Thank you for being here, we are going to discuss the topic of headache in the workplace. So disclosures, I mean I'm an executive editor of the Pain Medicine Journal and I receive book rarities from Oxford University Press and I get consulting fees from Pfizer and Mabel Neurovirtual Clinic. So why are we talking about headaches here at the Occupational Health Conference? It's highly disabling and prevalent in the US, it's about a 16% prevalence, mostly in women compared to men. The prevalence of chronic migraine is about 1-2% and chronic migraine is really having a headache at least 15 days per month and at least 8 of these being migraine and we care about chronic migraine because it's even more disabling than episodic migraine and there's a 2.5 conversion rate from episodic migraine to chronic migraine. Migraine is a leading cause of disability, actually I'm co-chair of the Global Patient Advocacy Coalition and when we met with the WHO Brain Health Unit in Geneva a few years ago really the thought was to reach the most people with migraine and make the most meaningful impact we should really focus on the workplace because that's where most patients are. Migraine disproportionately affects people during the most productive years of their life and people are going to not clean their house, not attend social or family events before they're going to miss work. So it's highly under-diagnosed and under-treated, more than 50% of people with migraine are not diagnosed including people who consulted for migraine, about half of people with migraine consulted a healthcare professional for migraine in the last year and most of these consults go to primary care. Really under-treated in the U.S. about 23% of people with migraine use a tryptan where that should be actually close to everyone unless they have contraindication and then about 40% of people are eligible for preventive treatment but only 17% use it in the U.S. So why do we care that it's under-diagnosed and under-treated, does a negative impact on quality of life for 89% of people and a negative impact on work life for nearly three quarters of people with migraine and under-diagnosis, under-treatment is one of the biggest risk factors for migraine chronification. So now we cover that why we are talking about migraine in the workplace, what we'll talk about during this talk. So contributing factors on work-related causes of headache, payor impact, work productivity impact, employer-based intervention and headache management in occupational medicine. So contributing factors on work-related causes, so from a scoping review we have identified several factors in the workplace that are positively associated with increased productivity, so sense of autonomy, social support, especially from supervisors, job satisfactions and then migraine-friendly physical adaptation to the environment, so sun-free area, noise reduction, natural light. Then factors that are negatively associated with productivity, quantitative demand, that's a hard one to change, emotional demands, really trying to reduce workplace conflict, misunderstanding, unnecessary stress, social demands, so there has been a study of people with migraine with much lower productivities on days when they had to interact with more than ten people at work during the day. Lower job status and shift work, actually since we had to submit those slides there has been another study about the negative impact of shift work for nurses with migraine, so those are two studies. So I'm not an occupational health physician, I'm a neurologist, I work in an outpatient neurology headache clinic, so these are some cases from regular outpatient neuroclinic, I don't do fitness for duty exam, but just for some work-related causes of headache example. So I saw a 34-year-old man, healthy, married, welder, who came to actually see me after many years of severe daily headache, no personal history, constant pressure around his eyes and the back of his head, didn't have any red flags, no migraine features, and then he also had these zaps of electricity in the back of his neck going up his head from time to time. Then a lot of muscle tension of his trapezius and cervical spinal muscles. So basically he has chronic tension type headache and occipital neuralgia, but there are many considerations of headaches in welders, the huge burden from the posture for putting his head down all day, putting tension on his neck, then eye consideration from possible exposure to bright light, eye straining, and debris that can come, and then they also need protection from metal dust and toxic gases. So from my headache standpoint, we did occipital nerve blocks, we went to neck physical therapy, we also studied on low-dose amitriptyline, which for a lot of people, you just need a low dose of amitriptyline. That can actually help without going into side effects, and it was better. Another patient that I saw as for head trauma, he was actually working in the same hospital as me, but he does night work, so he got hit on the back of his head on his way to the hospital in the dark parking lot at 11 p.m. So he went to the emergency room, no blood on head seat, he had brief loss of consciousness and amnesia after the hit. I saw him a few months later, actually, he was referred to me because he had persisted on headaches with light sensitivity and nausea too, and then he had still fatigue, issues with sleeping, concentration, and imbalance. So from a headache clinic standpoint, we did NSAID, Triptan, and antiemetic as needed for his headaches as needed. We studied vestibular physical therapy for his imbalance, and then from a preventive