Abrupt discontinuation of overused medications is standard treatment for medication overuse headache (MOH), but discontinuation is difficult to maintain. The aim was to evaluate the real-world clinical results of anti-calcitonin gene-related peptide monoclonal antibody (CGRP-mAb) treatment for migraine with MOH without abrupt drug discontinuation and no hospitalization. Data were collected before starting CGRP-mAb injections (baseline) and 1 month after each injection. The following items were compared between baseline and after the first, second, and third CGRP-mAb injections, monthly headache days (MHD), monthly migraine days (MMD), monthly acute medication use (AMU) days, monthly total amount of AMU tablets, headache impact test-6 (HIT-6), and the migraine-specific quality of life questionnaire (MSQ). Achieving reduction rates ≥50 % in the frequency of each headache and migraine was defined as a good response. Achieving reduction rates of both AMU days and tablets ≥50 % was defined as effective in reducing AMU. This study included 33 patients with migraine with MOH. After the third CGRP-mAb injection, MHD and MMD were significantly decreased from median 30.0 to 9.5 days, and 10.0 to 1.5 days, respectively. In addition, monthly AMU days and tablets were significantly decreased from median 28.0 to 8.0 days, and 30.0 to 9.5 tablets, respectively. After the third CGRP-mAb injection, the good MHD and MMD responder rates were 75.0 % and 85.7 %, respectively. The rate of reducing AMU was 78.6 %. HIT-6 and MSQ scores decreased significantly from baseline to after each CGRP-mAb injection. When CGRP-mAb was administered to migraine with MOH, frequency of headache symptoms and AMU were reduced without abrupt drug discontinuation and no hospitalization.

Background/Objectives: Anti-calcitonin gene-related peptide monoclonal antibodies (CGRP-mAbs) are effective injectable medications for the treatment of migraine. This study aimed to evaluate continuation, resumption, and withdrawal rates of CGRP-mAb treatment under real-world clinical conditions. Methods: Treatment-naïve patients with at least 3 months of follow-up after starting CGRP-mAb treatment were included. The decision to continue, discontinue, or resume CGRP-mAb treatment was made freely by the patients. Headache Impact Test-6 (HIT-6) and the Migraine-Specific Quality of Life Questionnaire (MSQ) were administered before starting treatment and one month after each CGRP-mAb injection. The endpoints were as follows: continuation rates of CGRP-mAb treatment after treatment initiation; resumption rate; withdrawal rate; changes in HIT-6 and MSQ scores; and differences in background factors between the resumption and withdrawal groups. Results: Of the 1162 migraine patients, 146 were included in the analysis. Continuation rates of CGRP-mAb treatment at 3, 6, 9, 12, 18, and 24 months were 93.2%, 80.2%, 68.9%, 58.8%, 55.4%, and 51.7%, respectively. For the patients who discontinued, the resumption rate was 76.8%, and the withdrawal rate was 20.7%. HIT-6 and MSQ scores were significantly decreased at all assessment points compared with before CGRP-mAb treatment. There were no significant differences in factors between the resumption and withdrawal groups. Conclusions: Under real-world clinical conditions in which patients were free to choose their own treatment, the continuation rate of CGRP-mAb treatment 12 months after treatment initiation was 58.8%, and more than half of patients remained on treatment after 24 months. The resumption rate was 76.8% and the withdrawal rate was 20.7%.

