Niushen Zhang's research while affiliated with Stanford University and other places

Purpose of Review A comprehensive headache treatment plan typically requires both medication and non-medication treatment strategies. Manual therapies offer another therapeutic approach to headache treatment. This article reviews the evidence for manual therapies in the treatment of headache disorders. Recent Findings Current evidence shows potential benefit from myofascial trigger point injections, myofascial release, and massage for the treatment of various headache types. There is also evidence for strain counterstrain technique, ischemic compression, and spinal manipulative therapies for cervicogenic headache. Summary Although larger randomized clinical trials are necessary for many of these modalities, recent findings show that manual therapies could be an important tool for the treatment of some headache disorders.

Migraine affects about 1 billion people worldwide, and up to 15% of adults in the United States have migraine attacks in any given year. Migraine is associated with substantial adverse socioeconomic and personal effects. It is the second leading cause of years lived with disability worldwide for all ages and the leading cause in women aged 15 to 49 years. Diagnostic uncertainty increases the likelihood of unnecessary investigations and suboptimal management. This article advises clinicians about diagnosing migraine, ruling out secondary headache disorders, developing acute and preventive treatment plans, and deciding when to refer the patient to a specialist.

Objective: To examine whether cannabis use predicts medication overuse headache (MOH) in patients with chronic migraine (CM). Methods: Electronic chart review was conducted by combining the terms "CM," "medication overuse," "cannabis," "cannabidiol," and "tetrahydrocannabinol" for patients seen at our headache clinics from 2015 to 2019. Of 729 charts consecutively screened, 368 met our inclusion criteria, that is, adult patients with CM with ≥1-year CM duration. The following variables were extracted from the included patient charts: MOH diagnosis, age, sex, migraine frequency, current CM duration, current cannabis use duration, overused acute migraine medications, current MOH duration, and types of cannabis products used. Logistic regression was used to identify variables predicting MOH while controlling for remaining predictors. Agglomerative hierarchical clustering (AHC) was conducted to explore natural clusters using all predictor variables. Results: There were 212 patients with CM and MOH (cases; median age 43 years, interquartile range [IQR] 33-54; 177 [83%] females) and 156 patients with CM without MOH (referents; median age 40 years, IQR 31-49; 130 [83%] females). MOH was present in 81% (122/150) of current cannabis users compared with 41% (90/218) in those without cannabis use-adjusted odds ratio 6.3 (95% CI: 3.56 to 11.1, p < 0.0001). Current cannabis use was significantly associated with opioid use (Spearman's rho 0.26, p < 0.0001). Both current cannabis use (rho 0.40, p < 0.0001) and opioid use (rho 0.36, p < 0.0001) were significantly associated with MOH. Similarly, AHC revealed two major natural clusters. Cluster I patients featured 9.3 times higher current cannabis use, 9.2 times higher current opioid use, and 1.8 times higher MOH burden than those in Cluster II (p < 0.0001). Conclusion: Cannabis use was significantly associated with increased prevalence of MOH in CM. Bidirectional cannabis-opioid association was observed-use of one was associated with use of the other. Advising patients with CM and MOH to reduce cannabis use may help treat MOH effectively.

Many patients turn to mind-body therapies for headache because standard pharmacological treatments have many shortcomings, while others incorporate these therapies into their treatment plan as adjuncts. This chapter aims to define commonly used mind-body therapies, to discuss the evidence that supports their use in headache treatment, and to explore how to counsel patients regarding the best way to incorporate these therapies into a comprehensive treatment plan. Within the class of mind-body therapies that will be discussed in this chapter, biofeedback has the highest level of evidence for treatment of headache, followed by acupuncture. There is growing evidence that mindfulness meditation and progressive muscle relaxation are beneficial modalities for headache. Massage, tai chi, and yoga are becoming more widely used therapies for the prevention and treatment of headaches, but their effectiveness remains in question, especially when compared to pharmacological treatments.

Objective: To examine whether cannabis use predicts medication overuse headache (MOH) in chronic migraine (CM) patients. Methods: Electronic chart review was conducted by combining the terms “chronic migraine”, “medication overuse”, “cannabis”, “CBD”, “THC” for patients seen at our headache clinics from 2015 to 2019. Of 729 charts identified, 368 (150 using cannabis; 218 not using cannabis) met our inclusion criteria, i.e., adult CM patients with ≥ 1-year CM duration. The following variables were extracted from each patient’s chart: MOH diagnosis as dependent variable, and predictor variables as age, sex, migraine frequency, current CM duration, current cannabis use duration, overused acute migraine medications, current MOH duration, and types of cannabis products used. Logistic regression was employed to identify variables predicting MOH while controlling for remaining predictors. Agglomerative hierarchical clustering (AHC) was conducted to explore natural clusters using all predictor variables. Results: There were 212 CM patients with MOH ( cases ) and 156 CM patients without MOH ( referents ). Current cannabis use statistically significantly predicted cases with MOH – odds ratio 6.0 (3.45, 10.43), p < 0.0001. Current cannabis use, opioid use, and MOH were significantly associated. AHC revealed two major natural clusters. Cluster I patients were younger with less migraine frequency, higher MOH burden, more current cannabis and opioid users than cluster II. Conclusion: Cannabis use significantly contributes to the prevalence of MOH in CM. Bidirectional cannabis-opioid association was observed – use of one increased use of the other. Advising CM patients with MOH to reduce cannabis use may help treat MOH effectively.

In March of 2020, the COVID-19 pandemic led to drastic changes in clinical practice and teaching methods. This article relates the experience of developing an almost virtual headache fellowship in response to the pandemic.

Objective: To build a national Headache Medicine fellowship opportunities website that promotes a unified application timeline and a more transparent application process. Background: In July 2019, the Consortium of Academic Headache Program Directors unanimously accepted the recommendations of the American Academy of Neurology Fellowship Application Timing Position Statement. To implement the unified application timeline, the American Headache Society agreed to host a fellowship opportunities website with information on the application process and resources for each fellowship program. Methods: We designed a main landing page that features the unified timeline for applications and offers. The page also features icons for all participating US fellowship programs (identified using the United Council for Neurologic Subspecialties certification database). The icons serve as links to each fellowship program's individual webpage. We sent an electronic form to each fellowship program director, asking them to submit program information to be included on each fellowship program's individual webpage. Key contents on each program webpage include an image of the program, brief program description, names of applicants who have filled positions, and open positions. Each institution webpage also includes an electronic form that allows applicants to directly send their name, contact, and a brief message to the program director. Results: We launched the website on May 15, 2020. As of June 19, 2020, the website featured 24 participating headache fellowship programs, including 5 pediatric programs and 19 adult training programs, from all regions of the US. Conclusion: The website serves as a central resource for Headache Medicine fellowship applicants and promotes a unified application timeline and a more transparent application process.