Evaluation of the Effectiveness of Greater Occipital Nerve Blockade in Menstrual Migraine

Evaluation of the Effectiveness of Greater Occipital Nerve Blockade in Menstrual Migraine | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evaluation of the Effectiveness of Greater Occipital Nerve Blockade in Menstrual Migraine Guldeniz Cetin, Ozlem Totuk, Serkan Demir, Sevki Sahin This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5362945/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 13 Feb, 2025 Read the published version in BMC Neurology → Version 1 posted 4 You are reading this latest preprint version Abstract Objective: This study aimed to compare the short-term prophylactic efficacy of greater occipital nerve (GON) blockade in menstrual migraine (MM) subgroups and evaluate the long-term effects on patients' quality of life. Methods: In this prospective study, 33 patients diagnosed with MM (15 with pure menstrual migraine [PMM] and 18 with menstrually related migraine [MRM]) received bilateral GON blockade once a month, one week before menstrual bleeding, for three months. Patients were evaluated before treatment (month 0) and after treatment completion (months 3 and 6) using the Visual Analog Scale (VAS), Headache Impact Test-6 (HIT-6), Migraine Disability Assessment (MIDAS), and Beck Depression Inventory (BDI) scores. Results: MRM patients had a lower age of MM onset (p=0.024), higher headache frequency (p=0.004), and increased medication overuse (p=0.027) compared to PMM patients. After GON blockade, significant improvements were observed in VAS, HIT-6, MIDAS, and BDI scores in both subgroups, with no significant differences between them. The improvement persisted during the medication-free follow-up period (months 3-6). Patients with mild or no depression showed a more substantial increase in quality of life. Patients experiencing a 50% reduction in headache days demonstrated significant improvement in BDI scores. Conclusion: GON blockade may be an effective option for short-term and long-term prophylaxis in the treatment of MM, reducing the frequency and severity of headaches and improving quality of life and psychological state. Further research with larger patient cohorts and placebo-controlled trials is necessary to validate these findings. menstrual migraine pure menstrual migraine menstrually related migraine GON blockade short term prophylacy Introduction Migraine is estimated to range from 1.4% to 2.2%, impacting millions of people and their families worldwide (Natoli et al., 2010). Migraine is mostly influenced by genetic factors and typically begins in childhood, adolescence, or young adulthood. It is characterized by periodic, often unilateral, throbbing headaches (Olesen, 2018) The prevalence of migraine in women is three times higher than in men (Aguilar-Shea & Diaz-de-Teran, 2022). The primary factors contributing to the higher prevalence of migraine in women encompass hormonal fluctuations (particularly variations in estrogen levels), genetic predisposition, and environmental influences. Estrogen has been observed to enhance the sensitivity of the trigeminal nerve system, thereby facilitating the initiation of migraine attacks. Moreover, hormonal alterations throughout the female life cycle (adolescence, menstrual cycle, pregnancy, and menopause) can significantly impact the prevalence and severity of migraines. (Vetvik & Russell, 2011). According to the International Classification of Headache Disorders (ICHD-3), migraine attacks associated with the menstrual cycle are categorized under the subgroup of Menstrual Migraine (MM). The definition of MM is further subdivided into two distinct categories (Olesen, 2018). Pure MM (PMM) attacks occur exclusively during menstruation and are observed in approximately 1% of the population. Menstrually related migraine (MRM) is more prevalent, with an incidence of approximately 6-7%, and can occur outside of menstruation as well. (Maasumi et al., 2017). The characteristics of MM attacks significantly differ from those of non-MM attacks (Vetvik & Russell, 2011). Previous research has demonstrated that MM attacks tend to last longer, are more severe and occur more frequently compared to non-MM