assessments and oEserved again Eetween Hours 18-22 on all days. Multiple Dose Study Blood pressure was recorded prior to the ¿rst dose, after 12 weeks of dosing and approximately 1 week after the end of dosing. No signi¿cant changes were noted in systolic or diastolic Elood pressure in any of the treated groups of animals relative to vehicle-treated animals). Group mean heart rates were consistent across the dose groups and time points measured, with no statistical differences measured.

P87 Does Intravenous Migraine Therapy Bene¿t Children with Post-Traumatic Headaches in the Emergency Department? Chan, S.1; Timm, N.1; Byczkowski, T.1; Kurowski, B.2 1 3ediatric Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA; 2Division of 3hysical Medicine and RehaEilitation, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA. Objectives: To determine if ,V migraine therapy reduces pain scores in children with post-traumatic headache and factors associated with improved response. Background: Over 500,000 children sustain mild traumatic Erain inMuries (mTB,) annually in the U.S. Treatment of headache, the most common symptom of mTB,, in the emergency department (ED) varies from oral analgesics to intravenous (,V) therapy. The Eene¿t of ,V migraine therapy for post-traumatic headaches is unknown. Methods: A retrospective descriptive study of children, 8-21 years of age, presenting to a large urEan pediatric ED for post-traumatic headache from NovemEer 2009 to June 2013. ,nclusion criteria were mTB, (de¿ned Ey diagnosis codes) within 1 days of the ED visit, persistent headache since inMury and administration of one or more ,V medications ketorolac, prochlorperazine, metoclopramide, chlorpromazine, ondansetron. Exclusion criteria were GCS  13, intracranial Eleedskull fractures and signi¿cant neurosurgicalneurologic history. 3rimary outcome was treatment success de¿ned Ey * 50 pain score reduction. Bivariate analysis and logistic regression were used to determine factors associated with treatment success including age, gender, migraineconcussion history, days since inMury, whether head CT was oEtained, pretreatment with oral analgesics. Results: 25 patients met inclusionexclusion criteria and were analyzed. Our primary outcome showed that 86 of patients experienced a greater than 50 reduction from their initial pain scores with 52 experiencing complete resolution of their headache. Study patients were female (51), white (80), mean age 13.8 years, had sportsrelated inMuries (58), had a prior concussion (1) and a history of migraines (21). A head CT was oEtained in 5 of patients, all of which were normal.  of patients were prescriEed ketorolac and 8 received an antiemetic (prochlorperazine, metoclopramide or ondansetron). 58 were prescriEed ketorolac plus an antiemetic. The Eivariate analysis showed that patients who had a head CT were less likely to respond to ,V migraine therapy (66 vs 2,

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Headache p=0.008). Other factors were not signi¿cant. Multivariate analysis showed similar results. Conclusion: ,V migraine therapy reduces pain scores in patients presenting within 1 days with concussion related post-traumatic headaches. Further prospective work is needed to determine potential long-term Eene¿ts.

B33V. A multifactor analysis of variance (ANOVA) to assess the factors inÀuencing the success showed younger patient age (50 years) and etiology of post concussion syndrome as signi¿cant factors with p values of 0.03 and 0.018 respectively. Gender, numEer of Epley’s maneuver, and type of headache did not signi¿cantly affect the success rate for resolution of concurrent headaches in B33V. Conclusion: The effectiveness of Epley’s maneuver in managing post concussion migrainous headaches has not Eeen puElished in the literature to the Eest of our knowledge. ,n the current analysis, more than 50 patients of B33V presented with concurrent complaints of signi¿cant headache. The application of Epley’s maneuver, although initially intended for B33V, was successful in resolving headaches in 86 of patients with the Eest results in those with younger age and 3CS etiology.

P88 Post Concussion Syndrome & BPPV Presenting with Migraine/Headaches in an Urgent Headache Clinic: Analysis of 90 Cases Kumar, S.1; Shah, 3.1; Jawahar, A.1; Kumar, M.2 1 Urgent Headache Clinic, Neurology and Headache Center ,nc., Shreveport, LA, USA; 2Urgent Dental Clinic, Shreveport, LA, USA. Objectives: We present our retrospective analysis of 90 consecutive patients of B33V with concurrent headaches (>50) and the success of Epley’s maneuver in managing the vertigo as well as headaches with signi¿cant success. Background: Epley’s maneuver is an estaElished method in managing Eenign paraoxysmal position vertigo (B33V) with 80 success rate in most puElished studies. However, the association of vertigo as a trigger for disaEling headaches as concurrent associated symptom has not Eeen studied in detail. Methods: 90 consecutive patients diagnosed with B33V were included in this retrospective study. The diagnostic criteria were Eased upon symptoms and positional nystagmus evoked Ey the Dix Hallpike test. There were 8 females and 2 males. The mean age at presentation was  years (range 18-93 years). Etiology was attriEuted to Meniere’s disease in 9 (10) patients, post concussion syndrome (3CS) in 2 (30) patients and cereErovascular event in  patients.  (52) patients had complaint of concurrent disaEling episodic headaches with vertigo. Of the 2 patients with post concussion syndrome, 12 () developed migraine-like headaches after the concussion inMury. Epley’s maneuver was performed in all patients to treat the B33V. The ¿rst maneuver was performed on the day of presentation and suEsequently at 3- weeks interval. 2 patients (80) had a single maneuver while 15 (16.6) had two, 2 (2.22) had three and 1 patient had  maneuvers respectively. The patients were followed up in the clinic and careful record of their vertigo and nystagmus as well as the headache was maintained. Results: B33V The follow-up period ranged from 1 to 38 months with mean follow up of . months. Of the 80 assessaEle patients, 6 (5.5) had complete resolution, 30 (3.5) experienced partial resolution and (5) had no Eene¿t. Thus the success rate for Epley’s maneuver was recorded as 95 in completely or partially resolving vertigo. Headache 3 patients with headache were followed up. 1 patients (39.5) had complete resolution of episodic migraine headache with no further need for medication; 20 (6.5) patients had signi¿cant reduction (>50) in the intensity and frequency of migraine episodes. Thus Epley’s maneuver was successful in 3 (86) patients for the management of disaEling headaches concurrent with

P89 A Case Series: Putting a Stop to Post-Traumatic Headaches with OnabotulinumtoxinA Krel, R.; Mirchandani, D.; WaMnszstaMn, D.; Spinner, D. Neurology, Stony Brook University Hospital, Stony Brook, NY, USA. Objectives: To possiEly provide a novel effective therapy in the management of refractory post-traumatic headaches. Background: Traumatic Erain inMury (TB,) is proElem of epidemic proportion, with an estimated 1. million cases occurring annually. Recent awareness to the consequences of TB, has made it imperative to not only recognize the post-traumatic syndromes, Eut to manage them as well. Headache is one of the most common complaints in TB, patients. 3ost-TB, headache patients are traditionally managed in the same way primary headache syndrome patients are; the headaches are classi¿ed Ey type and treated accordingly. A hurdle arises when those treatment options are refractory. A series of patients in which onaEotulinumtoxinA was used to successfully manage post-traumatic headaches is discussed. Methods: DescriEed are ¿ve patients age 26- who sustained TB, secondary to MVA or Eeing a pedestrian struck, and who have suffered from post-traumatic headaches for years with refractory headaches despite multiple prophylactic therapies. 3atients were transitioned to onaEotulinumtoxinA using the FDA migraine protocol, in addition to following the pain pattern. 3ain was assessed at 6 and 12-week intervals via the M,DAS questionnaire that was administered at every appointment visit. Results: All of the patients showed a greater than 50 improvement on their M,DAS questionnaire. Conclusion: Based on the patients descriEed aEove and one prior case study found on a 3uEMed search, the use of onaEotulinumtoxinA could prove to Ee part of a successful treatment regimen for patients with post-traumatic headaches.

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June 2014 P90 rTMS in Reducing Mild TBI Related Headache- a Pilot Study Leung, A.1; Shukla, S.2; Song, D.D.3; Lin, L.; Tsai, A.M.; 3olston, G.2; Fallah, A.1; Davani, A.1; Lee, R.5 1 Anesthesia 3ain Service, VASDHS, La Jolla, CA, USA; 2 Anesthesiology, UC San Diego, School of Medicine, La Jolla, CA, USA; 3Neurological Science, UC San Diego, La Jolla, CA, USA; RehaEilitation Medicine, VASDHS, La Jolla, CA, USA; 5Radiology, UC San Diego, School of Medicine, La Jolla, CA, USA.

intensity, frequency and duration of headache exacerEation at the current sample size. No treatment related side effect was noted. Conclusion: rTMS can Ee effective in reducing the incidence of constant MBT,-HA and the overall intensity of the headaches. More studies are required to fully validate its routine use in managing patients with MTB,-HA. 1. Khedr EM, KotE H, Kamel NF, Ahmed MA, Sadek R and Rothwell JC. Longlasting antalgic effects of daily sessions of repetitive transcranial magnetic stimulation in central and peripheral neuropathic pain. J Neurol Neurosurg Psychiatry. 2005; 6 833-8.

Objectives: Assess the effect of repetitive transcranial magnetic stimulation (rTMS) in alleviating mild TB, related headache. Background: Concussive or mild Traumatic Brain ,nMury (MTB,) is the most common form of comEat-related inMury in the ,raq and Afghanistan Wars. Along with post traumatic stress disorder (3TSD), cognitive and mood dysfunction, headache (HA) is the most deEilitating clinical symptom in patients with MTB,. Unfortunately, conventional pharmacological treatments for MTB, related headache (MTB,-HA) has not shown to Ee effective and contain many long term untoward psychosomatic and aEusive side effects. Non-invasivenon-pharmacological treatment option for MB,-HA should Ee assessed. Methods: Veteran with chronic headache due to MTB, were enrolled and randomized to receive Erain MR, neuronavigation guided either real(Group T) or sham(Group S) rTMS. Motor threshold(MT) at the left motor cortex was determined per estaElished method1. Real treatment was provided at 80 MT consisted of 2000 pulses given at 10 hz, 100 pulses per train, 20 trains with one-second interval train duration. Sham treatment was provided with the coil turned 180 degree and shielded with a molded cover made of Giron magnetic shielding ¿lm. 3 sessions of treatment were given within one week. Baseline(visit1), post treatment one-week(visit 2) and one-month(visit 3) assessments consisted of rating the intensity of constant(last >8 hours) headache on a 0-10 numerical pain rating scale(N3RS). The intensity(N3RS), frequency(numEer of episodes per day), duration(hours per episode) of headache exacerEation were also assessed in the study. Results: 13 Veteran(all male, average age=3, 6 for Group T and  for Group S) with Easeline constant headache (100 incidence for Eoth groups) intensity(N3RS) greater than 3.0 completed the pilot study. The Eetween-group difference in the incidence of constant headache was insigni¿cant at visit 1 Eut signi¿cantly(30.01) lower for Group T(16.) comparing with Group S(1.) at visit 2, and remained lower for Group T(50.0 vs. 1.) at visit 3. The Eetween-group difference in the average intensity of constant headache((SD) was insigni¿cant at visit 1 Eut was signi¿cantly lower in Group T >0.5((1.2)@ at visit 2 when compared with Group S>.1((2.0)@ and remained lower for Group T at visit 3>2.3((3.1) vs. 3.3((2.3)@. Between-group 2-factor(time x treatment) ANOVA showed a signi¿cant effect Eetween treatment and time for the intensity of constant headache. No signi¿cant Eetween-group difference was found in the average

P91 OnabotulinumtoxinA in the Treatment of New Daily Persistent Headache (NDPH) Vutien, 3.2; ViM, B.1; Tepper, D.1; Horvat, M.1; Tepper, S.J.1 1 Cleveland Clinic, Cleveland, OH, USA; 2Case Western Reserve Medical School, Cleveland, OH, USA. Objectives: This was a retrospective chart review on the potential ef¿cacy of onaEotulinumtoxinA in the treatment of ND3H. Background: There is no known treatment for ND3H. RoEEins et al (2010) found 1 patients remitted while on topiramate; 61 remitted while on nortriptyline. Since onaEot is use for Chronic Migraine, de¿ned in the prescriEing information as headache at least 15 days month at least  hours per day, and since ND3H meets those limited criteria, a review of ef¿cacy in patients who received onaEot for ND3H over 15 months was undertaken. Methods: This was an ,RB approved study. Electronic records were oEtained for the Headache Center from March 2012-June 2013. All patients receiving onaEot in the Headache Center were reviewed; those with ND3H were selected and analyzed. Results: 22 patients with the diagnosis of ND3H received onaEot. 18 received the FDA-approved protocol of *155 units; the others received 100 units. 95. of patients had >1 cycle. .6 had 21-30 headache-free daysmonth. 18.1 had 11-20 headache free daysmonth. 9.1 had 0-10 headache free daysmonth. 68.2 had no decrease in headache days. 13.6 had > 50 decrease in headache severity. 5.6 had ) 50 in headache severity. 31.8 had no effect on headache severity. Overall H,T6 did not change. 3ain disaEility index went down slightly from a mean of 15 to 12. ,mprovement, when it occurred, lasted aEout 8 weeks. Conclusion: Modest improvements in ND3H were noted in some patients after multiple onaEot cycles. Since ND3H is Eoth very refractory and continuous, the emergence of headache free days in 32 of patients suggests a need for a prospective, vehicle-controlled trial of onaEot in this patient group.

