Combined Hormonal Contraceptives: Is It Time to Reassess Their Role in Migraine?

Objective.— This paper will review the extensive array of hormonal contraceptives. It will examine the benefits and risks associated with them – particularly with regard to stroke risk – and shed light on divergent findings in the literature. Background.— Menstrual‐related migraine is a particularly disabling presentation of migraine often deserving of specific prevention. There is accumulating evidence that hormonal preventives may offer such protection. Although a legacy of research shows an increased risk of stroke with high‐dose oral contraceptives (OCs) (those containing 50‐150 µg of estrogen), there is evidence to suggest that this does not apply to ultralow‐dose OCs – those containing <25 µg ethinyl estradiol – when used in appropriate populations (ie, normotensive non‐smokers). Migraine with aura (MwA) increases stroke risk, and that risk is directly correlated to the frequency of aura, a factor that can be modified – either upward or downward – by combined hormonal contraceptives (CHCs). The argument against using CHCs in MwA is based on the concerns that (1) OCs increase stroke risk, (2) MwA increases stroke risk, and (3) combining these risk factors might produce additive or synergistic risk. Evidence does not support concerns (1) and (3), and suggests otherwise. Summary.— The risk/benefit analysis of CHCs is shifting. There is growing evidence for a potential role for CHCs in the prevention of menstrual‐related migraine. At the same time, the risk of these products is declining, as newer and lower dose formulations replace their historical predecessors. And although migraine aura is a risk factor for stroke, there is not convincing evidence to suggest that the addition of a low‐dose CHC alters that risk in non‐smoking, normotensive users. Selected hormonal preventives could potentially decrease stroke risk in MwA via reduction in aura frequency achieved by reducing peak estrogen exposure. With this shift in risk/benefit analysis, it is time to reconsider the role of CHCs in migraine – both with and without aura.     

Fibromyalgia Syndrome: Is It Related to Vitamin D Deficiency in Premenopausal Female Patients?

There are a number of studies that have evaluated the relationship between fibromyalgia (FM) and vitamin D deficiency with conflicting results. The aim of this study was to assess vitamin D deficiency in patients with FM and to evaluate the relationship with the common symptoms of FM and levels of serum vitamin D. Forty premenopausal female fibromyalgia patients and 40 age- and sex-matched control subjects were included in the study. The demographic characteristics of all subjects, including age, sex, and body mass index, were recorded. The number of tender points was recorded, and the intensity of the widespread pain of the subjects was measured by the visual analog scale. The activities of daily living component of the Fibromyalgia Impact Questionnaire (FIQ-ADL), was used to assess physical functional capacity. Serum vitamin D was measured in both groups, and vitamin D levels <37.5 nmol/L were accepted as vitamin D deficiency. The vitamin D levels and clinical and laboratory characteristics of the patient and control groups were comparatively analyzed. The relationship between vitamin D levels and clinical findings of the FM patients were also determined. The mean age was 41.23 ± 4.8 and 39.48 ± 4.08 years for the patient and control groups, respectively. The pain intensity, number of tender points, and FIQ-ADL scores were higher in FM patients than in control subjects. The mean levels of vitamin D in the patient and control groups were determined to be 31.97 ± 15.50 and 28.97 ± 13.31 nmol/L, respectively (p > .05). The incidence of vitamin D deficiency was similar between the patient and control groups (67.5% vs. 70%). Vitamin D levels significantly correlated with pain intensity (r = ?0.653; p = .001) and FIQ-ADL scores in the FM group (r = ?0.344; p = .030). In conclusion, the results of this study indicate that deficiency of vitamin D is not more common in premenopausal female patients with FM than in control subjects without FM. However, the association between pain and vitamin D levels in FM patients emphasizes that hypovitaminosis of vitamin D in the FM syndrome may have an augmenting impact on pain intensity and functional status. Future studies are needed to show the effect of vitamin D supplementation in the reduction of pain intensity and disability in patients suffering from this chronic condition.     

Abdominal Migraine in Children: Is It All in Their Heads?

Abdominal migraine in children is a migraine variant, described as isolated, paroxysmal attacks of severe periumbilical abdominal pain associated with nausea, vomiting, pallor, anorexia, headache, and photophobia, with intervening periods of normality. Abdominal migraine is a diagnosis of exclusion, as presenting symptomatology can also be characteristic of other disease processes. An extensive history and physical examination are necessary to differentiate between abdominal migraine and acute abdominal pain. Limited studies have been conducted on the management of children with an acute abdominal migraine attack. Treatment and prophylaxis of acute attacks is essential to reduce recurrence, severity, and extent of pain.     

Fast‐Track Training of Nonelectrophysiologists to Implant Defibrillators: Is It Needed?

Standard training pathways in cardiac electrophysiology are being short-circuited for a "fast-track" approach to train nonelectrophysiologists (not necessarily cardiologists) to implant defibrillators in patients. This approach has been undertaken by a professional society (The Heart Rhythm Society), a society that cannot police, or properly credential. They have support from the American College of Cardiology and, perhaps, even the Combined Medicare and Medicaid Services. This issue is particularly disturbing as there are no data to support the approach taken with regard to the safety and benefit for patients. This process disrupts the standard training pathways and will have long-term implications for the field of clinical cardiac electrophysiology and for the availability of highly trained individuals qualified to implant defibrillators. This issue has broad implications with regard to medical training pathways. We discuss these issues in detail and provide the results of two surveys, including a survey from members of the Heart Rhythm Society, most of whom disagree with the "fast-track" approach. A survey of cardiologist faculty members of the American College of Cardiology yielded similar results. We are particularly concerned about the disruption of training pathways in medicine and how this can affect patient care and can influence established training pathways in medicine.     

Introduction to the Special Issue on Processes of Cognitive Behavioral Therapy: Does “Necessary,But Not Sufficient” Still Capture It?

Research over the last four decades on cognitive behavioral therapy (CBT) is leading to a more comprehensive understanding of the mechanisms that underpin its efficacy. This introduction to the next generation of research on process offers a brief account of the evolution in the scientific foundations of CBT, to our current focus on treatment and in-session processes. It also provides a generic model for linking techniques with their target, uses, and treatment processes. In addition, how each component can be adapted according to CBT-specific elements of the client-therapist relationship (collaboration, empiricism, and Socratic dialogue) in a manner that is guided by the case conceptualization provides a more complex and comprehensive understanding of treatment delivery. The various research studies included within this special issue make important contributions to our understanding of the different ways in which both treatment and in-session processes are important to CBT.