Neurology Minute

Refractory Headache Disorders, New Consensus, and Emergency Department Migraine Guidelines - Part 2

In the second part of this series, Dr. Tesha Monteith and Dr. Jennifer Robblee discuss updates to the emergency room recommendations for the acute treatment of migraines.  Show citations:  Robblee J, Minen MT, Friedman BW, Cortel-LeBlanc MA, Cortel-LeBlanc A, Orr SL. 2025 Guideline Update to Acute Treatment of Migraine for Adults in the Emergency Department: The American Headache Society Evidence Assessment of Parenteral Pharmacotherapies. Headache. 2026;66(1):53-76. doi:10.1111/head.70016 Robblee J, Khan FA, Marmura MJ, et al. Reaching International Consensus on the Definition of Refractory Migraine Using the Delphi Method. Cephalalgia. 2025;45(9):3331024251367767. doi:10.1177/03331024251367767 Show transcript:  Dr. Tesha Monteith:   Hi, this is Tesha Monteith with the Neurology Minute. I've just been speaking with Jennifer Robblee about her exciting work, defining refractory migraine with an international consensus, as well as her work with the American Headache Society on a guideline update for parental pharmacotherapies for migraine in the emergency department. So Jennifer, we've just been chatting on the podcast about all the great work out of the American Headache Society, updating the emergency room recommendations for acute treatment of migraine. Can you give a summary of those findings? Dr. Jennifer Robblee:  We looked at all of the new data for randomized control trials in the emergency room. We found 26 new trials, and several of those were actually a class one study that we felt had a low risk of bias. And from that, we applied the grading. So we actually have two grade A medications where it is that you must offer, of course, to the appropriate patient. And that's prochlorperazine IV, and greater occipital nerve blocks. Now, there's also a grade A must not offer, and that's IV hydromorphone. Then we have some grade B, which is should offer, and that's dexketoprofen, ketorolac, metaclopramide, sumatriptan subcutaneous, and supraorbital nerve blocks. So really exciting that we have lots of things that we can now say we have pretty good evidence or very good evidence to offer them to our patients. Dr. Tesha Monteith:  Great. It's always nice to see this update based on evidence. Dr. Jennifer Robblee:  Yes, I think it's so important, because right now when we see patients, and I'm sure you get this all the time, they come back, say they were in the emergency room for a severe headache and they got a migraine cocktail. And you're like, "Do you know what you were given?" And they say, "I don't know. I was just told it's a migraine cocktail." And as you know, that mean many, many different things. And when you are able to pull the records, it is many, many different things that a migraine cocktail can mean. So I'm hoping that this can start to standardize what we're actually giving our patients as we await more trials in the future that might start to tell us what that combo of treatments really should be. For right now, these at least tell us what individual treatments have the best evidence. Dr. Tesha Monteith:  Thanks so much, Jennifer.  

March 9, 2026 Capitol Hill Report: Our 2026 Advocacy Priorities

In this episode, Dr. Jason Crowell reviews the March 9th Capitol Hill Report discussing the AAN's advocacy priorities for 2026. Stay updated with what's happening on the hill by visiting aan.com/chr.  Learn how you can get involved with AAN advocacy.  Show transcript:  Dr. Jason Crowell: Hey, this is Jason Crowell. Thanks for listening to today's Neurology Minute. Today, we have an advocacy update from the AAN's Capitol Hill Report. The AAN has come out with its top advocacy priorities for 2026, and the first is access to care which includes affordable prescription drug prices, telehealth, and adequate coverage policies. Neurological conditions can require expensive specialty drugs as we know, so the AAN supports policies that ensure prescription medications are accessible to patients. Related to this priority, the Center for Medicare and Medicaid Innovation recently announced the GLOBE and GUARD models, two proposed mandatory drug pricing models that would make manufacturers pay rebates if their drug prices exceed global benchmarks. The AAN has responded to these proposals with recommendations to avoid unintended access issues. It's also important to make telehealth flexibilities permanent for Medicare beneficiaries, and the AAN has been lobbying for the CONNECT for Healthcare Act to do that. The second top priority is reducing regulatory and administrative burdens, like prior authorization and step therapy which we're familiar with. This is a longtime problem for physicians who spend a lot of time each week. We deal with these processes and we'd rather be treating patients, as you know. A new Medicare initiative called the WISeR Model establishes new prior authorization requirements for some medical services, and while it doesn't directly affect neurology, the AAN and other organizations are pushing back and closely monitoring for future similar models. Next is the neurology workforce. This includes making sure Medicare reimbursement for neurological services is enough to maintain a practice, as well as supporting wellness and immigration policy to allow international medical graduates to practice in the US. Related to this priority, the AAN has been pushing for a permanent inflationary update to the Medicare Physician Fee Schedule and to end the schedule's outdated budget neutrality requirement that ends up causing cuts to reimbursement each year. The final priority is neuroscience research and brain health. There have been a lot of threats to research funding recently, and the AAN has been lobbying for NIH and NINDS funding that includes the BRAIN Initiative, an important program that's led to neurology breakthroughs. It's set to lose a big part of this funding at the end of the year when funding from the 21st Century Cures Act expires. So the AAN has been asking Congress to help make up the gap through appropriation spending. There's much more in this week's Capitol Hill Report, and this is available on aan.com/chr, and for our US members, you can also find this Capitol Hill Report in your inbox. So check it out to learn more. 