5

Headache P92 A Critical Evaluation of Migraine Trigger Site Deactivation Surgery Mathew, 3.G. Harvard Medical School, Brigham & Women’s Hospital, Department of Neurology, John R. Graham Headache Center, Boston, MA, USA.

P93 Gingko Biloba Could Improve the Migraine in the Patients with Right-to-Left Shunt 3ark, H.1; Ko, S.2 1 Neurology, ,nha university hospital, ,ncheon, RepuElic of Korea; 2Seoul National University Hospital, Seoul, RepuElic of Korea.

Objectives: To provide a critical evaluation of migraine trigger site deactivation surgery (MTSDS). Background: MTSDS is a term that encompasses  procedures performed for migraine prevention. For intranasal onset headaches, septoplasty and turEinectomy are performed. For frontal onset headaches, the corrugator supercilii, depressor supercilii and procerus are resected. For temporal onset headaches, a trigeminal nerve segment is resected. For occipital onset headaches, a portion of semispinalis capitis muscle is removed, and the greater occipital nerve is shielded using a Àap. Multiple studies have demonstrated some ef¿cacy of these procedures, Eut evaluation of study methodologies reveal maMor Àaws. Methods: Two studies advocating these procedures include ³A placeEo-controlled surgical trial of the treatment of migraine headaches´ and ³Five year outcome of surgical treatment of migraine headaches´. A critical evaluation of these studies was performed. Results: These two studies contain numerous methodological Àaws including unclear patient selection and unmatched groups. ,t is unclear who was performing post surgical evaluations, and whether they were Elinded. The 5 year study improperly uses the term control group, as there was no sham surgery group. ,n some cases, multiple procedures were performed simultaneously, so single procedure ef¿cacy cannot Ee determined. Botulinum toxin inMections and nerve Elocks were utilized as screening tools even though Eoth of these agents have demonstrated non-site speci¿c ef¿acacy for the treatment of migraine. ,t is unclear what aEortive and preventative medications were utilized Eefore and after surgical interventions were performed. The unvalidated endpoints utilized included 50 reduction in frequency, intensity, duration, or the migraine headache index (frequency X intensity X duration). Some patients experienced ³signi¿cant improvement´ after surgery, Eut proceeded with additional surgery during follow-up periods. These patients and others were excluded from the ¿nal data analysis for unclear reasons. Conclusion: MTSDS may Ee useful in a suEset of migraine patients with or without coexisting headache disorders, Eut the supporting data at this time are not convincing. ,n addition to unclear ef¿cacy, these procedures can also have complications including worsening pain and permanent itching. These procedures are often not covered Ey insurance, and can have an out of pocket cost of 10,000-15,000. Future studies should include imaging that demonstrates clear surgical targets that involve nerve compression (supraorEital neuralgia, occipital neuralgia) or intranasal contact points (contact point headache). MTSDS should Ee considered experimental at Eest Eased on availaEle data, and patients considering surgery should have it performed as part of a clinical trial.

Objectives: To determine the ef¿ciency of Gingko BiloEa in the migrainers with right to left shunt(RLS) Background: Right-to-left shunt (RLS) is known to Ee associated with classical migraine mayEe due to paradoxical emEolism or chemical effect to Erain. However, it has not Eeen studied, whether the gingko EiloEa can improve the migraine in the patients with RLS. Methods: We performed a retrospective review of the medical records of the migrainers with medication of gingko EiloEa , who visited our hospital for treatment of migraine from January, 2008 to July, 2013 and who took the agitated saline test, using Transcranial Doppler sonography for the detection of RLS, de¿ned as *11 microemEolic signals(MESs). We analyzed the association Eetween the existence of RLS and the change of numeric rating scale of headache Eefore and after medication of ginko EiloEa. Results: A total of 12 patients were included in this study. Among 3 patients with RLS, 38(88.2) patients showed the decrease of NRS. Among 81 patients without RLS, 5(55.6) suEMects showed the decrease of NRS. The medication other than ginkgo EiloEa was not different Eetween the participants with RLS or the ones without. On multivariate Einary regression test, the existence of RLS and the old age were signi¿cantly associated with headache improvement in the migrainers with the medication of gingko EiloEa. Conclusion: The gingko EiloEa wasa associated with the headache improvement in the migrainers with RLS. These results suggest that migraine in the patients with RLS could Ee controlled with the improvement of cereEral Elood Àow. P94 The Ef¿cacy of the Combined Therapy of Pregabalin and Cymbalta in the Treatment of Trigeminal Neuropathic Pain Elchami, Z.; ,ssa, M. 3ain & Headache Management Center of Excellence, ,nternational Medical Center, Jeddah, Saudi AraEia. Objectives: This study aims to evaluate the ef¿cacy of 3regaEaline >calcium channel [email protected] alone or in comEination with CymEalta (Duloxetine, a selective serotonin and norepinephrine reuptake inhiEitor antidepressant (SSNR,)), in the treatment of trigeminal neuropathic pain. Background: StaEEing, lancinating, recurrent facial pain associated with trigeminal neuralgia (TN) is considered as one of the most painful sensations which occurs in the distriEution of the trigeminal nerve, is of sudden onset, and is excruciating. Methods: 200 patients were evaluated according to the ,AS3 classi¿cation, in 3ain Center, ,MC, KSA. 3atients were randomly allocated to receive either 3regaEalin 58

June 2014 tapering alone or in comEination with CymEalta. First group (N=102) received 3regaEalin tapered as 5mg B,D > [email protected], 150mg B,D after that, in comEination with CymEalta 60mg at Eed time. Second group (N=98) received 3regaEalin alone. Both groups were evaluated over a 3-month period. ,nclusive criteria 120 females, 80 males; with ages ranging 35-80 years; mean of 58. Exclusive criteria pediatrics, pregnancy, and patients with contraindications for the medications used. Results: Average improvement of 80, as per numeric pain scale, was seen in patients receiving comEination therapy of 3regaEalin and CymEalta, appreciated within 10 days and sustained for at least 3 months. However, an average improvement of 60 was seen in patient receiving 3regaEalin alone, appreciated within 20 days and sustained for at least 3 months period. Conclusion: 3atients receiving 3regaEalin and CymEalta showed more signi¿cant and faster symptomatic improvement than those receiving only 3regaEalin.

stigma for Eoth episodic and chronic migraine patients. The Disaf¿liativeness (DSF) accounted for 23.2 of the variance for episodic migraine patients. For the chronic migraine patients, the Somatic Complaints (RC1) scale and the Activation (ACT) scale accounted for 36.8 and 8 of the variance in stigma scores, respectively. Conclusion: This novel study showed for the ¿rst time a relationship Eetween personality factors and stigma among patients with migraine headaches. P96 Anxiety and Depression in Migraineurs: Associations and Clinical Implications Chu, M.3; Oh, K.2; Cho, S.; Chung, Y.1; Kim, J.5; Kim, W.6 1 Occupational and Environmental Medicine, Hallym University, Anyang, Democratic 3eople’s RepuElic of Korea; 2Neurology, Korea University School of Medicine, Seoul, RepuElic of Korea; 3Neurology, Sacred Heart Hospital, Hallym University College of Medicine, Anyang, RepuElic of Korea; Neurology, Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, RepuElic of Korea; 5Neurology, Chungnam National University, College of Medicine, DaeMeon, RepuElic of Korea; 6Neurology, Gangnam Severance Hospital, Yonsei University, College of Medicine, Seoul, RepuElic of Korea.

P95 The Relationship Between Personality Factors And Perceptions of Stigma in Chronic and Episodic Migraine Patients McCrea, S.K.1; Kaiser, R.2; Young, W.2 1 ,nstitute for Graduate Clinical 3sychology, Widener University, Drexel Hill, 3A, USA; 2Neurology, Thomas Jefferson Univeristy Hospital, 3hiladelphia, 3A, USA.

Objectives: To assess the comorEidity of anxiety and depression in migrainuers and its clinical signi¿cance in a population-Eased sample in Korea. Background: Epidemiological and clinical studies have shown that migraine is comorEid with a numEer of psychiatric conditions such as anxiety and depression. Although anxiety and depression have Eeen classi¿ed as distinct traits of affective disorders, co-occurrence of anxiety and depression has Eeen found in clinical and epidemiological studies. However, the comorEidity of anxiety and depression in migrainuers and its clinical signi¿cance have rarely Eeen reported. Methods: We selected a strati¿ed random population sample of Koreans aged 19-65 and evaluated them with a 60-item semi-structured interview designed to identify headache type, anxiety and depression. We de¿ned as having anxiety if a participant positively answered *2 to the ¿rst  screening question and *5 to all GoldEerg Anxiety Scale questions. ,f a participant’s 3atient Health 4uestionnnaire-9 score was *10, heshe was assigned as having depression. Results: A total of 2,62 participants completed survey and 1 suEMects (5.) were classi¿ed as having migraine during the previous year. Among suEMects with migraine, 1 (11.6) had Eoth anxiety and depression, 28 (19.0) had anxiety alone, 9 (6.1) had depression alone and 93 (63.3) had neither anxiety nor depression. Headache frequency per month of remarkaEly high when migraineurs had Eoth anxiety and depression >8.0 (2.5-21.0), median 25-5 percentile [email protected], compared to migraineurs with anxiety alone >2.0 (1.0-5.0), [email protected], migraineurs with depression alone >1.0 (0.3-.0), [email protected], and migraineurs without anxiety nor depression >1.0 (0.3-3.0), p[email protected] Visual analogue scale (VAS) score for pain intensity of

Objectives: To study the relationship Eetween personality factors and stigma in chronic and episodic migraine populations. Background: Migraine disorders create illness related Eurdens worldwide, and have a negative impact on individuals, families, and society. The symptoms of migraine alone have Eeen insuf¿cient at explaining treatment outcomes amongst patients suffering from migraines. Thus, examining the contriEutions that other illness factors have on prognosis is a crucial step in informing comprehensive treatment approaches. Current treatments for migraines and other headache disorders take into account research on common illness factors such as personality traits and disaEility, Eut the inÀuence of stigma remains sorely under-evaluated. Methods: Based on the work of 3ark, Kempner, & Young (2009), this study examined the relationship Eetween personality factors and stigma in chronic and episodic migraine populations. Stigma was conceptualized as a socially discrediting situation, with an emphasis on the social, cultural, and economic settings surrounding the stigmatized individual. Migraine 3atients (N = 126), 5 with episodic and 59 with chronic migraines, completed the Stigma Scale for Chronic ,llness (SSC,) and either the MM3,-2 or the MM3,-2-RF. Results: Results indicated that MM3,-2 scales were related to stigma in the chronic migraine population, with 3sychasthenia (3t) scale accounting for the greatest amount of variance (18.). Further, a signi¿cant relationship was found Eetween the Conversion V pro¿le type and stigma in chronic migraine patients. Signi¿cant relationships were found Eetween MM3,-2-RF scales and 59

Headache migraineurs’ with anxiety alone was higher compared to migraineurs without anxiety nor depression >.0 (6.0-8.0)@ vs. 6.0 (5.0-.0), [email protected] ComEination of anxiety and depression in migraineurs was not signi¿cantly different from that of anxiety alone >.0 (5.0-9.0 vs. .0 (6.0-8.0), [email protected] Conclusion: Anxiety and depression are common comorEidities of migraineurs in the Korean population sample. Some clinical characteristics exacerEated with presentation of anxiety andor depression.

Conclusion: ,n young female migraineurs, a previous diagnosis of depression may serve as a roEust marker for increased risk for current mood and anxiety disorders, as well as for increased risk of suicide. This population warrants further psychiatric screening and possiEly evaluation Ey mental health professionals. P98 Psychological Flexibility in Migraine: Acceptance and Values-Based Action Foote, H.L.1; Crudup, B.M.1; Moynahan, V.L.1; Landy, S.H.3; Roland, M.2; Smitherman, T.A.1 1 3sychology, University of Mississippi, University, MS, USA; 2Oxford Neurology Clinic, Oxford, MS, USA; 3 Wesley Headache Clinic, Memphis, TN, USA.

P97 Depression Diagnosis is Associated with Heightened Risk of Other Psychiatric Disorders and of Suicide in Female Migraineurs Screened with the M.I.N.I. International Neuropsychiatric Interview TietMen, G.; Batizy, L.; White, L.; Herial, N.; Utley, C. University of Toledo, Toledo, OH, USA.