attacks. (Couturier et al., 2003). As yet, there is no spesific treatment that is designed to MM attacks. Nonsteroidal anti-inflammatory drugs (NSAIDs), triptans, and ergot derivatives, commonly used for general migraine treatment, are also recommended for MM. However, the frequent side effects of these treatments, such as menstrual irregularities, poor patient compliance, pregnancy concerns, and comorbid conditions, highlight the need for alternative therapeutic approaches in MM management (MacGregor, 2015) In recent years, numerous studies have been conducted on the use of greater occipital nerve (GON) blockade in migraine patients. (Dilli et al., 2015)(Inan et al., 2019a) As an interventional treatment, GON blockade offers an alternative option for patients who do not respond to pharmacological therapies or wish to avoid medication-related side effects. However, research on the efficacy of GON blockade in MM patient groups are limited. To date, no studies in the existing literature have directly compared the effectiveness of GON blockade between PMM and MRM subgroups. The goal of the present article is to compare the short-term prophylactic efficacy of GON blockade in different MM subgroups and to evaluate the long-term effects of this treatment on patients' quality of life. For this purpose, we randomly assigned patients from different MM subgroup to receive GON blockade treatment and then compared the frequency, severity, and duration of migraine attacks before and after treatment, as well as the patients' reported quality of life over a follow-up period. We hypothesized that the GON blockade would be effective in MM and that both subgroups would experience an improvement in long-term quality of life. Methods Patients diagnosed with MM who presented to the neurology outpatient clinic between January 2023 and July 2024 were prospectively examined following Ethics Committee approval (File No: 227, Date: 08.11.2023) A total of 41 patients diagnosed with MM were included in the study, of which 8 patients (PMM: 4, MRM: 4) were excluded due to non-compliance with follow-up. The medical data of the remaining 33 patients (PMM: 15, MRM: 18) were analyzed after obtaining informed consent. Patients diagnosed with MM according to ICHD-3, with regular menstrual cycles, who had used at least two prophylactic medications without benefit, were unwilling to use oral medication, and were considering pregnancy were included in the study. Exclusion criteria were determined as the presence of other primary and secondary headaches, use of hormone therapy, breastfeeding, and pregnancy. Cranial MRI was performed on all patients to exclude secondary headaches. Patients' demographic characteristics, body mass index (BMI), headache onset, location, triggers, accompanying symptoms, monthly headache days, and medication overuse status were evaluated. BMI was classified as normal (20-25 kg/m²), overweight (25-30 kg/m²), and obese (30 kg/m² and above). Headache intensity was assessed using the Visual Analog Scale (VAS) score, ranging from 0 to 10 points. Headache frequency and disability status were measured using Headache Impact Test-6 (HIT-6) -monthly- and Migraine Disability Assessment (MIDAS) -quarterly- scores. Depression assessment was conducted using the Beck Depression Inventory (BDI), with scores divided into two categories: category 1 for scores 0-16 (minimal-mild depressive) and category 2 for scores 17-63 (moderate-severe depressive). The group whose MIDAS scores, which determine the number of painful days, decreased by 50% at months 0 and 3 was identified as treatment responders, while the group without decrease was identified as non-responders (Tfelt-Hansen et al., 2000). Patients utilizing NSAIDs for 15 days or more were categorized as the ‘medication overuse’ (MO) group, while those without medication overuse were classified as the group ‘without medication overuse’ (wMO ) (Olesen, 2005). For short-term prophylaxis, patients received bilateral GON blockade once a month for three months, one week before the expected menstrually bleeding date. For the following three months, participants were monitored without receiving any additional preventive treatments. The GON blockade procedure