Seizures and Epilepsy in Patients With Untreated Cerebral Cavernous Malformations

Dr. Halley Alexander and Dr. Abel Sandmann discuss seizure rates and risk factors in patients with cerebral cavernous malformations (CCMs) during long-term follow-up without CCM intervention.  Show citation:  Sandmann ACA, Vandertop WP, White PM, Verbaan D, Coutinho JM, Al-Shahi Salman R. Seizures and Epilepsy in Patients With Untreated Cerebral Cavernous Malformations: A Prospective, Population-Based Cohort Study. Neurology. 2025;105(11):e214387. doi:10.1212/WNL.0000000000214387  Show transcript:  Dr. Halley Alexander: Hi, this is Halley Alexander with today's Neurology Minute. I'm here with Abel Sandmann from Amsterdam University Medical Center, and we just finished recording a full-length podcast about some exciting findings related to cerebral cavernous malformations and the risk of seizures and epilepsy. Abel, can you give our listeners a rundown of the most exciting findings and how it can change practice? Dr. Abel Sandmann:  In our paper, we show that patients with a cerebral cavernous malformation who have a first unprovoked seizure should be diagnosed with epilepsy and considered for anti-seizure medication, as most of them achieve long-term seizure freedom with medical therapy alone. These findings are based on a prospective population-based cohort study in which we analyze long-term follow-up and assess the rates and risk factors for: one, a first-ever epileptic seizure; two, seizure recurrence to evaluate the updated ILAE definition of epilepsy; and three, seizure freedom over two years and five years among patients with epilepsy. We found that among patients who had never experienced a seizure before, the 10-year risk of a first-ever seizure was only 6%. This supports current recommendations against prophylactic anti-seizure medication in patients who are incidentally diagnosed with a cerebral cavernous malformation. However, following a first unprovoked seizure, the 10-year risk of recurrence was 80%, which exceeds the 60% threshold defined by the ILAE. This justifies diagnosing epilepsy after the first and provoked seizure in this population. Given that the risk of recurrence was lower in patients treated with anti-seizure medication after the first seizure, this supports early initiation of therapy, although these treatment analyses were non-randomized and should be interpreted cautiously. Most patients who met the definition of epilepsy became two year and five years seizure-free with medical management alone. But some patients with cerebral cavernous malformations develop medically intractable seizures and might benefit from surgical treatments. Dr. Halley Alexander: Excellent. Thank you so much, Abel. You can find the full-length podcast, which is available now on the Neurology Podcast, or you can also find the full article in Neurology at neurology.org, or in the December 2025 print issue. As always, thanks for tuning in for today's Neurology Minute.   

Refractory Headache Disorders, New Consensus, and Emergency Department Migraine Guidelines - Part 1