Objectives: To examine relationships Eetween two core constructs of psychological ÀexiEility (acceptance of pain, values-Eased action) and migraine variaEles of clinical relevance. Background: Studies of chronic pain patients suggest that fear of pain is more strongly associated with disaEility than pain itself (CromEez et al., 1999) and that acceptance of pain and living according to one’s values are associated with reduced depression and disaEility (Huggins et al., 2012; McCracken, 2013) as well as improved quality of life (Gauntlet-GilEert et al., 2013; Mason et al., 2008). Two small trials have shown that a Eehavioral treatment targeting these constructs (Acceptance and Commitment Therapy, ACT) is ef¿cacious for reducing depressionanxiety and disaEility among headache patients (Mo’tamedi et al., 2012; Dindo et al., 2012). However, little research has explored the role of these speci¿c constructs in migraine or their unique relation to pain severity or disaEility. Methods: 103 treatment-seeking adults with an ,CHD-,, or ,CD-9 physician diagnosis of migraine, Eoth episodic (with >n = [email protected] and without >n = [email protected] aura) and chronic (n = 29), were recruited from medical clinics and administered measures of pain acceptance (C3A4; McCracken et al., 200), pursuit of valued activities (C3V,; McCracken & Yang, 2006), and headache disaEility (M,DAS, Stewart et al., 1998; H,T-6, Kosiniski et al., 2003). Hierarchical regressions were used to assess unique relationships Eetween acceptancevalues-Eased action and migraine variaEles. Because women reported lower levels of pain acceptance and higher headache severity than men, gender and severity were ¿rst entered as covariates in each regression. Results: Episodic and chronic migraine groups did not differ on measures of psychological ÀexiEility. Scores on the C3A4 and C3V, accounted for 10 of unique variance in migraine severity (p=.006); squared semipartial correlations indicated that C3V, scores contriEuted the maMority of this variance (8; p=.00). Acceptance of pain and values-Eased action accounted for a suEstantial amount of unique variance in headache-related disaEility, particularly as measured Ey the M,DAS (unique R2 = 20; p  .001). C3V, scores accounted for 10.2 of the variance in M,DAS scores, while C3A4 scores accounted for 3.8. ,n a second disaEility regression using the H,T-6, C3A4 and C3V, scores accounted for a signi¿cant Eut relatively

Objectives: To assess if an af¿rmative answer to the question ³have you ever Eeen diagnosed with depression"´ identi¿es increased risk for current psychiatric disorders in young women with migraine. Background: Depression and anxiety are comorEid with migraine, particularly when chronic, Eut there is less information regarding other psychiatric diagnoses in the this population. The M.,.N.,. ,nternational Neuropsychiatric ,nterview (M.,.N.,. 5.0.0) is a validated, short, structured diagnostic tool which screens for 1 Axis , disorders plus risk of suicide. Methods: After ,RB approval, we strati¿ed women (18 to 50 years old) with migraine seeking treatment in the UTMC Headache Clinic into two groups Eased on whether they self-reported a prior diagnosis of depression. Diagnosis of migraine was made after assessment Ey a headache specialist (GT), using ,CHD-,, criteria. Each participant completed an electronic questionnaire with data on demographics, headache, depression (3H4 9), anxiety (BA,), aEuse (CT4), and medical conditions. A Elinded assistant (either NH or LW) then conducted the face-to-face M.,.N.,. ,nterview. We compared the two groups using t-test, chi-square, or Fisher’s exact test, as appropriate (S3SS v.21) Results: Female migraineurs previously diagnosed with depression were of similar age to those without depression diagnosis (mean yrs 2 v 39, p=.12 ), Eut reported higher numEer of headache daysmonth (16 v 10, p.0001 ), and had higher scores on 3H4-9 depression test (10 v .1, p.0001) and Beck Anxiety ,ndex test (15 v 6.1, p.0001). Those who reported Eeing diagnosed with depression were more likely to screen positive for current maMor depressive episode (52 v 2), dysthymia (25 v 0 ), panic disorder (12 v 0 ), oEsessive compulsive disorder(15 v 1), (all p.0001), as well as for current agoraphoEia (28 v 10, p=.001), and 3TSD (11 v 2, p=.01). On the current suicidality module, female migraineurs with a prior depression diagnosis scored higher for low (26 v , p.0001), medium (9 v 2p=.03), and high (10 v 1, p=.006) suicide risk . There was no increased prevalence of suEstance aEuse, psychotic episodes, or eating disorders in the group reporting prior diagnosis of depression. 60

June 2014 smaller amount of incremental variance (6; p=.020), most of which was again attriEutaEle to C3V, scores. Conclusion: Higher levels of pain acceptance and valuesEased Eehavior were associated with lower levels of headache-related disaEility, even after accounting for gender and pain severity. The contriEution to M,DAS scores suggests that acceptance of pain and pursuing valued activities are more strongly associated with headache disaEility than is migraine severity itself; this contriEution approached a large effect size (Cohen, 1988). Compared to pain acceptance, pursuing valued life domains was more strongly related to migraine variaEles, suggesting that valued action in particular merits further exploration as a signi¿cant factor and potential mediator in the treatment of migraine.

reported signi¿cantly fewer triggers (3.3) than all other groups. After Bonferroni correction (requiring p  .00), stress, menstruation, noise, missing meals, and weather changes were more often reported as triggers among migraineurs than those with TTH. With the exception of noise, these triggers were also all more common among those with chronic (>1 daysmonth) versus episodic headache, regardless of migraine vs. TTH status; odors and poor sleep also were more common among those with high frequency headache. After accounting for gender, the stepwise regression selected headache frequency as the strongest predictor of numEer of triggers (unique R2 = 9.0, p  .0001). Diagnosis (migraine vs TTH) accounted for an additional .0 of unique variance (p  .0001). Conclusion: Consistent with prior studies, migraineurs reported more triggers than individuals with TTH, and particular triggers were reported more commonly among those with migraine. However, these patterns were also evident and even more roEust as a function of high (vs low) frequency of headache, regardless of diagnosis. Given the limitations of retrospective reporting, experimental studies are needed to con¿rm the present ¿ndings.

P99 Perceived Headache Triggers as a Function of Headache Diagnosis Versus Headache Frequency Black, A.1; Johnson, Y.L.1; Houle, T.T.2; Smitherman, T.A.1 1 3sychology, University of Mississippi, University, MS, USA; 2Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC, USA.

P100 Prevalence and Clinical Pro¿le of Headache after Intravenous Immunoglobulin Treatment in Patients with Guillain-Barré Syndrome ,keda, K.; Sawada, M.; Hanashiro, S.; Yanagihashi, M.; ,shikawa, Y.; Hirayama, T.; Takazawa, T.; Murata, K.; KawaEe, K.; ,wasaki, Y. Neurology, Toho University Omori Medical Center, Tokyo, Japan.

Objectives: To examine differences in perceived headache triggers as a function of headache diagnosis and headache frequency. Background: 3rior research has shown that individuals with migraine and TTH often report similar headache triggers such as stress, hormonal changes, not eating, and sleep disturEances (Kelman, 200; W|Eer &W|Eer-Bing|l, 2010). More limited evidence suggests that certain triggers differentiate migraine from TTH Eut that triggers unique to TTH are uncommon (Spierings, Ranke, & Honkoop, 2001). Recent literature has highlighted similarities Eetween primary headache disorders, suggesting that they perhaps represent ends of a continuum rather than distinct entities, and that features such as severity or frequency are more useful for classifying headache suEforms (Blumenfeld et al., 2010; Lipton et al, in press; Turner et al., 2013). The aim of the present study was to compare the utility of headache diagnosis versus headache frequency in quantifying associations with trigger prevalence and type. Methods: 8 young adults (M age = 19.2 >18-[email protected];  female) with symptoms of primary headache completed a computer-administered diagnostic headache interview and responded to questions pertaining to susceptiEility to 12 common headache triggers. Forty percent of respondents met criteria for episodic migraine (EM; 92 with aura, 228 without), 10 for chronic migraine (CM), 6 for ETTH, and  for CTTH. ANOVA and chi-squared tests quanti¿ed differences in reported triggers. After controlling for gender, stepwise linear regression analyses assessed the ³predictive´ power of diagnostic group (migraine vs TTH) and headache frequency on numEer of reported triggers. Results: ANOVA across diagnostic groups yielded a signi¿cant omniEus effect, F (,82) = 29.01, p  .0001. 3ost-hoc tests indicated that those with CM reported a higher numEer of triggers than either EM group (5.5 triggers vs. .6 >EM with [email protected], .2 EM without; Eoth ps  .02), who did not differ from one another. Those with ETTH

Objectives: Human intravenous immunogloEulin (,V,G) is a Elood product consisting primarily of intact ,gG molecules derived from pooled normal human plasma. Headache is the most common adverse effect of ,G,V therapy. The incidence of headache was reported as 5 to 56 in variaEle autoimmune diseases. Here we aim to evaluate the prevalence and clinical hallmarks of headache after ,V,G therapy in Japanese patients with Guillain-Barré syndrome (GBS). Background: Recently physicians have increased challenge of ,G,V therapy in numerous clinical conditions or autoimmune diseases. ,t is important for application of this medication to recognize serious or frequent adverse effects. Headache, low-grade fever, myalgia, nausea and mild urticarial reactions are well known as common and minor adverse effects in patients treated with ,G,V. Methods: The prevalence and the clinical pro¿le of ,V,Gassociated headache were examined Ey the clinical review in GBS patients. ,V,G was started in all patients after a cereErospinal study using lumEar puncture. The dose and the period of ,V,G were 0.3 gkgday for 5 days as Japanese standard regimen, and the infusion rate of ,V,G was slower than 10 ghour in all patients. Severity of GBS was assessed Ey Hughes function grade. Results: Fifty-three patients (31 men and 22 women) were participated in the present study. The mean age (SD) was .6 (1.) years, .5 (1.) in men and 52.1 (20.9) in women. Six patients (5 men and 1 woman) had headache. 61

Headache The prevalence was 11.0, 16.0 in men and .5 in women. Their age was ranged from 33 to 6 years, and the mean age was 6.2 years. The main portion of headache was the occipital region and the posterior neck in all patients. 3ain type revealed non-throEEing pain, tightening sense or heaviness of head in all patients. All patients had no prior history of headache, including migraine. No nausea, vomiting, and hypersensitivity of light and sound were accompanied in all patients. Three patients complained of positional headache. Headache was worsening at sitting up and attenuated at the supine position. Especially, the ¿rst lumEar puncture could contriEute to the orthostatic headache. ,nterestingly, 2 patients had no headache when 2nd follow-up of lumEar puncture was performed. Severity of headache showed mild degree without medication in 2 patients, and moderate degree requiring painkiller in  patients. Headache onset was the ¿rst day of ,V,G therapy in one patient. Two patients experienced headache at the 2nd day, and 3 patients at the third day. Duration of headache was ranged from one day to 15 days and the mean duration was 6.3 days. Headache was improved within  days in ¿ve patients. The severity of GBS was varied in patients with headache. The Hughes score exhiEited two degree in 1 patient, three degree in 1 patients and four degree in  patients. Conclusion: The present study indicated that the prevalence of ,V,G-triggered headache was 11. The main etiology of headache was related to Eoth ,V,G and lumEar puncture examination in GBS patients. ,V,G-induced serological hyperosmolality and intracranial hypotension after lumEar puncture might contriEute to the crucial pathogenesis of headache in our patients. Thus, adequate hydration, including Àuid infusion and dirking, has Eene¿ts for the prevention of headache onset.

Ey ipsilateral autonomic features of conMunctival inMection, tearing, ptosis, and periorEital edema. Early on, there was an associated foreign Eody ³sand-like´ sensation in her eye that improved over time. Neurological examination revealed right sided papilledema and was otherwise entirely normal. Brain MR, with and without gadolinium was performed and showed aEnormal enhancement within the orEit, most notaEly super¿cial to the sclera and in the regions of extraocular muscle attachments consistent with orEital pseudotumor. Screening for alternative etiologies was unremarkaEle including thyroid function tests, VZV and HSV serologies, ,gG level, ESR, CR3, ACE, ANCA panel, ENA, ANA, and rheumatoid factor. The patient had complete resolution of her pain on indomethacin 25 mg three times daily. This was prior to any speci¿c orEital pseudotumor treatment with prednisone. Conclusion: ,nÀammatory orEital pseudotumor should Ee considered as a cause of secondary hemicrania continua. Further, response to indomethacin does not always herald a primary headache disorder. P102 Pseudotumor-Like Headaches with Normal Intracranial Pressure ToEin, J.A.1; Georges, J.2; Flitman, S.1 1 Xenoscience, ,nc., 3hoenix, AZ, USA; 2College of Osteopathic Medicine, Midwestern University, 3hoenix, AZ, USA. Objectives: We descriEe four patients with pseudotumor cereEri (3TC)–like headaches Eut with normal opening pressure (O3), whose headaches nonetheless responded to therapies that lower intracranial pressure. Background: 3TC is a headache syndrome caused Ey increased intracranial pressure without a mass lesion. The 2013 3TC diagnostic criteria include an opening pressure greater than 25 cmH20. Removing CSF and acetazolamide often relieve pain. Methods: Chart review. Results: Patient 1. A 33-year-old male noted daily 10 severity headaches lasting 1-16 hours, starting 5 years prior. Headaches were worst when ¿rst opening his eyes in the morning. Sleep was ³not good.´ An MR, was normal except for old cereEral contusions. A 6-week trial of acetazolamide 50 mg B,D did not alter his headaches. O3 was 1.5 cm H20. The patient’s pain Must prior to L3 was 810 and decreased to 110 as 0 cc of CSF were removed. 3atient’s headache following L3 remained at 1–210 for two weeks, then returned to 810. Patient 2. A 0-year-old female descriEed 8 years of daily 610 pressure headaches, worse supine than standing up. She underwent ventriculostomy  years prior for aqueductal stenosis, without headache improvement. She then received a ventriculoperitoneal (V3) shunt 6 years prior that provided headache relief, Eut only for 3 months, and the line connecting the shunt reservoir to the peritoneum was removed. Since, she noted headache relief for 2 hours whenever 10–15 cc was aspirated from her shunt reservoir. They did not improve with furosemide 20 mg daily, or with two trials of acetazolamide, Eut when it was stopped her headache severity increased from –510

