Praxis

Abstract Pain Neuroscience Education (PNE) has established itself as a potential treatment for chronic pain. However, the evidence on the applicability of PNE in clinical practice for chronic pain syndromes such as migraine is limited. Investigation of the effectiveness of PNE in adults with migraine with regard to headache intensity, migraine and headache frequency and migraine-related impairments in activities of daily living. In this non-randomized hypothesis-generating pilot study, participants received PNE as a group intervention after an initial four-week control phase. Assessments took place before the control-phase, at baseline as well as 4 and 12 weeks after the intervention and were statistically analyzed. 14 participants were recruited. Headache intensity (NRS) decreased by a mean of 0.88 points after the intervention (median: 0.25; IQR: 1.63) and by 0.91 points during follow-up (median: 0,25; IQR: 1.38). Headache frequency decreased by 1.68 days after the intervention (median: 2; IQR: 4.5) and by 1.3 days during follow-up (median: 1; IQR: 2.5). Migraine days were reduced by 1.21 days both after the intervention and during follow-up (median: 1; IQR: 3.00; median: 1; IQR: 2.75). Anxiety, assessed using the total score of the Hospital Anxiety and Depression Scale (HADS-D/A), was reduced by 1.5 (median: 1.5; IQR: 3.5) after the intervention and by 2.07 (median: 3; IQR: 4) at follow-up. Depression, as assessed by the total score of the HADS-D/D, showed a mean difference of 1.33 (median: 0; IQR: 3) after the intervention and 1.46 (median: 1; IQR: 2) in the follow-up. Restrictions in activities of daily living (HIT-6) showed an improvement of 2.57 points after the intervention (median: 3; IQR: 5.75) and 4.69 points at follow-up (median: 4; IQR: 8). HDQ-G showed a post-intervention decrease of 8.79 points (median: 7; IQR: 6.25) and a follow-up decrease of 7.88 points (median: 5.5; IQR: 11.3). No adverse events were observed during the study. In adults with migraine, PNE leads to a clinically relevant improvement in anxiety and the restriction of activities of daily living, as well as to a moderate reduction in headache or migraine frequency and headache intensity. Further research is required to validate results. The study was registered with the German Register of Clinical Studies (DRKS00034262).

The care of patients with rare diseases in Germany poses a challenge; endogenous Cushing's syndrome highlights this issue. An analysis of the care situation aims to identify areas for improvement. A systematic literature search on the care situation was compared with prescription data from Germany and France as well as physician statistics from various European countries. In Germany, there is a low density of endocrinologists, a lower treatment prevalence than in France and a longer time to diagnosis than in other countries with well-developed healthcare systems. In order to guarantee need-based care for rare diseases, investments in the training and further education of specialists, such as endocrinologists, and in new, cross-sectoral forms of care are necessary.

Oxytocin has been implicated in migraine pathophysiology through its roles in pain modulation and vascular regulation. Its receptors are present in migraine-related brain regions and cerebral vessels and interact with key migraine mediators such as calcitonin gene-related peptide (CGRP). Declining oxytocin levels coincide with increased migraine frequency, but a causal role in humans remains unclear. This study examined whether acute oxytocin receptor blockade provokes migraine attacks or alters cerebrovascular function. In this randomized, double-blind, placebo-controlled, cross-over study, women with episodic migraine (WM), healthy women (HC), and men with episodic migraine (MM) aged 18-45 years received the oxytocin receptor antagonist atosiban (6.75mg bolus followed by 54mg over 3h) or placebo on two separate visits. Women used continuous hormonal contraception to ensure stable hormone levels. The primary endpoint was the incidence of migraine-like attacks in WM within 12h post-infusion. Secondary endpoints included the incidence and intensity of any headache and vascular responses. A total of 20 WM (27.1 ± 5.6 years), 20 HC (25.7 ± 6.8 years) and 20MM (29.3 ± 6.1 years) completed both provocations visits. During the 12-hour observation period, the incidence of migraine-like attacks in WM did not differ between atosiban and placebo (atosiban: 6 (30%) vs. placebo: 4 (20%; p = 0.75)). Headache of any kind were reported in 15 (75%) vs. 11 (55%) (p = 0.34). HC did not experience migraine-like attacks, though nine (45%) participants reported headache of any kind after atosiban vs. six (30%) after placebo (p = 0.25). Among MM, migraine attacks occurred in two (10%) participants after atosiban vs. three (15%) after placebo (p > 0.999). While HC showed significantly increased temporal artery diameter and middle cerebral artery flow velocity during atosiban administration, no significant vascular changes were observed in participants with migraine. Short-acting oxytocin receptor antagonism did not trigger migraine attacks, suggesting that acute suppression of oxytocin signaling alone is unlikely to trigger migraine under stable hormonal conditions. Instead, oxytocin may act as a modulatory factor within neurovascular networks. Future studies using longer-lasting or brain-penetrant antagonists are needed to further clarify oxytocin's role in migraine susceptibility. DRKS - Deutsches Register Klinischer Studien: DRKS00033341. Registered: 08.01.2024. First patient enrolled: 08.07.2024.

Zusammenfassung Das Primärarztmodell adressiert demografische und strukturelle Herausforderungen des deutschen Gesundheitswesens. Baden-Württemberg demonstriert mit der Kombination aus HZV und kardiologischen Selektivverträgen nach § 140a SGB V deutliche Versorgungs- und Qualitätsgewinne. Gleichzeitig zeigt die hausärztliche Perspektive, dass eine bundesweite Integration klare Steuerungsprinzipien, digitale Vernetzung und ausreichende Ressourcen erfordert.