treatment initially studied him on riboflavin, magnesium, propranolol, because of the guidelines of what we have to try. And then after the other, he did therapy, both for his emotional trauma, but also cognitive behavioral therapy for insomnia, for his sleep. I didn't go into topiramid because he had cognitive issues. Sometimes you can get away with cognitive side effects of topiramid with long-acting topiramid, but that's harder to get covered. So I didn't choose tricyclics, Depakote, or Atogepant because you really had profound fatigue. Some people can also have dizziness on Atogepant, and eventually moved him through the different lines of preventive medication, but he did much better once he was studied on Botox injections. So how many of you heard of Bernardino Ramazzini? It's certainly all the ACOM members and definitely all the residency trained occupational medicine physicians. So as you know, a professor at the University of Padua in Italy wrote a book 320 years ago about the disorders of workers, wrote about 69 different conditions in that book. Twelve of the occupations had headache as one of the primary symptoms. So we've been talking about headache in the workplace, living for over 300 years. And it started in Europe, and we're continuing to emphasize this today. So Stephen Serra, I'm a national medical director for Aetna, so I work for CVS Health. First half of my career I was a plant physician at Chrysler, and then a regional flight surgeon at United Airlines. I certainly saw headaches due to tension neck syndrome, as have you. This is where ergonomic evaluations, partnering with the HR team for a quick ergo, can ameliorate many of those. Some of the more interesting cases that I recall throughout my career were carbon monoxide poisoning. Remember the oil changers, you go into Jiffy Lube's and the mechanics are down in the pit and you roll your car in. I seem to recall that in the winter when the cars were running but the doors were closed, we saw a number of folks suffering from carbon monoxide associated headache. And sometimes you see nausea, vomiting, dizziness. Carboxyhemoglobin levels seem to be over 20-25, but to me they didn't really correlate that well with symptomatology. I actually was in the emergency room. I bought my first new home in Newark, Delaware, and the HVAC installation company forgot to vent the furnace that was just installed. I had the worst headache of my life. I thought I was having a subarachnoid hemorrhage. And I went to the ER, and initially after the CT of the head they thought it was ethmoid sinusitis, but one of the medical students got clever and ordered a carboxyhemoglobin, and the treatment actually was very different. So pesticides, solvents, just about all of them, you know, from the benzene and the carbon tetrachloride to, you know, just the whole lot of the volatile organic compounds could cause and are associated with headache, both acute and then long-term. Obviously they could cause organic brain syndrome and encephalopathy. And really a high-dose, short-term release of almost any chemical. Chlorine was the one, when the chlorine alarm went off, that was the one that I recall was very common. In fact, there's a name for it now, right, chemical headache exposure syndrome. Mass psychogenic illness, we haven't read a lot about this in the last 40 years, but headache was very prevalent in the diagnosis of those conditions in the 70s and 80s, and multiple chemical sensitivity. Inadequate workplace ventilation is something that can unmask headaches related to chemicals. I remember the very last job on the assembly line when I was at Chrysler, it was called the gas fill drive. So there was 1,200 different assembly stations. The last one, there was a robot that put the, basically the gas in the car and then took the gas out, and when the gas came out, there was a few drips of gas, and the worker was there doing quality control. And normally what happened, there were these grates, and there was a lake of water that ran to capture any of the residual gasoline. Well that lake, that drip lake stopped running, then the gasoline accumulated, and the worker presented with, I'll never forget, irritant-induced vocal cord paralysis and acute headache. So back to the solvents, back to the VOCs, and I know many of you have cases, right? You could have just a plethora of causes of headache in the workplace. I think a couple of them, and I was so impressed to see the metal fume fever, how you opened with the first case, and I think the other one that we see on the boards quite frequently is the Monday disease with the nitrates, right? So you could think the proverbial fertilizer plant, the worker is there five days a week exposed to high levels of nitrates converted to nitrites in the gut, right? And you get this tremendous vasodilatation that occurs on the weekend, and then it presents with the headache on Monday. So let's talk, we're going to spend maybe the next 10 or 15 minutes talking about claims. So this is an employer, large healthcare system in the Northeast with 41,000 employees. And we wanted, actually this is a project that we collaborated on together, we wanted to get at the prevalence of headache in the workplace. So we looked at, and the specific ICD-10 code is the G43 codes, there's about 20 of them, so this includes migraine with aura, without aura. And there, of the 41,000 employees, we had, you could see, around 900, and the population over three years was fairly consistent, and there were approximately 900 claims each year with migraine headache. Now you heard at the beginning of the presentation that the