Introduction Rimegepant is an oral calcitonin gene-related peptide receptor antagonist approved for both acute and preventive treatment of migraine. However, limited information is available regarding its effectiveness and tolerability when used as a second- or third-line acute treatment in patients for whom triptans and/or lasmiditan are ineffective, poorly tolerated, contraindicated, or otherwise unsuitable. This study evaluated the effectiveness and tolerability of rimegepant in this real-world clinical setting. Methods A prospective observational study was conducted in 89 patients (76 female; mean age 40.6 ± 12.2 years) prescribed rimegepant 75 mg after prior use of triptans and/or lasmiditan. Participants self-recorded headache intensity using a visual analog scale (VAS) before and 2 and 4 h after taking rimegepant. Pain freedom was defined as a VAS score of 0, and treatment efficacy as a ≥ 50% reduction in VAS score. The Patient Global Impression of Change (PGIC) was assessed at 2 h. Continuation was defined as a request for ongoing prescription after the initial dose. Results The study population included 35 patients (39.3%) with chronic migraine and 65 (73.0%) with prior calcitonin gene-related peptide (CGRP) monoclonal antibody exposure. Median VAS scores decreased from 77.0 at baseline to 18.0 at 2 h and 0.0 at 4 h (p < 0.001). Pain-free rates were 24.7% (95% CI 16.2–35.0%) at 2 h and 52.8% (95% CI 41.9–63.5%) at 4 h. Efficacy rates (≥ 50% VAS reduction) were 68.5% and 87.6% at 2 and 4 h, respectively. The continuation rate was 82.0%. Meaningful improvement on the PGIC was reported by 65.2% of patients. Adverse events occurred in 13.5% of patients. No adverse events leading to treatment discontinuation were observed. Conclusion Rimegepant was associated with clinically meaningful pain relief and favorable patient-reported outcomes when used as a second- or third-line acute treatment in real-world clinical practice.

Objective: Maintaining the occipito-axial (O–C2) angle following occipitocervical fusion is crucial to prevent postoperative complications. Although automated O–C2 measurement has been reported, practical methods that provide rapid results for routine practice remain limited. This study aimed to develop a deep learning model using the YOLO (You Only Look Once) object detection algorithm to automatically identify anatomical landmarks and rapidly calculate the O–C2 angle.Methods: A retrospective analysis was conducted using cervical spine radiographs from 2 independent facilities. The internal dataset comprised 574 lateral cervical radiographs from 271 patients for model development, while the external validation dataset included 100 radiographs from 100 patients. Model performance was evaluated against manual measurements by 3 expert raters.Results: The model demonstrated excellent detection performance, achieving perfect metrics for the hard palate (F1 score: 1.00) and high performance for the occipital bone (F1 score: 0.97), anteroinferior corner of C2 (F1 score: 0.99), and posteroinferior corner of C2 (F1 score: 0.99). For O–C2 angle estimation, the mean absolute error was 2.35° and root mean squared error was 2.98°, with an accuracy of 94.7% for determining the presence or absence of the O–C2 angle (i.e., whether all 4 anatomical landmarks were simultaneously detected). Bland-Altman analysis revealed minimal bias (0.57°; 95% confidence interval, -0.06° to 1.12°) with limits of agreement from -5.19° to 6.33°. Inference time was approximately 0.14 s per image.Conclusion: Our deep learning model enables rapid and accurate O–C2 angle measurement on lateral cervical radiographs, demonstrating performance comparable to expert raters and potential clinical utility.

要旨：74歳の女性．右半身麻痺，失語で救急搬送された．来院時発熱，項部硬直を認めた．Glasgow Coma Scale E3V2M5，右上下肢不全麻痺，全失語を認めた．検査所見では，血小板減少，血液凝固異常を認め，急性期DIC scoreは6点であった．頭部CTで，左側頭葉脳内出血，くも膜下出血，左側急性硬膜下血腫を認めた．入院後，急性水頭症を来し，脳室ドレナージ術を行った．血液および髄液の細菌学的検査結果から Neisseria meningitidis が検出され，細菌性髄膜炎と診断し，抗生剤治療を行った．意識障害は改善せず，modified Rankin Scale（mRS） 5 で転院した．髄膜炎菌に伴う髄膜炎は稀であるが，初期治療が転帰に大きな影響を与えるため，発熱を伴う出血性脳卒中は，細菌性髄膜炎を考慮し，迅速かつ適確な治療の開始について周知し得る必要がある．