P101 Hemicrania Continua-Like Headache Due to Ipsilateral InÀammatory Orbital Pseudotumor DeLange, J.M.; RoEertson, C.E.; Garza, ,. Neurology, Mayo Clinic, Rochester, MN, USA. Objectives: We report a case of a 55 year-old woman with a hemicrania continua-like headache due to inÀammatory orEital pseudotumor that was aEsolutely responsive to low dose indomethacin. Background: OrEital pseudotumor tends to present with proptosis, erythema, periorEital edema, and painful, restricted eye movement. While cluster-like headaches have Eeen previously reported with orEital pseudotumor, to our knowledge this is the ¿rst case of a hemicrania continua-like headache syndrome (including aEsolute response to indomethacin) due to orEital inÀammatory pseudotumor. Methods: Case report Results: A 55 year-old diaEetic woman presented to our headache clinic with a  month history of new-onset, continuous right head and facial pain. Her pain was descriEed as a dull continuous pain with exacerEations of sharp pains in the head and face. Her pain localized to the right parietal and maxillary areas with radiation to the ipsilateral Maw, eye, and occipital regions. Her exacerEations were characterized 62

June 2014 to 610. She took lithium 600mg twice daily. A new V3 shunt was placed, at which time her O3 was 11cm H20. 3rior to shunt placement, her headaches were 3–10, worst in the morning, and continuous throughout the day. ,mmediately after shunt placement, they decreased to 3–10 upon awakening and 0–310 for the rest of the day. Thirty-one months after her shunt was placed, she noted daily headache pain that remained at 0–210 throughout the day. Patient 3. A 3-year-old female noted 11 years of 510 daily holocranial pain, continuous and 910 for 2 months prior to presentation, worse supine and worse at night. She also noted Elurred vision and nausea. Acetazolamide and furosemide were ineffective. O3 was 19cm H20, and pain decreased from 10 to 0 with withdrawal of 0cc CSF. A cisternoperitoneal shunt was placed, whereupon her headache frequency decreased from daily to twice monthly, 10 and lasting 2 hours. Patient 4. A 36-year-old female noted 2 years of throEEing pressure 610 headaches refractory to multiple migraine prophylactics, worse supine than standing, and continuous for 2ò weeks at presentation. O3 was 11cm H20. 3ain Eefore L3 was 810, Eut increased to 910 after 0cc CSF was withdrawn. Acetazolamide decreased the severity from 8 to 6, and decreased frequency from 15-16 per month to 9 per month. Conclusion: Three patients with O3s of less than 25 cm H20 Eene¿ted from CSF volume reduction, and one Eene¿ted from acetazolamide. Hence, some patients may Ee outliers to the formal 3TC criteria requiring an opening pressure of 25 cm H20, such that they experience 3TC-like headaches at lower CSF opening pressures.

Results: Nine out of 1 patients with Eacterial meningitis showed Elood CR3 levels *10 mgdl, whereas CR3 levels 10 mgdl were oEserved in all patients with aseptic or TE meningitis. Using a CR3 level of *10 mgdl as a positive discriminatory factor for Eacterial meningitis resulted in positive and negative predictive values of 0.91 and 1.0, respectively. To Eetter discriminate Eacterial from nonEacterial meningitis, we analyzed changes in CR3 and cereErospinal Àuid (CSF) levels using one-way analysis of variance (ANOVA) and concluded that Elood CR3 is statically signi¿cant indicator which is differentiates Eacterial meningitis from other meningitis or encephalitis at admission. Conclusion: This study suggests that serum CR3 analysis, which is Eoth simple and inexpensive, is helpful to differentiate Eacterial meningitis from other aseptic or suEacute meningitis. P104 Two Cases of Conversion to Chronic Migraine (CM) and Remission to Episodic Migraine (EM) in Temporal Relation to Warfarin Therapy Kuruvilla, D.E.1; Buse, D.C.1; GrosEerg, B.1; EisenEerger, A.2 1 Neurology, The AlEert Einstein College of Medicine and The Monte¿ore Headache center, Bronx, NY, USA; 2 ColumEia University, New York, NY, USA. Objectives: To descriEe two cases of conversion from EM to CM associated with initiation of warfarin and remission to EM associated with its discontinuation. Background: Warfarin is commonly used for anticoagulation. Warfarin has Eeen associated with decreased headache frequency in previous case reports for headache prophylaxis. However, we oEserved two cases where patients with EM developed CM when warfarin therapy was initiated and remitted to EM following discontinuation. Methods: We treated two patients at a tertiary headache center with EM without aura. Herein we descriEe the clinical course of their treatment. Consent to puElish data was oEtained from patients. Results: 3atient 1 was a 5 year old female with a >20 year history of EM without aura with 8 headache days per month on average. Her headaches were treated with NSA,Ds and narcotics acutely. Triptans were contraindicated Eecause of her history of ischemic stroke and atrial ¿Erillation. Due to these conditions she was started on warfarin. She reported that within a week of starting warfarin she experienced daily migraine headaches. Multiple preventive agents in all FDA approved classes were tried over the course of three years with minimal Eene¿t. Given the temporal relationship Eetween starting warfarin and development of CM, warfarin was transitioned to daEigatran. Within one week, her headache frequency decreased from daily to two days per week. Two months later, the patient developed hematuria, which was attriEuted to daEigatran and she was restarted on warfarin. Within one week of restarting warfarin, her migraine headaches Eecame daily. Discontinuing warfarin again and restarting daEigatran

P103 Usefulness of C-reactive Protein in Distinguishing Forms of Adult Meningitis Shin, D.1; Baek, S.1; Lee, Y.2; Lee, K.3; Lee, S.1 1 Neurology, ChungEuk National University Hospital, CheongMu, RepuElic of Korea; 2Neurology, CheongMu St. Mary’s Hospital, CheongMu, RepuElic of Korea; 3Neurology, DaeMeon Veterans Hospital, DaeMeon, RepuElic of Korea. Objectives: The aim of this study was to clarify to what extent Eacterial meningitis could Ee distinguished from aseptic or other infectious meningitis through CR3 levels in adults. Background: Various hematological indices are used to screen for Eacterial meningitis, the maMority of which are neither highly sensitive nor speci¿c. C-reactive protein (CR3), an acute phase reactant, has Eeen used to diagnose and follow the course of infection. We examined the clinical value of CR3 in the diagnosis of meningitis through the comparison of serum CR3 measurements and CSF ¿ndings in adults with Eacterial meningitis, aseptic meningitis, and TE meningitis. Methods: A total of 113 adult cases (aged 15-98 years), includingpatients with Eacterial meningitis (n=1), aseptic meningitis (n=8), and tuEerculous (TE) meningitis (n=15), were retrospectively analyzed Eased on data from the initial examination.

63

Headache decreased her headaches to two days per week, which has Eeen sustained for the past year. 3atient 2 was a 39 year old female with very infrequent migraine with aura. At age 36 she was placed on warfarin for a pulmonary emEolism. She had no history of miscarriages or hypercoagulaEility. A hypercoagulaEle workup was negative. Three days after starting warfarin, the patient started having daily migraine headaches. An MR, of the Erain was normal. Within three days of discontinuing a three month course of warfarin, her headache frequency decreased Eack to once weekly which has Eeen sustained for the past year. Conclusion: Although a few case reports suggested the Eene¿ts of warfarin as a prophylactic agent for migraine, these two cases suggest that it may induce CM in patients with EM. ,n addition, when the agent was discontinued Eoth patients reverted to EM. While causality cannot Ee determined in this oEservational study, these ¿ndings suggest a temporal relationship. Future work to determine a mechanism would Ee useful. To the Eest of our knowledge these are the ¿rst puElished cases descriEing this phenomenon.

lymphocytic pleocytosis, 136 protein, and 39,000 RBC. During a month long hospitalization, workup for infectious, autoimmune, demyelinating, and metastatic etiologies was unremarkaEle. CNS Eiopsies were not performed. He was discharged on dexamethasone with plan for outpatient followup for presumed CNS malignancy. Though his symptoms and CSF pro¿le improved initially with steroids, he presented to our facility one week later somnolent. Unfortunately, repeat imaging demonstrated continued growth of pontine and medullary lesions, concerning for neoplastic process versus neurosarcoidosis. Despite increased ,V steroid treatment, he continued to decline, eventually developing communicating hydrocephalus requiring ventriculoperitoneal shunting. A leptomeningeal Eiopsy demonstrated a primary CNS lesion most consistent with grade ,,,-,V astrocytoma. Our patient elected for hospice and passed away soon after; an autopsy was declined. Conclusion: There should Ee a high index of suspicion for secondary headache disorders in patients over the age of 50 who present with new onset headaches. Our patient did not undergo imaging at age 55 on initial headache presentation despite a lack of prior headache history. His symptoms were mild at that time Eut were likely a suEtle indicator to the neoplastic process that led to his passing. Early evaluation of atypical headaches that may herald intracranial malignancy is critical to our aEility to provide prompt treatment and palliative relief. We strongly recommend considering evaluation for a secondary process for new onset headaches in patients > 50 years of age. As in the atypical presentation of our patient, testing should Ee catered to the patient’s history and clinical suspicion.

P105 When a Headache is More Than a Headache: A Case Report of a 59 y/o Diagnosed with Primary CNS Neoplasm after Protracted Evaluation Zha, A.M.; Oas, J.G.; Kelley, B. Neurology, Ohio State University Wexner Medical Center, ColumEus, OH, USA. Objectives: We introduce the case of a 59 year old male who presented with atypical new onset headaches whom, after prolonged evaluation, was diagnosed with terminal CNS malignancy. We have reviewed the literature and will discuss the evaluation of new headaches in patients over the age of 50 to assist prompt diagnosis. Background: Headache is the presenting symptom in 23-56 of patients with intracranial neoplasms and the likelihood of intracranial pathology causing new onset headaches increases drastically after age 50. Early recognition of CNS malignancy is critical to prognosis and patient morEidity. A detailed headache history in this population can Ee the difference Eetween early or late recognition. Methods: Case report and review of the literature. Results: Our patient presented for a second opinion with 2 months of daily severe Eilateral frontal-occipital headaches with progressive neurological decline. He initially developed daily occipital headaches with Elurred vision at age 55. At the time he only underwent ophthalmologic evaluation and was given timolol drops for glaucoma; these improved vision Eut did not alleviate his headaches. Four years later, his Eilateral headaches radiated down his neck and were associated with nausea, vomiting, and unintentional weight loss. A Erain MR, demonstrated diffuse leptomeningeal enhancement with non-enhancing lesions in the medulla and pons. He was sent home with the presumed diagnosis of viral infection without additional studies. His symptoms continued to worsen and two weeks later, at another facility, CSF studies demonstrated

P106 SMART Syndrome- A Case Report Sheikh, H.; Burch, R. John Graham Headache Center, Boston, MA, USA. Objectives: To descriEe a case of SMART Syndrome, including its primary symptoms and possiEle underlying pathophysiology. Background: A 55 yo right handed woman with history of life-long migraines with an aura of right-sided numEnes developed a low grade occipital osteosarcoma in 2001. She underwent craniectomy and cranioplasty, followed Ey proton Eeam radiation. Her headaches were staEle for some time until 2008, when she sustained a concussion while skiing. She then developed frequent headaches with elements of occipital neuralgia. Topamax was helpful Eut had to Ee discontinued due to nephrolithaisis. OnaEotulinum-A and occipital nerve Elocks provided some control of headache pain. ,n July 2011, she developed discrete episodes of her characteristic migraines Eut now associated with left sided hemiparesis and numEness. Between July 2011 and July 2013, she had -5 distinct episodes. During the ¿rst episode in July 2011, exam revealed a left hemineglect, homonymous hemianopsia and mild left sided weakness. During the ¿rst few encounters in the ER, she had Erain MR,s that consistently showed R parieto-occipital gyral thickening with contrast enhancement and no DW, changes. LumEar puncture 6