prevalence of headache is closer to 16%. We saw here the prevalence is closer to 6%. What's that tell you? Well there's a tremendous portion of the workforce that is either not insured, insured elsewhere, for example on a spouse's plan, or more likely under-reporting or not reporting or actually not in active treatment. We're going to look at a couple other studies to kind of elucidate what kind of cohorts those members are saying. So the important message here is that the headache-specific costs, the costs to manage medical costs and the drug costs to manage the headache are relatively small, about 10 to 15%. We're going to see more data as well. But what happens compared to the average cost, so the average cost of an employee's commercial medical insurance, it's different in Medicare, different in Medicaid, different in worker's comp, but a commercially insured member costs about $8,000 to $8,500 a year. A member with migraine, as you can see, ranged here from about $16,000 to $20,000. So approximately, approximately double. And then at the same population, we heard again, headache is a big driver of lost performance, right, absenteeism and presenteeism. So we endeavored to look at family medical leave claims, and I know when I was at United Airlines at JFK after 9-11, the amount of headaches and sinusitis claims I saw were very, very high, intermittent leave more than continuous leave. We saw in the 41,000 employees, 243. About 24 of these were related to brain and head conditions, and many of these were not only in the clinical staff, but also the patient service coordinator, technicians, medical assistants. But again, if you reflect back on the research, you have over 50% of adults that are calling out on sick leave that they're not revealing to their supervisor the reason for the headache. So this continues to be underreported, probably a stigma associated with self-reporting of headache, and so there is a lot of opportunity here. So let's increase the sample size a little bit to 71,000 patients and 71,000 match cohorts. This is Truven, so the IBM, again, commercial database, five years of data here. The difference in this study is it brought in absenteeism. So it brought in short-term disability claims that are typically up to six months, depending on how the policy is written, and then long-term disability. And so as you can see bolded in the bottom of the third, there were about $9,000 higher costs for patients experiencing migraine when compared to employees without migraine. The prevalence of short-term disability claim was twofold. And again, if you look, you see about a doubling of medical costs, right? So when we look at all costs, not just headache costs, because members that are experiencing migraine also have higher medical costs, right? They end up in the emergency room. They end up with subsequent admissions. There's behavioral health comorbidities. Here is an Optum database that looks at three years of data, about 46,000 patients, again, in the commercial space. And I think it's interesting to see the prevalence of episodic versus chronic migraine and then tension-type headache. And if you look at the direct medical cost for tension-type headache, very low. I'm guessing maybe these patients are frequently treated with tricyclic antidepressants, inexpensive, right? We've mentioned the amitriptyline. So very small compared to medical costs associated with chronic migraine. And again, the tension-type headache member coming in at around $7,900, that's essentially equivalent to the average PMPM spend of a commercial member, the average commercial member, right? Whereas again, the chronic migraine patient comes in at almost double that. This is a study out of Finland, which is interesting in a number of regards. This is two years of registry data, a big sample, 175,000, and begins to look at a menagerie of different things, but particularly the new CGRP medications, right? These are the calcitonin gene receptor peptide antagonists, the monoclonal antibodies, what we call as G-PENs, we're gonna refer to as G-PENs. First one I think was, was it Amovig in 2018? They're coming in, at least if I look at our Caremark data, around $6,500 per annual cost, just to kind of give you a sense. So I think many of us kind of, we default in our thinking that members managed with G-PENs are extremely expensive, right? Given the high annual cost, I just say it's $6,500. What this study showed in it, it spectrumed the patients into nine different cohorts, depending on how they were treated. A tryptin alone, multiple tryptins, three or more tryptins, number of different preventive meds, or a monoclonal antibody, such as the G-PEN on the far right. To me, what jumped out was the patient cohort that were treated with the G-PENs were about $2,100 less expensive, these are costs in euros, that include migraine-related costs and all other costs, than the members that had three or more preventive medications. And we're gonna look, actually, we're gonna kind of double-click a little deeper into the impact of G-PENs in a few minutes. This study, by Tepper et al., published in Headache in 2023, was interesting in so much as it looked at 1,900 patients in the Komodo database, but looked at their costs before they commenced the G-PEN, and then six months after. So they compared the pre-aretomob experience with the post-experience. And if you look at the migraine-specific costs on the lower two bars, you see, as would be expected, that the prescription costs ballooned, right? They went from $1,100 to $4,500. But if you look at the medical costs, right, commercial costs are a bucket, the PBM