Adolescents exposed to violence or terror attacks have an increased risk for daily and weekly migraine and tension-type headache (TTH) following the event, according to study findings published in Neurology.

In this study, adolescent survivors of a 2011 mass shooting that occurred on the Utøya islet in Norway were interviewed (n=358) to evaluate the association of migraine frequency and severity with terror exposure. A total of 8 matched controls from the Young-HUNT3 Study were obtained for each survivor.

Primary outcome for this study was recurrent migraine and TTH over a 3-month period prior to the interview. Investigators used a validated headache interview in accordance with the International Classification of Headache Disorders to measure the primary outcome 4 to 5 months following the terror attack.


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A greater percentage of survivors reported experiencing headache more frequently than matched controls. In addition, survivors were 3 times more likely to report daily or weekly headaches than controls.


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According to findings from a multivariable logistic regression analysis adjusted for multiple patient baseline characteristics, prior physical or sexual abuse for survivors was significantly associated with reporting migraine (odds ratio [OR] 6.10 [3.73-9.99], P <.001) and TTH (OR 4.67 [3.12-7.00]; P <.001). In addition, the odds of reporting migraine and TTH following exposure to the violent event was 4.27 (95% CI, 2.54-7.17; P <.001) and 3.39 (95% CI, 2.22-5.18; P <.001), respectively.

For adolescent survivors who are exposed to terror incidents, the investigators suggest “emergency preparedness planning, surveillance, and interventions may need to address survivors’ headaches to hinder chronification and to facilitate recovery.”

Reference

Stensland SØ, Zwart JA, Wentzel-Larsen T, Dyb G. The headache of terror: A matched cohort study of adolescents from the Utøya and the HUNT Study. Neurology. 2018;90(2):e111-e118.

Teprotumumab has potential to be used as monotherapy for the treatment of dysthyroid optic neuropathy (DON), according to data presented at the American Society of Ophthalmic Plastic & Reconstructive Surgery 2021 Annual Meeting, held November 11-12 in New Orleans. 

Dysthyroid optic neuropathy (DON), a complication of thyroid eye disease (TED), that occurs in 5% to 9% of patients, is the result of an expansion of orbital fat or muscles, or both. If left untreated this complication can result in permanent vision loss. Traditional modes of treatment include orbital decompression, systemic glucocorticoids, and radiotherapy, according to the report. Recently, teprotumumab, a human monoclonal antibody targeting the insulin-like growth factor I receptor has been approved by the FDA for the treatment of thyroid eye disease and data suggests use of this therapy leads to a decrease in extraocular muscle size as measured by radiography and has proven to be particularly useful in patients with DON who have not responded to conventional treatments. This study reported on early experiences using teprotumumab as the first-line therapy for treating patients with DON.

This study was performed as a retrospective single-center interventional case series. TED patients included in the study were treated with teprotumumab infusions of 10 mg/kg for the first infusion, followed by 20 mg/kg for subsequent infusions every 3 weeks for a total of 8 infusions. Baseline and post-treatment data gathered included Snellen best-corrected visual acuity (BCVA), pupil exam, color vision, dilated exam, and automated Humphrey visual fields (HVF) after the 2nd, 4th, 6th, and 8th infusions were completed. 

All patients assessed showed improvements in BCVA and HVF in addition to normalization of color vision and relative afferent pupillary defect with teprotumumab treatment. After the second infusion, all patients showed significant improvement in all variables tested. In all cases, clinical improvement remained stable or continued for the full follow-up period. Additionally, no patients required subsequent surgical decompression, steroids, or radiotherapy. With a mean follow-up of 5.5 months, no patients had a recurrence of symptoms. Only 1 mild adverse event was noted, related to muscle cramps, in a single patient. 

Overall, researchers concluded that teprotumumab led to significant improvement in resolving DON in patients with TED and while larger prospective studies are needed, preliminary data indicates teprotumumab is extremely promising. 

The benefits associated with medical cannabis therapy may be overestimated because of inadequate blinding in clinical trials, according to an article published in JAMA Internal Medicine.

David Casarett, MD, MA, of Duke University School of Medicine, Durham, North Carolina, notes that many trials are flawed by inadequate blinding because subjects can distinguish between active cannabis and placebo. In one placebo-controlled crossover trial, 93% of those assigned to the active treatment group first guessed their treatment assignment correctly, whereas only 38% of those assigned to placebo guessed correctly, but almost all (92%) of the participants in the second group guessed correctly when they crossed over to active cannabis.

Inadequate blinding can lead subjects to overestimate the beneficial effects of an intervention. However, Dr Casarett notes that designing a well-blinded study for cannabis therapy is difficult, as most participants can detect the psychoactive properties of active cannabis treatment.

Dr Casarett suggests that randomized clinical trials of medical cannabis should include a psychoactive control, but it is not clear what might best serve as a psychoactive control to cannabis. The control would have to mimic the most prominent effects, such as dry mouth, increased heart rate, and euphoria, while at the same time having no effect on the primary end point. He also suggests recruiting only participants who are naive to cannabis, but this may increase the risk for new adverse effects or addiction in these subjects. Researchers could also assess the adequacy of blinding by questioning participants’ beliefs regarding which treatment group they are in. These assessments could then serve to guide the interpretation of the trial results.


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The author’s final suggestion is to explore the use of cannabis strains that are enriched for cannabidiol, which does not have the psychoactive effects of tetrahydrocannabinol. However, obtaining such tailored strains of cannabis from a reputable source poses a problem. 

Dr Casarett suggests that in the meantime, patients and physicians use caution when interpreting the findings of cannabis trials.

Reference

Casarett D. The Achilles heel of medical cannabis research—inadequate blinding of placebo-controlled trials [published online November 20, 2017]. JAMA Intern Med. doi:10.1001/jamainternmed.2017.5308

Reference

Artymowicz A, Shinder R. Teprotumumab as monotherapy for dysthyroid optic neuropathy. Poster presented at: American Society of Ophthalmic Plastic & Reconstructive Surgery 2021 Annual Meeting; November 12-15, 2021; New Orleans, LA.

This article originally appeared on Ophthalmology Advisor