June 2014 showed elevated opening pressure and EEG revealed R >L cereEral dysfunction with left occipital Ereach rhythm. Methods: Case report. Results: MR,during her attack. Conclusion: ,n someone with a history of a CNS tumor, recurrence is always at the top of the differential diagnosis for headache and neurological de¿cits. When recurrence is ruled out, there are other possiEilities that must Ee considered, for example, 3RES, stroke as well as a recently recognized syndrome, stroke-like migraine attacks after radiation therapy (SMART). ,t was ¿rst descriEed in 1995 in a group of eight patients and since then, many other case reports with similar clinical and radiological ¿ndings have Eeen descriEed. >[email protected] SMART syndrome is characterized Ey migraine-like headaches with transient neurological dysfunction along with gyriform thickening and enhancement on MR,. >1,[email protected] Typically the MR, ¿ndings resolve over weeks.>[email protected] Documented neuro-cognitive de¿cits and seizures may Ee associated with this syndrome >1,[email protected] Although the pathophysiology is poorly understood, it is thought that irradiation causes damage to the Elood-Erain Earrier with the posterior circulation Eeing more vulneraEle. There are therefore clinical and pathophysiologic overlaps with 3osterior ReversiEle Leukoencephalopathy Syndome (3RES), which is thought to Ee a form of a vasculoapthy. However, SMART syndrome may also involve neuronal dysfunction that impairs the trigeminovascular system, lowering the threshold for cortical spreading depression and migraines. >1,[email protected] There are no randomized trials that pertain to treamtent. ,t is mostly Eased on expert opinion Eut has generally involved antiepileptic medications and vascular staEilizing agents. This patient had excellent control of symptoms on a comEination of verapamil and depakote. When depakote was withdrawn due to side effects, she had recurrence of Erief auras. These resolved after the addition of lamotrigine to verapamil. Brain MR, performed Eetween episodes showed reduction in the areas of contrast enhancement.

craniotomies are reported in up to 91 of neurosurgical cases. Local in¿ltrations of these scar neuromas are often used for Eoth diagnostic and therapeutic purposes with permanent improvement after a single in¿ltration may Ee possiEle. Headaches due to scar neuroma in craniotomy patients responds well to treatment and complete remission has Eeen noted in cases reported. Methods: This is a case report and review of literature. Results: 32 year old male presented with history of chronic daily headache for 10 years, which commenced after multiple hair transplant surgery and revisions. 3atient reported right temporal headache throEEing radiating to the right shoulder, neck and arm. ExacerEations of Easeline headaches were triggered Ey weather changes, alcohol, and sleep deprivation, lifting weight and pressure to the posterior temporoparietal region. ,magings of the Erain withCT and MR, without contrast were unremarkaEle. He reported seeing multiple doctors and had failed treatments including anticonvulsants, NSA,Ds and other pain medications which gave him only temporary relief or intoleraEle side effects. Neurological examination was unremarkaEle except for ¿rm thickening of the scar area which on even minor digital pressure, reproduced and triggered ipsilateral headaches. ,nMection of the most tender points of the scar with a solution of lidocaine 2 and dexamethasone completely resolved the headache. 3atient symptoms have resolved and he is headache free for past 2 months. Conclusion: Local scalp pathology may result in disaEling and deEilitating chronic daily headaches. Headaches due to cutaneous scar neuroma may present a diagnostic dilemma, Eut when treated appropriately respond very well to treatment. P108 The Menopausal Transition Is Associated with Higher Headache Frequencies in Women with Migraine: Results of the American Migraine Prevalence and Prevention (AMPP) Study Martin, V.T.1; 3avlovic, J.2; Fanning, K.3; Buse, D.C.2; Reed, M.3; DerEy, C.2; Lipton, R.B.2; Serrano, D.3 1 ,nternal Medicine, University of Cincinnati, Cincinnati, OH, USA; 2Neurology, AlEert Einstein College of Medicin, New York, NY, USA; 3Vedanta, Raleigh, NC, USA.

P107 Refractory Chronic Daily Headaches after Hair Transplant Surgery Khan, K.J.; Sahai-Srivastava, S. Neurology, University of Southern California, Los Angeles, CA, USA.

Objectives: To examine the relationship of headache frequency to stage of the menopausal transition in mid-life women wiht migraine. Background: 3ast studies suggest that the perimenopause is associated with an increased prevalence of migraine particularly in those with a history of premenstrual stress disorder. The effect of the menopausal transition on the frequency of headache attacks in women with migraine has not Eeen explored. Methods: Using data from the 2006 AM33 Study survey, women meeting modi¿ed ,CHD-3 Eeta criteria for migraine Eetween the ages of 35-65 years were included in analyses. Women who had never menstruated, were pregnant, Ereast feeding or using exogenous sex hormones were excluded. Other exclusions included polycystic ovarian syndrome, hysterectomy, or oophorectomy. The

Objectives: To descriEe a patient who developed disaEling chronic daily headaches secondary to scar neuroma after hair transplant surgery and to review literature of similar cases. Background: Hair restoration is one of the most exciting and innovative surgical ¿elds in aesthetic surgery today. MaMor complications as a result of hair transplantation are extremely rare. Occasionally, a person may have proElems with delayed healing, infection, scarring, or reMection of the graft. Although the reasons Eehind postoperative chronic pain are multifactorial, one cause may Ee entrapment of cutaneous nerve in the surgical scar. Scar neuroma has Eeen descriEed as a complication of craniotomy, Eut not in the setting of hair transplant surgery. Headaches following 65

Headache 2006 survey was selected Eecause it included detailed questions on the menstrual cycle. The premenopausal stage was characterized Ey regular menstrual cycles without variation in cycle length. The perimenopausal stage included women with cycle lengths that varied Ey *  days or periods of amenorrhea lasting 2-11 months. The postmenopausal stage was de¿ned Ey amenorrhea persisting for * 12 months. The primary outcome, high vs low headache frequency was de¿ned using a cut-score of * 10 headache days per month. Binary logistic regression models were used to assess the inÀuence of menopausal stage on headache frequency category using premenopause as the reference group. Model 1 included stage of menopausal transition, age, income, Eody mass index, preventative medication use and smoking as independent covariates in the model. Model 2 added to Model 1 cutaneous allodynia (ASC-12; scored dichotomously with a cut-score of 3) and depression (3H4-9; scored dichotomously with a cut-score of 10). Results: The study sample included 3,603 women at a mean age of 5 years. Among women who were premenopausal, 8.0 were in the high frequency headache group in comparison with 12.2 of peri-menopausal and 12.0 of post-menopausal women. Compared with premenopausal women, the adMusted odds of Eeing in the high frequency headache group was 1.5 (95 C,=1.1, 2.0) for perimenopausal and 1.6 (95 C,= 1.1, 2.3) for postmenopausal women (Model 1). Additional adMustment (in Model 2) for Eoth cutaneous allodynia and depression slightly attenuated the ORs for these contrasts though they remained statistically signi¿cant. Conclusion: Consistent with the clinical impression that migraine worsens during the menopausal transition these data show that the risk of high frequency headache is 5060 higher during perimenopause and post-menopause as compared with the premenopause. Longitudinal studies should examine within person tragectories of headache frequency and the role of hormonal mechanisms among migraineurs during the menopausal transition.

acute headache attacks in pregnant women at an urEan, tertiary hospital setting was captured in a cross-sectional registry from 109 through 123113 in a retrospective chart review. Clinical diagnoses made in real time were con¿rmed Ey application of the ,nternational Classi¿cation of Headache Disorders, 3rd edition (Eeta) criteria. Results: Of 121 pregnant women presenting with acute headache in pregnancy, 6 (62.8) had primary headache disorders. Of the primary headache group, 2 women (35.5) presented with aura, including 19 without any previous lifetime aura attacks (0.). Most women (81.6) presenting with aura, and nearly all women (9.) presenting with new aura, had imaging to assist clinical criteria in the exclusion of secondary headache. Aura symptoms were isolated visual (66.), visual and sensory (18.5), visual, sensory and motor (.), and isolated sensory (.). Aura usually presented in the 3rd trimester (63.0). 3regnant women presenting with aura did not differ from pregnant women presenting without aura in terms of age (29.6(6.5 years vs 28.6(6.3 years, p=0.51), numEer of total pregnancies (.3(2.6 vs 3.5(2.3, p=0.1), gestational week of presentation (29.8(.5 vs 2.(.8, p=0.20), lack of any headache history (18.5 vs 10.2, p=0.31) presence of status migrainosus (33.3 vs 6.9, p=0.25) or chronic migraine (3. vs 18., p=0.08). Conclusion: Over one-third of pregnant women presenting with acute primary headache in this cohort experienced aura. Most patients with aura in pregnancy had no previous aura history, developed their ¿rst aura during the third trimester, and had primarily visual symptoms. There were no differences in demographics, pregnancy stage, or headache diagnoses in pregnant women presenting with or without aura. P110 Salivary Biomarkers and Their Relationship to Menstrual Migraine Before and after Treatment with Sumatriptan-Naproxen or Placebo Martin, V.T.3; Cady, R.K.1; Cady, R.J.2; Manley, H.R.2; Clark, E.J.; Durham, 3.L. 1 Headache Care Center, Spring¿eld, MO, USA; 2Clinvest, Spring¿eld, MO, USA; 3,nternal Medicine, University of Cincinnati, Cincinnati, OH, USA; Center for Biomedical and Life Sciences, Missouri State University, Spring¿eld, MO, USA.

P109 Migraine Aura in Pregnancy: A Cross-Sectional Registry Study RoEEins, M.S.1; Farmakidis, C.2; Dayal, A.K.3; Lipton, R.B.1 1 Neurology, Monte¿ore Headache Center, AlEert Einstein College of Medicine, Bronx, NY, USA; 2Neurology, AlEert Einstein College of Medicine, Bronx, NY, USA; 3 OEstetrics & Gynecology and Women’s Health, AlEert Einstein College of Medicine, Bronx, NY, USA.

Objectives: 1) To determine if salivary levels of calcitonin gene-related peptide (CGR3), prostaglandins E2,2 (3GE2, 3G,2), cortisol, a-amylase and V,3 differ Eetween mid-luteal time periods and premenstrual time periods in women with menstrual migraine 2) To ascertain if salivary levels of these Eiomarkers change after treatment with either sumatriptan-naproxen or placeEo during attacks of menstrual migraine as compared to premenstrual time periods. Background: Menstrual migraine has a prevalence of 3 in the general female population Eut can occur in up to 61 of female migraineurs. Serum levels of 3GE2 have Eeen reported to increase during attacks of menstrual migraine, Eut it has not Eeen determined if other salivary

Objectives: To characterize migraine aura in pregnancy, and to compare pregnant women with migraine with aura to pregnant women with migraine Eut no aura. Background: ,n small case series migraine with aura has Eeen descriEed to occur for the ¿rst time in pregnant women. However, the characteristics of aura in pregnancy have not Eeen well-descriEed in the context of a larger cohort of pregnant women. Methods: A retrospective chart review of consecutive emergency and inpatient neurology consultations for 66

June 2014 neuropeptides, hormones or 3G,2 change Eefore or during attacks of menstrual migraine. Methods: This was a 2 center, randomized, douEle-Elind, placeEo controlled study consisting of 1 suEMects, 18 to 65 years of age, meeting the ,HS-,, criteria for menstrual migraine without aura. SuEMects were given saliva collection kits and instructed to collect stimulated saliva a Easeline, during the mid-luteal and premenstrual time periods, headache onset, 2 hours post treatment, , and 2 hours after headache resolution. SuEMects were randomized 11 and received either sumatriptan-naproxen (n=1) or placeEo (n=11) to treat their next menstrual headache. Saliva samples were assayed for levels of CGR3, V,3, a-amalyase, 3GE2, cortisol, 3G,2 and estradiol. Repeated measure analysis of variance was used for the analyses to determine if salivary Eiomarkers changed during different time periods Eefore or after the onset of menstrual migraine. Results: SuEMects receiving sumatriptan-naproxen reported quicker time to pain free than those receiving placeEo (3.90 hrs vs. .6 hrs, p = 0.02). Furthermore, the sumatriptannaproxen group had a signi¿cant decrease in pain levels two hours post treatment (1.93 vs. 1.1, p = 0.00) while there was no change in pain levels for the placeEo group (1.91 vs. 2.00). Salivary levels of CGR3 were increased 3.1 fold during the mid-luteal time period as compared to the premenstrual time period (p  0.005). However, CGR3 was not increased for any group at headache onset or post treatment regardless of the degree of treatment success. A similar pattern was seen for cortisol with a 3.85 fold increase during the mid-luteal time period compared to the premenstrual times (p  0.002) and no change at headache onset or post treatment. There were no signi¿cant changes in salivary levels of V,3, amylase, 3GE2, 3G,2 or estradiol at any time point and no correlation was found Eetween these salivary Eiomarkers and pain relief. Conclusion: Salivary levels of CGR3 and cortisol decrease during premenstrual as compared to mid-luteal time periods while no change was oEserved in other salivary Eiomarkers. Treatment with either sumatriptan-naproxen or placeEo had little effect on any of the salivary Eiomarkers during post treatment time periods. These results could suggest that peripheral release of CGR3 plays little role in the pathophysiology of menstrual migraine. Low levels of cortisol occurring during premenstrual time periods might render attacks of menstrual migraine more dif¿cult to treat.