costs for the medicine, and then the medical costs, the medical costs went down to about a third of the pre-intervention levels. And then when you look on the right side, there was actually a $4,000 decrease in all medical costs pre- and post-initiation of the CGRP medication. And then, of course, the medicine, we said, at today's dollars, 6,500. This was a 2023 study, so it was a little less expensive at that time. I believe the first G-PEN comes off patent in 2033. So the factors, the market dynamics that tend to change cost of medications are, when A, the medication goes off patent, B, you have additional entrance into the market, and which I think we have, what, we have five? We have five G-PENs now on the market, is that? So we have four CGRP monoclonal antibodies and three G-PENs. Yep. So to me, this is interesting. You're already seeing reductions in overall medical cost, even with a substantially higher medication. And this is before we factor in productivity. And I think, if you look at external analyses, like the Institute for Clinical and Economic Review, it also suggests that G-PENs, even though they've been out a brief time, are affordable. This study essentially broadens that pre- and post-implementation to about a year, but again, has very similar experience, pre- and post-migraine, in terms of the overall reduction in both outpatient cost and inpatient cost. This is a study out of Spain by Lozaro and Hernandez. It's a small, it's a small sample, but it's interesting for a couple reasons. One, my understanding is that this study was published shortly after CGRPs became available in Spain. And if you look at the, there's M0 and M3. So within three short months of initiating these 256 workers on CGRPs, they reached a break-even point when absenteeism and presenteeism was factored, right? So again, Europe, prices are a little different, but $453 a month times 12, you're about that 6,000 point, and then you see at three months the indirect savings from absenteeism and presenteeism, and that those savings in performance neutralized the high cost of the medication in a very short period of time. So. So work productivity impact, why is migraine so disabling? Migraine is so much more than a headache. When people with migraine were asked to read the different migraine-related factors that affect their productivity, cognitive dysfunction came second after pain, and before light sensitivity, noise sensitivity, and nausea. So migraine's so much more than a headache. Most people have three to four phases of migraine attack. About one third of people can have symptoms up to 48 hours before the onset of the headache. People can already have cognitive changes and light sensitivity, mood changes, neck stiffness, and then there's increased sort of a headache specialist, again, the notion of triggers, because people can have food cravings as part of the first stages of the migraine attack. So people, for example, crave chocolate, and they attribute chocolate to be the trigger, but it's because they were craving chocolate as one of the initial part of the migraine attack. Then about a third of people have aura, then there's a headache phase that most people know about that can also have cognitive changes, and then there's migraine post-trauma, commonly called migraine hangover, where people feel fatigue, have difficulty concentrating, neck stiffness, and about 40% of people during their young adulthood before the turn in their 50s or early 60s have cognitive dysfunction even outside of the migraine attack, and this is mostly in terms of attention, language, executive function, visual, spatial skills, and processing speed. Also, the unpredictability of the disease makes it hard to plan work tasks or makes it hard to RSVP for work social events. Migraine comorbidities, some of them are also independently associated with lower productivity, so every five-point increase on the PHQ-9, the depression scale, or four-point increase on the CAT-7, the anxiety scale is associated with 3.5 times more odds of severe migraine-related productivity loss. So under-diagnosis and under-treatment also is a huge issue, and the more under-diagnosis and under-treatment, then the more risk of migraine chronification, increase of frequency and severity, and there's a spectrum from lower frequency to higher frequency, and people have more absences and more presentism with a higher frequency of migraine attack. And then the stigma is huge, especially in the workplace. There's more stigma against migraine than any other neurological disease. In the OVERCOM study, which is a huge US population-based study of a representative sample, about 32% of people with migraine experience one type of migraine-related stigma, often or very often, and that's usually people who think that they use migraine as an excuse to get out of work or that they exaggerate the symptoms. And only 22% of employers think that migraine is a serious enough condition to warrant staying away from work, and internalized stigma is independently associated with lower productivity. So the personal impact of migraine is huge. 68% of people report lower productivity, at least half change career goals, and that's why I'm here, because when you work at a quaternary headache center, a lot of the patients that then get to the headache specialist, by the time they see a headache specialist, already start losing their job, like I recently saw an international lawyer who now was working as a Uber driver because he couldn't keep his job because of his migraine. More than a third miss work opportunities, promotion, additional earning potential, and