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• W4281747797 abstract "Disaster events have been associated with a high need for headache care in the weeks and years that follow,1, 2 and may be associated with an increase in migraine prevalence.3 In the summer of 2018, severe floods and landslides devasted areas of Japan. In this issue of the journal,4 Okazaki et al. utilized data from the National Database of Health Insurance Claims, a public health insurance system in which all Japanese citizens are enrolled, to identify victims of the floods (as certified by residential local government). They compared the cumulative incidence of new prescriptions for migraine-specific acute medications (triptans or ergotamine) between victims versus non-victims in the year following the disaster. They also examined the incidence of new migraine preventive prescriptions, and the number of acute medication tablets prescribed. The authors found that victims of the flood were more likely to be newly prescribed acute migraine treatment, (0.70% of victims vs. 0.43% of non-victims, adjusted hazard ratio 1.68; 95% confidence interval [CI] 1.39–2.02), and to be prescribed a higher number of tablets. In contrast, the incidence of new migraine preventive prescriptions did not differ (adjusted hazard ratio 1.18; 95% CI 0.49–2.85). These results imply that following exposure to a natural disaster, people with migraine may be more likely to develop worsening of migraine attacks. Clinicians should be made aware of this, and have a lower threshold for optimizing treatment if attacks start to intensify, rather than allow for watchful waiting. Importantly, even before the flood the prevalence of migraine was higher in the group that ultimately became flood victims than in the non-victim group. They speculate that this may be because those who were living in the low-lying, flood-prone areas, where housing is less expensive, are more likely to be from more disadvantaged socioeconomic backgrounds. It is well established that migraine is more prevalent in people who are less affluent,5, 6 a social determinant of health that urgently needs to be addressed. However, this likely difference in epidemiology between victims and non-victims was not the cause of the main study findings. By comparing the incidence rates of new prescriptions for triptans and ergotamine in the six months immediately preceding the flood, the authors demonstrate that incidence of new prescriptions did not differ between groups pre-flood. It is only a couple of months after the flood that incidence rates of new acute prescriptions diverged between groups on the Kaplan-Meier curves (see figure 1), and then remained higher in the victim group for the remainder of the 12-month follow-up. The reason for the apparent delayed effect of disasters on migraine is not clear. It may be that in the first days to weeks after a natural disaster, people are focused on survival and not yet able to schedule an appointment and get to an outpatient clinic to discuss their headaches with a clinician and be provided with a new prescription. Alternatively, the worsening in headache pattern that a natural disaster precipitates may occur in a delayed fashion as observed in studies assessing the “let-down headache” hypothesis. Proposed mechanisms include sustained secondary trigger exposure during a period of intense perceived stress such as missed medications, skipped meals, and diminished sleep; increased stress vulnerability directly in people with migraine in the premonitory phase; and falling of endogenous glucocorticoid tone when the hypothalamic-pituitary axis deactivates after onset of a stressful period.7 Evidence from a large population-based study demonstrates that a stressful life event, such as change of residence, employment, marriage, child issue, death of a loved one, and “extremely stressful” ongoing situations, may be a risk factor for developing chronic daily headache within one year.8 The current study demonstrates that natural disaster preparedness is an important part of migraine management, and that we need to consider it as clinicians and counsel our patients regarding how to prepare. Patients may enter our practice upon settling in a new area after displacement by a natural disaster. Cognizance of the patient experience impacting their migraine pattern, and the amount of treatment needed, can guide clinical decision-making. Clinicians may want to have a lower threshold for starting or escalating preventive treatment if they know a patient has just experienced a natural disaster. If the headache pattern worsening following disasters is a delayed effect, there are opportunities to intervene and help prevent migraine chronification. Future studies of migraine prediction models for more day-to-day perceived stress may need to assess singular disaster events and the migraine attack patterns that follow.9 Though it is interesting that new prescriptions for migraine preventive treatment did not correspondingly increase in the victim group along with the number of new acute treatment prescriptions, this may represent a missed opportunity for intervention. As the authors suggest, “physicians should provide prophylactic medications for patients with migraine when a natural disaster occurs.” The advent of telemedicine, accelerated by the COVID-19 pandemic, may mitigate adverse migraine outcomes following regional or global events or disasters. In natural disasters with geographic displacement and disrupted transportation impacting both patients and clinicians, telemedicine may provide better continuity of care.10 However, inequities in telemedicine access clearly need to be addressed.11, 12 As natural disasters can occur anywhere and potentially without warning, it is worth discussing with patients the need to have a plan for their migraine treatment—even if medical care access is transiently disrupted. Just as patients with epilepsy are encouraged to keep extra seizure medication on hand in the event of a need to evacuate, patients living with migraine also may benefit from such contingency planning. To facilitate this, insurers and clinicians may need to be more flexible regarding how many medication doses/month they provide to patients. For example, if a clinician usually limits triptan tablets to 9/month to help prevent medication-overuse headache, providing more tablets on at least one prescription might be necessary to allow patients to stockpile extra doses to keep with their evacuation “go bag.” Using a 90-day prescription method may also provide an inherent buffer. Given the high prevalence of migraine, hospitals and disaster planning medical response teams should anticipate an increase in people seeking care for migraine and have prescription acute treatments on hand in the months following a disaster. Table 1 provides a more detailed list of possible considerations, including both what clinicians can counsel patients to do ahead of time to be better prepared for a natural disaster, and what clinicians and disaster management personnel can do to prepare for an increased migraine treatment need after a disaster. The manuscript by Okazaki et al. adds an additional perspective on the social determinants of health that can impact migraine, by sharing the multiple layers and complexities that natural disasters can have on diagnosis and management. By doing so, they allow clinicians an opportunity to reflect on how we can best meet the needs of our patients the next time one should occur. AAG: In the last 24 months, Dr. Gelfand has received honoraria from UpToDate (for authorship), and stipends from JAMA Neurology for editorial work (last in July 2020) and from the American Headache Society for her role as Editor of Headache. She received grant support from the Duke Clinical Research Institute and the UCSF Resource Allocation Program. Her spouse reports research support (to UCSF) from Genentech for a clinical trial, honoraria for editorial work from Dynamed Plus, and personal compensation for medical-legal consulting. RHS: In the last 24 months, Dr. Halker Singh has received Honoria from Impel and Teva for serving on Advisory Boards (last in 2020). She receives honoraria from the American Headache Society for her role as the Online and Social Media Editor of Headache, and from Current Neurology and Neuroscience Reports for her work as the Headache Section Editor. Her employer receives grant funds from Amgen for a clinical trial for which she serves as PI. MSR: Dr. Robbins serves on the Board of Directors of the American Headache Society and the New York State Neurological Society, the editorial boards of Headache, Continuum, and Current Pain and Headache Reports, and receives book royalties from Wiley." @default.
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• W4281747797 title "Worsening migraine: Another casualty of natural disasters" @default.
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