headache features that were associated may help to reduce the disaEility caused Ey TTH. Methods: KHS is a nation-wide interview survey regarding headache for all Korean adults aged 19–65. TTH diagnosis was validated with 86.2 sensitivity and 5.5 speci¿city. DisaEility was de¿ned as having any day of headache-related activity restriction or missed work during the previous 3 months. We assessed factors associated with disaEility of TTH through univariate and multivariate analyses. Multivariate analyses were adMusted for sociodemographic variaEles and headache characteristics. Results: Of 150 individuals, the 1-year prevalence rate of TTH was 30. (n=63). ,n individuals with TTH, 22 (.8) reported headache-related disaEility activity restriction (n=10) and missed work (n=12). ,n univariate analyses, socio-demographic variaEles were not associated with disaEility. DisaEility increased with headache time duration and headache intensity, Eut decreased in individuals with no aggravation Ey routine activity. After adMustment of covariates, moderate headache intensity and no aggravation Ey routine activity were independently associated with disaEility of TTH (odds ratio >[email protected] .1, 95 con¿dence interval >C,@ 1.6–13.2 and OR 0.32, 95 C, 0.12–0.88, respectively). Conclusion: ,n this study, disaEility caused Ey TTH was low, Eut which should not Ee overlooked, considering its prevalence. TTH individuals with moderate headache intensity andor aggravation Ey routine activity were at an increased risk of disaEility. P112 Intravenous Lidocaine Treatment in Classical Trigeminal Neuralgia with Concomitant Persistent Facial Pain Chaudhry, 3.; Friedman, D.,. Department of Neurology and Neurotherapeutics, UT Southwestern Medical Center, Dallas, TX, USA. Objectives: We report a 0-year-old with intractaEle trigeminal neuralgia with interictal pain that improved with intravenous lidocaine infusion. Background: Trigeminal Neuralgia (TN) is a facial pain disorder descriEed Ey the ,CHD-3 Eeta as unilateral pain in trigeminal nerve distriEution characterized Ey Erief electric shock like sensations. Between paroxysms, most patients are asymptomatic. However, in certain cases there is a prolonged Eackground pain in the affected area. This is classi¿ed as ³Classical trigeminal neuralgia with concomitant persistent facial pain´. This disorder responds poorly to conservative treatment and to neurosurgical interventions. Methods: A 0-year-old woman was diagnosed with classical trigeminal around 15 years prior to our evaluation. Over next 2 years, she developed moderate pain in Eetween her TN attacks. She was started on carEamazepine 00 mg a day, and responded well for a few years; however she continued to have moderate Eackground pain. She was admitted with multiple severe intractaEle attacks of TN lasting a few seconds, occurring every 2-3 minutes. Her Eackground pain was sharp and had increased in intensity from Easeline. The MaEs were deEilitating enough that the

P111 Factors Associated with Disability of Tension-Type Headache: Findings of the Korean Headache Survey Kim, B.1; Chung, C.1; Lee, C.1; Chu, M.2; Kim, J.3 1 Neurology, Samsung Medical Center, Seoul, RepuElic of Korea; 2Neurology, Sacred Heart Hospital, Anyang, RepuElic of Korea; 3Neurology, Chungnam National University Hospital, DeaMun, RepuElic of Korea. Objectives: This study sought to assess factors associated with disaEility of tension-type headache (TTH) using data of the Korean Headache survey (KHS). Background: Although tension-type headache (TTH) is mostly mild in symptoms, it causes disaEility in some individuals. Understanding the socio-demographic and 6

Headache patient was afraid to open her Maw to chew, talk or Erush her teeth as these would provoke her TN. Several paroxysms of left trigeminal neuralgia producing Maw clenching and left facial spasm were oEserved. ,ntravenous lidocaine was initiated at 1 mgmin and then 2 mgmin. Within an hour of starting lidocaine, her pain decreased signi¿cantly. As her pain improved, patient was aEle to chew solid foods and Erush her teeth. Results: At her  month follow-up, she reported recurrent symptoms although intensity of interictal pain and TN frequency had signi¿cantly reduced. She was having 1-2 episodes of TN weekly, and her interictal pain as 1 out of 10. Conclusion: ,n patients with trigeminal neuralgia with concomitant chronic facial pain central facilitation of trigeminal nociceptive processing was oEserved indicating overactive central sensory transmission. Lidocaine causes Elockade of central sensitization via its action on peripheral and central sodium channels. Lidocaine has short half-life, and its analgesic effect usually wears off quickly following discontinuation. The mechanism for prolonged action of lidocaine after discontinuation of infusion is unknown. This case report demonstrates that intravenous lidocaine may Ee considered for patients with intractaEle TN.

inciting event. Headaches were most commonly descriEed as pressure-like and frontal in location with 5 Eeing gloEal or Eilateral in distriEution. 69 of patients had associated migrainous features of which photophoEia and phonophoEia were the most common (6 each), followed Ey nausea (3). 1 of the patients had a history of episodic migraine or some other primary headache disorder prior to the diagnosis of ND3H and 53 had a positive family history of headaches. Conclusion: The etiology of ND3H is not well understood. Our data suggest that ND3H is an uncommon diagnosis, even in the quaternary headache center setting. Of the 359 patients seen Ey the Stanford Headache group over 2.5 years, 36 (1) had ND3H and 8 (2) had post-traumatic headache (3TH), while 260 (3) had a diagnosis of migraine with the remainder of patients having other primary and secondary headache disorders. Based on our review, ND3H seems to have a slight gender preference toward males. ,n the maMority of cases, there does appear to Ee a precipitating incident, with viral infection Eeing the most common. Given this association, the question arises whether ND3H should Ee more properly classi¿ed as a secondary headache disorder, similar to 3TH. A comparison with Stanford’s 3TH population is currently in process. Further research is needed to Eetter understand the underlying mechanism of ND3H to Eetter guide more effective treatment options.

P113 Identifying New Daily Persistent Headache in a Quaternary Headache Center Boykoff, N.; Hindiyeh, N.A.; Aurora, S.; Cowan, R. Stanford, Menlo park, CA, USA.

P114 Different Therapeutic Strategies Are Needed in Patients with Spontaneous Intracranial Hypotension or PostDural Puncture Headache: Retrospective Review Kim, J.; Lee, J.; Oh, J. Neurology, Chungnam National University Hospital, DaeMeon, RepuElic of Korea.

Objectives: To Eetter understand the etiology and further characterize the features of New Daily 3ersistent Headache (ND3H). Background: ND3H is a rare, poorly understood primary headache disorder characterized Ey an unremitting headache that is daily from onset. Methods: We performed a search of Stanford’s medical records Eetween July 2011 and January 201 via the Stanford Translational Research ,ntegrated DataEase Environment (STR,DE) for the ,CD9 diagnosis code corresponding to ND3H. The proMect was supported Ey N,H CTSA award numEer UL1 RR025. Of the 85 patients coded to have ND3H in our electronic dataEase, 36 met ,CHD ,,,-Eeta diagnostic criteria, leading to further detailed chart review and analysis. The excluded patients did not meet criteria for ND3H, usually Eecause the chart noted a history of a worsening episodic headache disorder or headaches were not daily from onset. Results: Of the 36 patients who met diagnostic criteria for ND3H, 56 of the patients were male and  were female. 53 were Caucasian, 8 were Asian, and 39 were of unknown or other ethnicity. The average age of headache onset was 1 years old. 5 of patients were aEle to indentify an inciting event prior to ND3H onset, 22 could not identify an inciting event and 3 had a possiEle trigger. Of the patients in which inciting event was identi¿ed, 8 had preceding infection (predominantly viral), 26 had undergone recent surgery (3 intracranial, 5 extracranial), . had physical trauma, . had psychological stress, and 11 had some other

Objectives: To elucidate whether initial aEsolute Eed rest is needed in all the patients with spontaneous intracranial hypotension(S,H) or post-dural puncture headache(3D3H). Background: Spontaneous intracranial hypotension(S,H) and post-dural puncture headache(3D3H) are common causes of orthostatic headache. Treatment of these headache ranges from conservative management to invasive procedures. Conservative management like prolonged Eed rest is dif¿cult to maintain, as it causes proElems like neck pain and multiple somatic pains. So we tried to make effective therapeutic strategies of the management of S,H and 3D3H. Methods: We reviewed medical records of 2 patients admitted in Chungnam National University hospital with orthostatic headache from Jan 2010 to FeE 2013, retrospectively. All the patients met the diagnostic criteria of ,CHD-,,. ,f their symptoms did not resolve spontaneously with hydration and Eed rest, treatment with EB3 was done in all patients. Results: Thirty three patients were S,H, and 39 patients were 3D3H. 20 patients (85) with S,H received single or repeated EB3. 20 out of 21 patients (95) with S,H whose myelogram had CSF leakage did not improve Ey ABR and required EB3. Eighty percents (n=25) of 3D3H caused Ey lumEar puncture, nerve Elock, or spinal anesthesia 68

June 2014 spontaneously improved Ey ABR. Fifty percents (n=) of 3D3H caused Ey acupuncture and discectomy needed repeated EB3. Conclusion: Orthostatic headache should consider the therapeutic strategy Ey its cause or whether presenting evidence of active leakage. S,H patients who have evidence of leakage in MR myelogram should get early EB3. ,nitial treatment of 3D3H caused Ey lumEar puncture should Ee treated Ey conservative management of Eed rest. But, if 3D3H is caused Ey acupuncture and discectomy, EB3 could Ee the initial treatment.

P116 Auditory Hallucinations Associated with Primary Headache Attacks: Descriptive Case Series and Literature Review RoEEins, M.S.1; GrosEerg, B.1; Crystal, S.C.2; Miller, E.E.1 1 Neurology, Monte¿ore Headache Center, AlEert Einstein College of Medicine, Bronx, NY, USA; 2Neurology, New York Headache Center and New York University Langone Medical Center, New York, NY, USA. Objectives: To descriEe the phenomenology of auditory hallucinations (paracusias) associated with primary headache attacks to yield insights into their clinical signi¿cance and pathogenesis. Background: ,solated oEservations have documented a rare association of migraine with auditory hallucinations. Unlike visual, somatosensory, language, motor, and Erainstem symptoms, paracusias in the acute headache attack setting are not a recognized aura symptom Ey the ,nternational Classi¿cation of Headache Disorders (,CHD3-Eeta), and no systematic review has addressed this association. Methods: We retrospectively studied patients experiencing paracusias associated with headache attacks at our center (2006-2013) and reported in the literature (through 122013). Results: We encountered 16 patients (our center=, literature=9), 56 of whom were female. At our center, the prevalence was 0.1 among all patients with headache. For those patients where enough data permitted applying an ,CHD-3-Eeta diagnosis, 92 had migraine and 8 had new daily-persistent headache. 56 of total patients suffered from typical migraine aura, and 38 had phonophoEia. Hallucination content most commonly featured distinct human voices (n=9, 56), followed Ey crickets (n=2, 13), ringing Eells (n=2, 13), general white noise (n=2, 13), and repetitive Eeeping (n=1, 6). Regarding timing, 81 experienced hallucinations concurrent with headache, with 19 hearing sounds prior to attacks. 3aracusia duration was frequently 1 hour (n=, 50), Eut occasionally lasted -5 hours (n=1) or the duration of the headache (n=1). None of the patients with aura descriEed an evolutive pattern of their visual symptoms to paracusias. Most patients (n=9, 56) had either a current or previous psychiatric disorder, most commonly depression (56, n=5), Eut only 1 patient had any other symptoms of psychosis. ,n all patients, the course of headache and paracusias were congruent. ,mprovement in Eoth symptoms occurred Eoth spontaneously and often (58) when headache prophylaxis was prescriEed, which included propranolol (n=), topiramate (n=3) and amitriptyline (n=3). Conclusion: 3aracusias are an uncommon co-occurrence with headache disorders, most commonly migraine, and usually feature the sound of human voices. Their timing and high prevalence in patients with depression may suggest that paracusias are not necessarily a form of migraine aura. Other possiEle mechanisms include perfusion changes in primary auditory cortex, serotonin-related ictal perceptual changes, or release phenomenon in the setting of phonophoEia with avoidance of a noisy environment.

P115 Multifocal Multiform Nummular Headache (NH): A Case Report WroEel GoldEerg, S.; GrosEerg, B.; VollEracht, S. Headache, Monte¿ore Headache Center, New York, NY, USA. Objectives: DescriEe the ¿rst case of multifocal, multiform NH. Background: NH is a rare headache disorder characterized Ey sharply contoured pain ¿xed in size and shape within a round or elliptical region of the head. These headaches are typically unilateral, side-locked, ¿xed in one speci¿c location, although multifocal presentations of similar shape have Eeen reported. We report the ¿rst case of multifocal NH presenting with varied shapes and sizes. Methods: Case report and literature review. Results: We present a 52-year-old woman with an 11-month history of nine focal well-circumscriEed mirrorimage areas of head pain in Eilateral frontal regions (ovals measuring  cm x 6 cm), Eilateral parietal regions (ovals measuring 3 cm x 6cm), Eilateral parasagittal regions (vertical rectangles measuring 1 cm x  cm), vertex (a single horizontal rectangle measuring 1 cm x 5 cm), and Eilateral parasagittal-parietal regions (diagonal rectangles measuring 1 cm x  cm). 3ain was sharp, severe and continuous. 3alpation of the cranium demonstrated dysesthesias, allodynia, and tenderness within the affected regions, Eut no alopecia or lesions. Extensive serologic testings, MR, Erain with gadolinium, MRA head and neck, and MR, cervical spine were normal. Treatment with daily doses of nortriptyline 85mg, pregaEalin 300mg, topirimate 100mg, celecoxiE 100mg and a total of 290 units of onaEotulinum toxin type A inMected every three months into the affected regions, resulted in reduction in the frequency and intensity of headaches over 2 years of follow-up (¿ve mild headaches per month). Conclusion: This patient ful¿lls most of the ,nternational Headache Society diagnostic criteria (,CHD-3 Eeta) for NH except that two of the affected regions were rectangular, instead of round or elliptical in shape. This is the ¿rst case of simultaneous multifocal NH presenting with varied shapes and sizes, expanding the spectrum of this disorder and suggesting that different shapes could Ee incorporated in future criteria.