then there's a huge stress of the unpredictability of the attacks. Thank you. Yeah, as Olivia mentioned at the top of the presentation, headache and migraine is a leading cause of DALI, so Disability Adjusted Life Years in working employees age 20 to 59. It is the number one neurological cause of DALI's and it's in the top 10 driver of employers in terms of indirect cost. It typically, because of the very small contribution to medical cost, is not always on employer's radar. The medical costs usually are less than 1% and the pharmacy costs are usually less than two or 3%, although that's changing with the CDRPs, but until absenteeism and presenteeism are factored, it's a very small contributor. The impact productivity, as has been highlighted here, is substantial, $240 billion a year to wrap your head around that. That is the magnitude of the impact that the CDC estimates that smoking has. It's also the magnitude that the EPA estimates that the environment has on health, so it's significant. I wanna end with two studies. I see the author, one of them sitting in the back, Dr. Wayne Burton, to chronicle. These are both studies published in JOAM. This one's over 20 years, but it's a goody. Perhaps it's more appropriate for Dr. Burton to speak to it, but I thought this was very interesting work. So this goes to the Bank One experience, and Bank One, I believe had about 80,000 employees and 20% of them completed the health risk appraisal. And as many of you know, who've used health risk appraisals, and we saw the Spanish study by Lazaro with the 248 work, they used the WPAI there. But there's a number of health and productivity questionnaires that could be embedded in HRAs to estimate absenteeism and presenteeism. So when you looked at the 20,000 Bank One employees that had completed the HRA and the WLQ, there were about eight, slightly over eight days per year for those migraine sufferers, about three related to absence and four estimated to presenteeism. And you could take those FTE days and model out estimated salary in the financial services sector and come up with the estimated financial impact as was done in this study. Not insignificant for this employer, $46 million a year, $48 per employee per month, about $24 PM-PM. That totals about five to 8% of health care costs, right? So we're taking a condition with direct costs that are less than 1%, and when we add, again, the impact of presenteeism, absenteeism, it balloons to five to 8%. Still not the 10 to 12 occupied by musculoskeletal, oncology, and digestive, but it could be a close number four or number five. So it just, it gives you a new view, a new frame to look at the impact of headache in the workplace. And then finally, this study, which was published in JOEM in 2018, again, looks at direct and indirect cost among employees in the United States. Commercially insured, but this study not only looked at their commercial group health plan, but it looked at their STD plan, their LTD plan, and the work comp plan. Actually, the finish analysis did that as well. To me, it's rare to find studies that are overarching, and they look across buckets. And so what we've elucidated, what could we elucidate from this here? I mean, one of the things that jumps out, if you look at, and look, this is 2018 dollars. That's when the CGRPs came out. So the cost structure for the average patient with migraine was very different then, and you could see that at $1,100 in STD, and about $3,200 for the match control, and $13,000. But if you look, if you wanna adjust for inflation, or net present dollars, you could look at the absolute difference. And the absolute difference in patients with migraine versus the match cohorts in the STD bucket was 22X. And the direct cost was 4X, which was slightly higher than we saw across the other studies. Remember, the hospital system analysis and other studies, we saw about two to 2.5 fold increase in cost, so this came in a little higher. But again, there are multifold differences across essentially every disability bucket and every disability system here. So fortunately, there are ways that we can make a difference. So employer-based intervention. So going back to the people affected, when they were asked what is one challenge, and it was free tech survey, what is one challenge that would help you in the workplace, the most frequent answer was increased awareness and understanding. So it seems pretty easy, in a sense. People with migraine want to feel understood and heard. Then the second thing was a supportive work environment and a third, flexibility. So there's some evidence for workplace intervention. There's six prospective core studies for workplace education programs that increase productivity by 29% to 36%. And then there's also six prospective core studies for workplace education and management programs that cut absences by about half and increase productivity at work during a migraine attack. So there are different workplace education program modules out there, but no details about the increased productivity. They cut absences by about 25%, decreased the number of days worked with a migraine attack by about 32%, and increased productivity at work during a migraine attack by about 10% and decreased stigma. So workplace education and management program, not all of the core studies look at cost analysis. The one done for the Spanish postal service worker looked at the cost saving, but they didn't balance that with investment in the program. The two studies that tried to match the investment on the return was a Novartis study done for employees in Switzerland and the Fujitsu headache project that was done for the Fujitsu employees in Japan. So the Novartis migraine care program example, they have about 7,000 employees in Switzerland. 