In part one of this series, Dr. Tesha Monteith and Dr. Jennifer Robblee discuss an international consensus definition for refractory migraine and why clearer criteria are needed.  Show citations: Robblee J, Minen MT, Friedman BW, Cortel-LeBlanc MA, Cortel-LeBlanc A, Orr SL. 2025 Guideline Update to Acute Treatment of Migraine for Adults in the Emergency Department: The American Headache Society Evidence Assessment of Parenteral Pharmacotherapies. Headache. 2026;66(1):53-76. doi:10.1111/head.70016 Robblee J, Khan FA, Marmura MJ, et al. Reaching International Consensus on the Definition of Refractory Migraine Using the Delphi Method. Cephalalgia. 2025;45(9):3331024251367767. doi:10.1177/03331024251367767 Show transcript:  Dr. Tesha Monteith: Hi, this is Tesha Monteith with the Neurology Minute. I've just been speaking with Jennifer Robblee about her exciting work defining refractory migraine with an international consensus, as well as her work with the American Headache Society on a guideline update for parental pharmacotherapies for migraine in the emergency department. Hi, Jennifer. Thanks again for coming on our Neurology Minute. Dr. Jennifer Robblee: Thank you so much for having me. I'm delighted to be here. Dr. Tesha Monteith: You've done a lot of work in the area of refractory migraine. Why don't you tell us why you felt there need to be clarification on the definition? Dr. Jennifer Robblee: Well, this is a patient population that I'm really passionate about. There's not enough research out there. We don't really know who these patients are, why they're not responding to treatment, and we don't know how to help them because we have no guidelines, obviously, since they're refractory to what we use for treating. So I thought it was really good to get an international group to standardize our definition and hopefully help move the research forward. Dr. Tesha Monteith: Why don't you tell us a little bit about the consensus definition Dr. Jennifer Robblee: So we came up with an international consensus definition for refractory migraine that was laid out the same way that migraine is, say, laid out in the ICHD-3 diagnostic manual, if you want to call it that. So we have different criteria on. So criterion A basically allowed for it to be episodic or chronic migraine. Criterion B had three subcriteria, so you needed to have at least two out of three of severe to very severe disability and/or a constant background headache and/or at least eight monthly migraine days. Criterion C was about the lack of response to treatment. And basically it says that you needed to have failure of all medication categories, and there is an extra one for an other in case any new treatments emerge before the diagnostic criteria get updated. And what we considered a, quote, unquote, failure was that you did not have a 50% improvement in monthly migraine days, or you had intolerable side effects, or you had an absolute contraindication. There is a caveat that you need to have at least four true lack of efficacies. And then the CGRP monoclonal antibody or gepant category and the onabotulinumtoxin toxin category both had to be a true lack of response. And of course, there's a criterion B to say that this should not be from another diagnosis. Dr. Tesha Monteith: Thanks so much, Jennifer.

Lab Minute: Vitamin B7

Dr. Stacey Clardy reviews biotin deficiency and biotin-related lab interference. Show transcript:  Dr. Stacey Clardy: Hi, this is Stacey Clardy from the Salt Lake City VA and the University of Utah, and I'm back with you for another lab minute. Today, let's talk about Biotin or vitamin B7, because the Biotin story in neurology has two very different aspects. The first is a real deficiency, which is uncommon, but clinically really important. And the second is the modern problem of biotin supplementation that's quietly wrecking our lab interpretation. So first, true biotin deficiency in adults is less common, but it can look like a multi-system neurologic syndrome. The classic teaching is dermatitis and alopecia, so keep those in your mind. But neurologists end up seeing the downstream features. So lethargy, depression, paresthesias and sometimes ataxia. Now, in infants and children, the bigger higher stakes entity is biotinidase deficiency, which is fortunately screened in many newborn programs in the US. Untreated, it can produce seizures, developmental delay, optic atrophy, and hearing loss. And the key point is that these neurologic injuries can be prevented if biotin is started early enough. Also, remember, there are numerous reports now in the literature of it mimicking the clinical and radiological features of neuromyelitis optica spectrum disorder or multiple sclerosis. So if you have one of those diagnoses and you're not quite sure that it's right, keep biotinidase deficiency in the back of your mind. Now, what most of us clinicians are living with is the biotin supplement era. So high dose biotin, taken by a lot of people, either knowingly or unknowingly, can interfere with biotin streptavidin immunoassay platforms. And the direction of error depends on the assay design, but the practical pitfalls are simple. You can be handed a lab pattern that screams something like hyperthyroidism or other endocrine pathology, and it can actually be purely analytical artifact. Thyroid testing is the most common example, and troponin and other assays can also be affected depending on the assay platform. So a common clinical misstep is to treat the lab burnout rather than the patient. So if your patient symptoms don't match this new endocrine emergency that the lab appears to be showing, ask, are they taking biotin? This is commonly in hair and nail supplements or buried in the myriad ingredients of another fix all supplement. So you need to find out if it's in any of those. The easiest thing is to say, tell me all of the supplements and the brands you're taking. And then I usually do a quick internet search right there to find out if biotin's in there. And so the lowest friction fix is generally to repeat the test after holding biotin for an appropriate interval. At least a week is usually a safe time to guess about. The key is coordination with the laboratory. Not every lab behaves the same and some systems now actually have evolved mitigations, which is quite helpful. So that's the biotin update. So remember, biotin deficiency is treatable and sometimes urgent. And also, biotin supplementation is now a common lab confounder that can trigger avoidable diagnostic and therapeutic errors. Thanks for spending a few minutes with me. This is Stacey Clardy, and that's your lab minute.