69

Headache P117 Accumulative Blindness and Persistent Visual Auras in the Setting of Migraine: Role of Calcium Channel N-type and P/Q-type Antibodies? Weiss, D.L.3; Schatz, N.1; SheEert, R.T.2; Monteith, T.S.2 1 Ophthalmology, University of Miami School of Medicine, Miami, FL, USA; 2Neurology, University of Miami School of Medicine, Miami, FL, USA; 3University of Miami Miller School of Medicine, Miami, FL, USA.

last attack over a year ago, Eoth visual auras (descriEed as Àuctuating kaleidoscopes) and allodynia persist. She is currently on oral magnesium and reports no maMor attacks. Conclusion: We descriEe a case of a patient with permanent scotomas during migrainous attacks. Her history and persistent visual perturEations suggest a possiEle channelopathy. ,schemic, inÀammatory or metaEolic processes are plausiEle. The role of calcium channel N-type and 34-type antiEodies remains unclear.

Objectives: The aim of this case report is to discuss an unusual case of repetitive attacks of permanent scotomas and persistent visual auras during migraine attacks. Background: Repetitive attacks of Elindness during migraine are rare. Herein, we descriEe a case of recurring attacks of permanent visual de¿cits and persistent positive visual auras. 3ermanent de¿cits have Eeen seen in migraines in association with ischemia of the retina and optic nerve; LeEer hereditary optic neuropathy (LHON); and CereEral Autosomal Dominant Arteriopathy with SuEcortical ,nfarcts and Leukoencephalopy to name a few. Methods: A 28 year-old woman with congenital nystagmus presented to clinic for evaluation of visual loss in the setting of headache. Her ¿rst migraine was at age 11. She has a longstanding history of phonophoEia and osmophoEia. Her family history is signi¿cant for congenital nystagmus, migraine with aura, and hypothyroidism. At age 16, she developed attacks of migraine with aura, persistent vomiting, phonophoEia, and photophoEia. Although the headaches resolved, her visual ¿eld de¿cits persisted. She has had 11 of these episodes over a decade with periods of decreased vision and scotoma, followed Ey partial visual recovery. Results: Records over the years showed Eilateral visual acuities Àuctuating from 2020 to less than 10200 proximal with severe headache episodes and eventual recovery near Easeline. The most recent neurological exam showed Eilateral optic atrophy and left nasal scotoma. Ophthalmologic exam revealed esotropia of 20 prism diopters and latent nystagmus present when occluding either eye. Visual acuity was 2025 -1 OD and 2020 OS. Visual ¿elds showed an inferonasal arcuate superior nasal step on the right and a superonasal arcuate inferior nasal step on the left. Likewise, visual ¿eld tests showed increased contraction near maMor attacks with some recovery months after. Average retinal nerve ¿Eer layer (RNFL) thickness was +m OD and 51+m OS. RNFL thickness was Eelow 1 of predicted on right superonasal inferior temporal and left superotemporal inferior regions. ,nitial contrastenhanced MR, at age 11 showed an increased signal at the right caudate head; a repeat study 1 years later showed a proEaEle chorodoidal cyst in the left hippocampus. Spine imaging was normal. S3ECT, EMG, CSF oligoclonal Eands, NMO antiEodies, and autoimmune titers were all negative. Genetic screening for common LHON mutations was negative; genome analysis is pending. On ¿ve occasions, paraneoplastic investigations showed elevated voltage-gated calcium channel N-type and 34-type antiEodies, which were -.5 times and 5-16.5 times the normal reference ranges respectively. She was treated with ,V steroids or ,V,G without oEvious success. Despite her

P118 Occipital Neuralgia after Metastatic Tonsilar Squamous Cell Carcinoma Green, L.; Ugurlu, C.; Sahai-Srivastava, S. Neurology, University of Southern California, Los Angeles, CA, USA. Objectives: To descriEe a patient who developed occipital neuralgia secondary to metastatic tonsillar squamous cell carcinoma (TSCC) and to review literature of similar cases. Background: Occipital neuralgia (ON) is characterized Ey paroxysms of pain occurring within the distriEution of the greater andor lesser occipital nerves. Known secondary causes include closed head inMury, direct occipital nerve trauma, neuroma formation, or upper cervical root compression, the maMority of patients have no demonstraEle lesion. Most articles suggest prevalence in the general population of Eetween 0. and , other reports from specialty clinics report higher rates, as high as 16. ON has Eeen reported as the only symptom in a patient with a foramen magnum meningioma. BallesterosDel Rio et al. reported a case of ON Secondary to Greater Occipital Nerve Schwannoma. Clavel et al. reported a case of a 8-year-old woman suffering from right ON with imaging demonstrating an irregular Eone mass in the C-2 verteEral Eody. There have Eeen no reported cases of occipital neuralgia due to metastatic lesion affecting the occipital nerve. Methods: This is a case report and review of literature. Results: 62-year old right handed male with metastatic carcinoma Eegan experiencing posterior headaches 1 year ago. He was aphonic due to removal of his larynx and wrote all responses. The pain was located in the right occipital region and radiated into the frontotemporal area and right ear. ,t was constant, ranging Eetween 2-910 on the pain scale. A maMor concern was for the patients’ quality of life. The pain Eothered him more than the disease itself. The patients’ past medical history is signi¿cant for TSCC with metastasis to the regional lymph nodes, pharynx, larynx, Ease of tongue, and thyroid loEe. His cancer was treated with multiple surgeries, radiation, and chemotherapy. ,maging done 3 months prior to our clinic presentation was reported normal. 3hysical exam was signi¿cant for tenderness over the affected nerve and ON was con¿rmed Ey complete resolution of pain with occipital nerve Elock. Then conservative management continued with nortriptyline and physical therapy. MR, was repeated with a time interval of 3 months showed skull Ease metastasis and enhancing tissue extending into the right perimedullary cistern with mass effect on the right side of the medulla. A T2 hyperintensity was noted in the 0

June 2014 C2 nerve root. Radiofrequency aElation (RFA) of C2 nerve root was done Eecause the occipital nerve Elock resolved the pain. The patient remains pain free two months post RFA. Chemotherapy with ErEitux for new metastatic lesions was resumed and a follow up 3ET scan showed interval marked response to treatment in the right Ease of the skull lesion. Conclusion: One case is descriEed in which occipital neuralgia developed after squamous cell carcinoma metastasized to the C2 nerve root. We hypothesize that the lesion triggered new onset occipital neuralgia. ON with a history of head and neck cancer should Ee imaged with contrast to evaluate c23 area. For patients with ON secondary to cancer consider early RFA for pain improvement and Eetter quality of life. More research is necessary to con¿rm our ¿ndings.

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Program Author Index Authors -AAErouk, N. ................................................. 325 Ahn, A.H. ........................................... 38, 385 Ailani, J. .................................................. OR16 Akerman, S. ............................ OR, OR9, 39 Ali, A. ......................................................... 366 AliEhoy, A. ......................................... 329, 386 Allen, ,.E. .................................................. OR5 Allen, J.R. .......................................OR1, 31 Alvarez, R. ................................................. 321 AmErose, C.E. ............................................ 3 Andreou, A.3. .......................................... OR12 Angst, M.S. ................................................ 325 Ansari, H. ................................................... 333 Arango, J. ................................................... 365 Assaf, A. ..................................................... 31 Atalay, Y. .................................................... 32 AuEe, M. ...................................................... 31 Aurora, S. ......................................... 3, 3113 Aurora, S.K. .................................33, 315, 318 Ayata, C. ............................................OR3, 32 -BBaek, S. .................................................... 3103 Baggaley, S. ......................................OR8, 36 Barad, M. ............................................. 38, 3 Barch, C. .................................................... 3 Basile, A.S.................................................... 3 Batizy, L. .................................................... 39 Baykan, B........................................... 358, 380 Becker, W. ............................................ 31, 318 Bell, K.R. ................................................ OR15 Berger, A. ................................................... 311 Bernstein, M............................................... 336 Bevilaqua-Grossi, D...................316, 320, 332 BhamEri, R. ........................................ 310, 38 Bigal, M. .................................................... 332 Bigal, M.E. ........ 316, 320, 329, 338, 339, 386 Black, A...................................................... 399 Blake, 3. ..................................................... 335 Blumenfeld, A.M. ...................OR16, 315, 318 Boykoff, N. ...................................... 3, 3113 Brennan, K.C. . OR2, OR8, OR10, OR13, 33, 36 Bronson, M. .......................329, 338, 339, 386 Bulger, R. ................................................... 30 Burch, R. .................................................. 3106 Burstein, R. ................................................ 335 Buse, D.C. .....OR6, 31, 318, 35, 32, 310, 3108 Byczkowski, T. ........................................... 38 -CCadle, R........................................................ 39 Cady, R.K. ......... 39, 322, 323, 32, 33, 3110 Cady, R.J. ...........................39, 322, 323, 3110 Caparso, A. ......................................... 351, 31 Carothers, J. ....................................... 32, 33 Carvalho, G. ....................................... 320, 332 Caudle, R.M. .............................................. 38 Cernuda-Morollon, E. ................................ 321 ChamEerlain, J. ....................................... OR12 Chan, S. ...................................................... 38 Charles, A................................................ OR20 Chaudhry, 3. ............................................. 3112 Chaves, T. ........................................... 320, 332 Chaves, T.C. ............................................... 316 Chen, S. ..................................................... OR3 Cho, S......................................................... 396

Chou, D.E......................................ORWA, 39 Christie, C.C............................................... 33 Christie, S..................................................... 31 Chu, M. .................................... 361, 396, 3111 Chung, C. ..................................................3111 Chung, Y..................................................... 396 Clark, E.J.................................................. 3110 Conidi, F. .................................................... 30 Cooper, M.E. .............................................. 383 Cooper, W................................................... 33 Copsey, C. .................................................. 36 CorEell, C. .................................................. 311 Cortez, M. .................................................. 33 Couch, J.R. .............................................. OR18 Cowan, R.................................. 30, 3, 3113 Crudup, B.M. ............................................. 398 Crystal, S.C. ............................................. 3116 Curta, A. ..................................................... 38 Cutrer, F.M. ........................................ 331, 333 -DD Biase, L. ................................................. 319 Dach Eckeli, F. ...........................316, 320, 332 Datta, S....................................................... 30 Davani, A. .................................................. 390 Davar, G. ....................................33, 3, 35, 3 Davenport, W. .............................................. 31 Davis, R.E. ................................................. 3 Dayal, A.K. .............................................. 3109 De Col, R. ............................................... OR11 DeLange, J.M. .......................................... 3101 DerEy, C. .................................................. 3108 Di 3iero, V. ................................................. 319 Diaz, E........................................................ 350 Diazgranados-Sánchez, J. .......................... 312 Dickinson, G. ............................................... 31 Diener, H. ................................................... 318 Digre, K.............................................OR8, 36 Dikmen, S. .............................................. OR15 Dilli, E. ......................................................... 31 Dimayuga, J.S. ........................................... 331 DMupesland, 3.G.................................. 32, 33 Dodick, D. ....................................31, 31, 353 Dodick, D.W. ..................................... 318, 32 Druyts, E. ........................................... 310, 38 Durham, 3................................................ OR1 Durham, 3.L. ............................................ 3110 -EEapen, S. .................................................... 38 Earl, N.L................................................. 33, 35 Eaton, K. ...................................................... 38 EErahim, S.................................................. 38 Eikermann-Haerter, K. ......................OR3, 32 EisenEerger, A. ......................................... 310 Ekizoglu, E................................................. 380 Elchami, Z. ......................................... 350, 39 Eller, M. ................................................ ORWA Ertas, M. ..................................................... 358 Escandon, R. ......................329, 338, 339, 386 Evans, C. .................................................... 315 -FFallah, A. .................................................... 390 Fanning, K........................................ 35, 3108 Fanning, K.M. ............................................ 32 Farmakidis, C. .......................................... 3109 Farrell, C.3. ............................................... OR8 Ferracini, G.N. ........................................... 316