339 participants, people participated in the program, so 5%, and 79% completed the six-month program. So they were company-wide awareness campaign, and then people could get screened for migraine, and then if they were screened positive for migraine, they could get migraine care and also coaching sessions. So that program costed about $1,000 per participant. It's hard to compare the different investments of the different programs, because different countries have different health care system and cost of medication. About 50% dropped off early. They looked at productivity with MIDAS migraine disability assessment questionnaire, but they found an increase in 10.8 more work days per year. So that was a five times positive return on investment. And mostly, the increase was in the decrease of the number of days with presentism. So that's a program that I was actually involved with, the Fujitsu headache project. So that was migraine education and management program for all the employees at Fujitsu based in Japan. So they were e-learning program for all employees. That was mandatory for supervisors and also leadership. Then people who wanted to know more could be attending webinars. It was supposed to be seminars, but then COVID hit. So it was webinars. And then those interested could get a consultation by a headache specialist. So one of the occupational health physician who works for Fujitsu is actually also board certified in headache medicine. Then there were a huge effort to help with the work environment and not only light, noise, smell, but really trying to make a positive, supportive, understanding work environment. And then people were also invited to participate in yoga and headache exercises. So that was still done in collaboration. And with the support of the WHO Western Pacific Office, the huge participation, 91% of employees completed the e-learning module. So more than 73,000 employees completed it. So from screening people who attended the modules, it was 17% migraine prevalence. And that's knowing that more than 80% of employees for Fujitsu in Japan are males. There was 70% prevalence of headaches and about 5% of employees had moderate to severe headaches. So about 4% of the participants sought consultation for headaches through the program. 91% of people found the program useful or very useful. It increased their understanding of headache disorders for 73% of people. And most people who said they didn't help them with understanding of headaches, they said it's because they already knew a lot about headache. One of my favorite data is 83%. 83% of people without headache said they would change their attitude towards colleagues with headache disorders as a result of their program. So we're trying to target the stigma. So the increase in productivity as a result of the program was 1.2 days of absences and 14 days of presentism per employees with moderate to severe headache per year. So that was a 32-fold positive return on investment. In Japan, most of the drugs are covered by the state. And then Fujitsu has a culture of health promotion programs. So they already had a good system in place for health promotion programs. So just basic broad lines of headache management. So it's really easy to screen for migraine with the ID migraine. So if people have light sensitivity, headaches that lead to some impairment in their daily life, and nausea, so if they have two of three, it's 93% sensitivity. And if they have three out of three, 98% sensitivity. So that's kind of like the easiest way to screen for migraine. The big thing is to make sure that there are not any red flags, because you don't want to miss secondary causes that may make migraine. There's a mnemonic for red flags, a SNOOP mnemonic. So systemic symptoms, secondary risk factors, any abnormality on neurological exam, thunderclap onset, which means peak maximum intensity within one minute. People who have a new progressive headache after 50, any change in pattern, and then precipitants such as postural headache. And then to look at the tag category, if it's unilateral, usually in the front of the head with autonomic symptoms or restlessness. This is mostly in the trigeminal autonomic cephalalgia category to just broadly triage patients. When you see patients with headache, a lot of people with migraine says they have cluster because they have cluster of migraine. But it's not based on the frequency. It's based on the phenotype. So then migraine management. So we recommend acute treatment for everyone. Everyone should get acute treatment. Then it's stratified care. So people should have different pills in their toolbox. So if they have a mild headache, they can use NSAID. If it's moderate, they can use a tryptan with the NSAID. If it's severe, you can do tryptan, antiemetic, NSAID. Then I like people to have different tools if they're at work or if they're at home. If they're at work and their goal is return to function with a minimal amount of side effects, we can try a G-PAN, NSAIDs. There are some NSAIDs like dissolvable diclofenac or intramuscular intranasal ketogrelax that tends to work faster for some people. And then at home, when the goal is to kill the migraine attack and it doesn't matter if they're sedated or a little bit dizzy, we can use tryptans. We can use DHE. We can use more potentially sedating medication like procopyrazine with Benadryl. So options of acute treatments. So we have the tryptans, which are still first line, dihydrogutamine. We have the