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Ferrari, M. ................................................. OR3 Fillingim, R.B. ........................................... 385 Flitman, S. ................................................ 3102 Florencio, L. ............................................... 320 Florencio, L.L. ........................................... 332 Foote, H.L. ................................................. 398 Frey, W.H. .................................................. 325 Fried, N.T. .................................................. 383 Friedman, B............................................... OR1 Friedman, D.,. .......................OR19, 35, 3112 Fuh, J. ......................................................... 360 -GGadient, 3. .................................................. 328 Gadient, 3.M............................................... 331 Garza, ,. ............................................ 36, 3101 Gaul, C. ...................................................... 351 Gelfand, A.A. ............................................ OR5 Georges, J. ................................................ 3102 Giammarco, R. ............................................. 31 Gillard, 3.J. ......................................... 315, 318 Gladstone, J. ................................................. 31 GoadsEy, 3.J. .............OR, OR5, OR9, ORWA Gonçalves, M.C. ........................................ 320 Gonçalves, M. ............................................ 332 Goodman, A. .............................................. 351 Green, L. .................................................. 3118 Gren, L.H. ................................................. OR8 GrosEerg, B. .................32, 310, 3115, 3116 -HHaghdoost, F. ............................................. 363 Halker, R.B. ............................................... 353 Hanashiro, S. ............................................ 3100 Harding, T. ................................................... 36 Hawkins, J. .............................................. OR1 Haziot, M.E. ............................................... 38 Herial, N..................................................... 39 Hershey, A.D. ................. OR1, 31, 36, 368 Hillerup, S. ................................................. 31 Hindiyeh, N. ............................................... 3 Hindiyeh, N.A. ......................................... 3113 Hirayama, T. ............................................. 3100 Hoffman, J............................................... OR15 HoldErook, F. ...................................33, 35, 3 Holden, A. .................................................. 32 Holt, J. ................................................ 38, 385 Horn, 3........................................................ 36 Horvat, M. .................................................. 391 Houle, T.T........................................... 3, 399 Hunter, L. ................................................... 33 -I,keda, K. ................................................... 3100 ,shikawa, Y. .............................................. 3100 ,ssa, M. ............................................... 350, 39 ,uliano, S. ................................................... 36 ,wasaki, Y. ................................................ 3100 ,zumi, R...................................................... 325 -JJacoEs, D. ................................................... 325 Jawahar, A. ................................................. 388 Jensen, R. ........................................... 351, 31 Johnson, Y.L. .............................................. 399 Johnston, M.M. ....................................... OR20 Jordan, M. .................................................. 385 Jordan, S.................................................. OR20 Joshi, S. .............................................. 326, 369

June 2014 Joyce, A. ..................................................... 33 Jürgens, T. .................................................. 31 -KKaEEouche, M. ............... OR1, 31, 36, 368 Kacperski, J. ................... OR1, 31, 36, 368 Kaiser, R..................................................... 395 Kanters, S. .......................................... 310, 38 Kao, M. ........................................................ 38 Karli, N. ..................................................... 358 Kashikar-Zuck, S.M. .......................OR1, 31 Kaufmann, D. ............................................ OR2 KawaEe, K................................................ 3100 Kellerman, D. ......................................... 33, 3 Kelley, B. ................................................. 3105 Keough, G. ................................................ OR8 Khan, K.J. ........................................ 352, 310 Kim, B. ..................................... 3111, 361, 3 Kim, J. ............................ 396, 3111, 311, 3 Kim, W. .............................................. 361, 396 KimElin Licht, H. ....................................... 33 King, C.D. .................................................. 385 Ko, S. ................................................. 382, 393 Kocasoy Orhan, E. ..................................... 358 Kozminski, M. ............................................. 32 Krel, R. ............................................... 326, 389 Kumar, M. .................................................. 388 Kumar, S. ................................................... 388 Kurowski, B. .............................................. 38 Kurth, T. .................................................... OR Kuruvilla, D.E. ................................. 32, 310 -LLacey, D.J................................................... 330 Lagman-Bartolome, A................................ 35 Lai, H. ........................................................ 315 Lainez, J. .................................................... 351 Lanau, S. .................................................... 365 Landy, S.H. ................................................ 398 Lane, C.J. ................................................... 336 Lantéri-Minet, M........................................ 351 Larrosa, D. ................................................. 321 Lawler, V. ................................................... 35 Laws, E.R. .................................................. 36 Lay, C. ........................................................ 35 LeCates, S.L. ...................................OR1, 31 Lee, C. .......................................................3111 Lee, J. ....................................................... 311 Lee, K....................................................... 3103 Lee, R. ........................................................ 390 Lee, S. ...................................................... 3103 Lee, Y. ...................................................... 3103 Leroux, E...................................................... 31 Leung, A..................................................... 390 Lew, D. ....................................................... 336 Lin, L.......................................................... 390 Lipton, R.B...OR6, 318, 32, 35, 3108, 3109 Loder, E.W. ............................................... OR1 Lucas, S. .................................................. OR15 -MMagayano, D. ............................................. 350 Mahmoud, R.A................................... 32, 33 Manack, A.N. ............................OR6, 31, 32 Manh, C...................................................... 33 Maniyar, F. ............................................ ORWA Manley, H.R. ......................39, 322, 323, 3110 Manouchehri, N. ........................................ 363 Martin, A.T. ................................................ 359 Martin, V.T. ....................35, 359, 3108, 3110 Martinez, O.D. ........................................... 365 Martínez-CamElor, 3. ................................. 321 Martins Oliveira, M. ................................. OR9

Massaro, M.M. ........................................... 365 Massoud, R. ............................................... 350 Mathew, 3.G. ..............................326, 35, 392 May, A. ....................................................... 351 McAllister, 3....................................... 32, 33 McCrea, S.K............................................... 395 Mechanic, J. ............................................... 325 Mendez, J.M............................................ OR10 Messali, A. ................................................. 311 Messina, J........................................... 32, 33 Messlinger, K. ......................................... OR11 Miller, E.E. ............................................... 3116 Mills, E............................................... 310, 38 Minen, M.T. ......................................OR1, 369 MiramEel, A. .............................................. 350 Mirchandani, D. ......................................... 389 Monteith, T. ................................................ 369 Monteith, T.S............................................ 311 Montoya, L................................................. 365 Monzillo, 3.H. ............................................ 38 Moriarty, M. ............................................... 356 Moynahan, A.3. .......................................... 311 Moynahan, V.L. .......................................... 398 Mueller, L................................................... 31 Müller, O. ................................................... 31 Munoz, J..................................................... 312 Murata, K. ................................................ 3100 Musonza, T. ................................................ 36 Mutgi, S.A.................................................. 3 -NNandmer, V.K............................................. 313 Nemoto, 3.H. .............................................. 38 NeuEert, J. .................................................. 38 NeuhuEer, W............................................ OR11 Newman, L................................................... 35 Nicholson, R.A........................................... 362 -OO’Brien, H...................... OR1, 31, 36, 368 Oas, J.G. ........................................... 3, 3105 Oge, A. ....................................................... 380 Oh, A. ................................................. 322, 323 Oh, J. ........................................................ 311 Oh, K. ......................................................... 396 Orr, S.L. ....................................................... 31 Oshinsky, M.L. ........................................... 383 Oster, G. ..................................................... 311 -P3ark, H. .............................................. 382, 393 3ark, J......................................................... 361 3ascual, J. ................................................... 321 3assarelli, F. ............................................... 319 3avlovic, J. ....................................... 318, 3108 3eng, K....................................................... 360 3erry, C. ..................................................... 335 3eterson, J. ................................................. 33 3etolicchio, B. ............................................ 319 3im, H. ......................................................... 31 3inney, S.M. ............................................... 359 3ippitt, K. ..........................................OR8, 36 3irmohamed, F. .......................................... 355 3ohl, S. ...................................................... OR8 3olston, G................................................... 390 3owers, S.W. ...................................OR1, 31 3uche, M. ................................................... 31 -Q4in, T. ....................................................... OR3

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-RRains, J. ...................................................... 3 Ramón, C. .................................................. 321 Ramos, E. ........................................... 310, 38 Rangel, N. .................................................. 365 Rausch, J. ........................................OR1, 31 Reed, K. ..................................................... 30 Reed, M. ................................................... 3108 Reed, M.L. .................................318, 32, 35 Rexrode, K.M............................................ OR Rizzoli, 3. ................................................... 36 RoEEins, M.S. .....................OR16, 3109, 3116 RoEertson, C.E. ........................36, 35, 3101 Rodrigues, A.B. .......................................... 316 Roland, M. ......................................... 3, 398 Romero Reyes, M. ..................................... 39 Rosa, K....................................................... 315 Rostgaard, J. ............................................... 31 Rothner, A. ................................................. 366 Rueda-Sánchez, M. .................................... 312 Ryan, S. ...................................................... 328 -SSaadatnia, M. ............................................. 363 Sager, 3. ...................................................... 329 Sahai-Srivastava, S. ........336, 33, 352, 310, 3118 Saip, S. ....................................................... 358 Sanderson, J.C............................................ 318 Sawada, M................................................ 3100 Sawant, 3. ................................................ OR13 Schankin, C. .......................................... ORWA Schatz, N. ................................................. 311 Schoenen, J. ............................................... 351 Schueler, M. ............................................ OR11 Seidel, J. .................................................... OR3 Seng, E. ...................................................... 369 Serrano, D. .....OR6, 31, 318, 32, 35, 3108 Shah, 3. ....................................................... 388 SheEert, R.T.............................................. 311 Sheikh, H.................................................. 3106 Shenk, C. .........................................OR1, 31 Shin, D. .................................................... 3103 Shukla, S. ................................................... 390 SilEerstein, S. ............................................. 311 SilEerstein, S.D. ........................................... 3 Silva, F. ...................................................... 312 Silva, G.S. .................................................. 38 Siva, A. ....................................................... 358 Slater, S. ......................... OR1, 31, 36, 368 Slayton, R.M. ............................................. 362 Smith, B.M. ............................................. OR15 Smith, J.H........................................... 328, 331 Smith, T.R. ................................................. 362 Smith, V.D. ................................................. 331 Smitherman, T.A. .......................3, 398, 399 Song, D.D................................................... 390 Sozer-Topcular, N. ..................................... 380 Speciali, J.G. .............................................. 316 Spierings, E.L..................................... 32, 33 Spinner, D. ......................................... 326, 389 Sprenger, T. ........................................... ORWA Stewart, K.E. ........................................... OR18 Stewart, W. ................................................ OR6 -TTakazawa, T.............................................. 3100 Takeuchi-Tan, Y. ........................................ 312 Tarrasch, J. ...................................39, 322, 323 Tatulli, D. ................................................... 319 Temkin, N. .............................................. OR15 Tepper, D. ................................................... 391

Headache Tepper, S.J. ........................................... 35, 391 Theriot, J. ........................................OR10, 33 Thirucote, R. .............................................. 325 Thorlund, K. ....................................... 310, 38 TietMen, G. .................................................. 39 Timm, N. .................................................... 38 ToEin, J.A. ................................................ 3102 Tsai, A.M. ................................................... 390 Turkish Headache study group, T. ............. 358 Turner, ,........................................................ 36 -UUgurlu, C.......................................... 33, 3118 Utley, C. ..................................................... 39 -VValenti, J..................................................... 39 van den MaagdenEerg, A. ......................... OR3 VanvalkenEurgh, 3...................................... 381 Varon, S.F. .................................................. 318 Vaughan, 3. ......................................... 36, 368 Velez, A.L................................................... 365 Vicenzini, E. ............................................... 319

Viganò, A. .................................................. 319 ViM, B. ......................................................... 391 Vincent, M.B. ............................................. 318 Volcy Gomez, M. ....................................... 365 VollEracht, S. ............................................ 3115 Vota, S. ....................................................... 355 Vutien, 3. .................................................... 391 -WWaMnszstaMn, D. .......................................... 389 Walter, S. ............................329, 338, 339, 386 Walters, A. .................................................. 3 Wang, S. ............................................. 318, 360 Weiss, D.L. ............................................... 311 WeizenEaum, E. ......................................... 36 White, L. .................................................... 39 Will, K. ....................................................... 30 Winner, 3. ..................................................... 3 Winter, A. .................................................. OR Woldeamanuel, Y. ...................................... 30 Wood, B. .................................................... 36 WroEel GoldEerg, S. ................................ 3115 Wu, 3. ......................................................... 310



-XXie, C. ........................................................ 359 -YYalcin, N. ................................................... 32 Yanagihashi, M. ....................................... 3100 Yang, K. ..................................................... 361 Yang, M. ..................................................... 315 Yeomans, C. ............................................... 325 Yeomans, D.C. ........................................... 325 Young, W. ................................................... 395 Yount, B. .................................................... 362 Yu, E........................................................... 32 Yun, C. ....................................................... 361 -ZZafar, M. .........................................OR1, 31 Zandifar, A. ................................................ 363 Zandifar, S. ................................................. 363 Zarfo÷lu, M. ............................................... 358 Zha, A.M. ................................................. 3105

Abstracts of the 56th Annual Meeting of the American Headache Society, June 26-29, 2014, Los Angeles, CA.

Abstracts of the 56th Annual Meeting of the American Headache Society, June 26-29, 2014, Los Angeles, CA. - PDF Download Free
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