G-PANs. So that's a small molecule of C-GRP, inhibitors, lasmethadone, which is H5 serotonin. One agonist, so it doesn't have the cardiovascular contra indication as a tryptans, then NSAIDs, combination, analgesics, and then magnesium and antiemetics. Preventive therapies is many options of present preventive therapy. So in broad categories, you have the nutraceutical, mostly riboflavin and magnesium. Lifestyle modification, so I like the SIDS mnemonic. So sleep, exercise, eating healthy and regularly, dehydration, prevention, and stress management. Environmental modification, pharmacological treatments, and then biobehavioral option, and neurostimulation. So we consider preventive treatment for people who have at least four headache days per month. But that's really a combination of the frequency of headache days per month and the degree of disability. So for example, if they have two migraine days per month, but those are horrible, they cannot do anything, we can already start preventive treatment. So it's getting a little bit confusing because the recent American Headache Society consistent statement states that all the preventive medication is established on probable efficacy on duloxetine in our first line. But we do have a lot of different options for migraine preventive treatment. So beta-blockers, candesartan, topiramate, Depakote, and the CGRP monoclonal antibodies. Botox injections is only approved for the prevention of chronic migraine because it was not shown to be effective for the prevention of episodic migraine. Then amitriptyline, venafaxine, memantine, cyproheptadine, lisinopril, and the G-pens. And I put some more ideas in case you run out of ideas, but there's always more we can try. So that's actually, I didn't know about this, and Stephen sent it to me. But that's a PCORI table of different migraine preventive medication with effectiveness, and then a trial dropout from adverse events in the trial. I think this is a really neat table, and to me, it proves I use Depakote a lot. Those Depakote works wonderful for some people. Here it shows very effective, but it's not one of the fancy medications to use anymore. But it's a nice table for reference to look at efficacy with side effects with keeping in mind this is from trials because, for example, for atogepens, there were more adverse events in the placebo in the randomized control trial, but we see some side effects in real life. So just a brief mention of tension type headache treatment. So as you mentioned, cheaper, but usually much less severe. Most people don't come to the headache specialist for tension type unless it's chronic daily, but usually acute treatment. So aspirin, NSAIDs, combination analgesic, and preventive treatment, first-line amitriptyline, cognitive behavioral therapy, biofeedback. You can try mirtazapine, venlafaxine, and tizanidine low-dose. So as a summary, migraine is prevalent, disabling, and unfortunately often missed in the workplace because most of migraine-related productivity loss is in terms of presentism. It doesn't get picked up as much in the claims data. It's very underdiagnosed and undertreated. There are preventable work-related causes of headaches to keep in mind. A supportive migraine-friendly work environment help company-wide migraine education and our management program in the workplace help break down stigma, increase diagnosis management, quality of life, and increase productivity. Thank you, and we are happy to answer any questions. Thank you. Some employers are bringing more employees back to the workplace who have been working remotely, and in the occupational field we're seeing more patients bringing notes from their doctors that the workplace is triggering their migraines. Can you comment on, is there a checklist of environmental controls, or ergonomics, or do you like walking, glasses, work, any of those things that help? You like glasses, unless you have glasses because they will press on some of the branches of the trigeminal nerve, so then you have to deal with that. So I tell them if it's possible, put a blue light filtering screen on your computer, on your monitor, so we're not pressing on the trigeminal nerve, trying to have natural light as much as possible. But that also is a mean one for the workplace factors, so try to move them to a more remote area with less passage, less noise, closer to the window, yeah. Not under the AC vent, too. Yes? had a head injury and died. Yeah, extremely common, and you see migraine, TBI, migraine, COVID, things blow up, and Dr. Sumner was here, he had a wonderful talk about some of the concussion management, I think, yesterday or the day before. But it's complicated, and we do not have good data, because there's not much trials, and then you cannot get approved most of the headache treatment on the TBI, so we have to put them as migraines, and then you cannot even do retrospective study, so it's hard, but we treat it as phenotype, and there's not good data, but a lot of us in clinical practice, we try to treat early, aggressively, as much as possible, the headache, because the longer you let the headache go, the worse, and usually tricyclics, Botox injections tend to be pretty helpful, but we try to throw a lot of different preventive medications at them, because we know that's a predictor for worse outcomes, and then make sure the rest is taken care of, you know, the sleep disturbance, and all the other stuff with the concussion. It's 4 p.m., so thank you for coming. Thank you.

headaches

migraines

workplace impact

disability

underdiagnosis

undertreatment

environmental controls

ergonomics

stress management