involved injecting a standard dose of 2 cc (20 mg) lidocaine hydrochloride at each injection site (Inan et al., 2015). Evaluations were conducted before treatment (month 0) and after treatment completion (months 3 and 6). Statistical analysis: The data were analyzed using IBM SPSS.26 software. Descriptive statistics for continuous variables were presented as mean and standard deviation, while descriptive statistics for categorical variables were presented as number (n) and percentage (%). Relationships between categorical variables were examined using the Chi-square test. The Shapiro-Wilk and Kolmogorov-Smirnov normality tests were employed to assess whether continuous variables exhibited normal distribution. The t-test was utilized for comparing continuous variables between groups. Repeated measures analysis was conducted using the GLM repeated measures test to compare measurements across groups. For all analyses, a p-value of <0.05 was considered statistically significant. Results During an 18-month study period, 33 patients diagnosed with MM at our hospital's neurology outpatient clinic who met our study criteria were prospectively evaluated. Table 1 illustrates the demographic characteristics, MM subtype and onset age, headache frequency, medication overuse and treatment benefit status of the examined population. Table 1: Demographic characteristics and headache features of patients PMM (n=15) MRM (n=18) MM(n=33) P Age (years) 41,3±6,4 38,9±5,7 40±6.1 0,271 BMİ Normal Overweight/obese 4(%26.7) 11(%73.3) 6(%33.3) 12(%66.7) 10(%30.3) 23(%69.7) 0,702 Educational Status Primary school and below Middle school and above 10(%66.7) 5(%33.3) 6(%33.4) 12(%66.6) 16(%48.4) 17(%51.6) 0,070 Age of onset MM (mean ± SD) 31,3±7,2 24,4±9,0 27.58±8,8 0,024 Headache Frequency (days/month) (mean ± SD) 6,0±4,5 12,2±6,9 9.3±6.6 0,004 Medication Overuse (MO) 5(%33.3) 14(%77.8) 19(%57.5) 0,027 Response to Treatment 12 (%88.0) 12(%66.7) 24(%72.7) 0,458 Analysis of the demographic data revealed that the mean age of 33 patients was 40.0±6.1 years. The mean age, BMI, and educational status of patients diagnosed with MM did not demonstrate significant differences among MM subgroups. However, the age of MM onset was significantly lower (p=0.024) in MRM patients, compared to the PMM patient group, while headache frequency (p=0.004) and MO were significantly higher (p=0.027). Both subgroups exhibited improvement following treatment, with no significant differences observed between the groups. Table 2: Headache characteristics, triggers, and associated symptoms of the patients, as well as the total number of patients. PMM (n=15) MRM (n=18) MM (n=33) Presentation of the headache Prominent during fasting Prominent in the night Prominent during exercise Prominent with laughing Same during daytime Prominent with straining Prominent in the mornings Prominent in the cough 5(%33.3) 1 (%6.6) 3 (%20) 2(%13.3) 12 (%80) 1 (%6.6) 1 (%6.6) 1 (%6.6) 6(%33.3) 8(%44.4) 3(%16.6) 1(%5.5) 8(%44.4) 1(%5.5) 2(%11.1) 1(%5.5) 11(%33.3) 9 (%27.7) 6 (%18.1) 3 (%9) 20(%60.6) 2 (%6) 3 (%9) 2 (%6) Headache triggers Stress Fatigue Seasonal relationship Alcohol Fasting Odor Loud noise High-intensity light 15 (%100) 15 (%100) 1 (%6.6) - 11(%73.3) 7 (%46.6) 13(%86.6) 10(%66.6) 18(%100) 16(%88.8) 4(%22.2) 2(%11.1) 14(%77.7) 11(%61.1) 13(%72.2) 11(%61.1) 33 (%100) 31(%93.9) 5 (%15.1) 2 (%6) 25(%75.7) 18(%54.5) 26(%78.7) 21(%63.6) Features of headache Penetrating-Jabbing Dull Compressive Throbbing Lightning Sudden 1 (%6.6) 2 (%13.3) 3 (%20) 14(%93.3) - 6 (%40) 1 (%5.5) 1 (%5.5) 5 (%27.7) 16(%88.8) - 6 (%33.3) 2 (%6) 3 (%9) 8 (%24.2) 30(%90.9) - 12(%36.3) Associated symptoms Nausea Vomiting Photophobia Phonophobia Dizziness Vertigo Allodynia Tinnitus 15 (%100) 7 (%46.6) 13(%86.6) 13 (%86.6 12 (%80) 1 (%6.6) 3 (%20) 2 (%13.3) 16(%88.8) 11(%61.1) 16(%88.8) 16(%88.8) 16(%88.8) - 6 (%33.3) 1 (%5.5) 32(%96.9) 18(%54.5) 29(%87.8) 29(%87.8) 28(%84.8) 1 (%3) 9 (%27.7) 3 (%9) In the evaluation of the presentation, triggers, features, and associated symptoms of headache, no significant difference was observed between MM groups. (Table 2) Tablo 3: VAS, HIT-6, MIDAS and BDI scores by the groups and total number of the patients before and after treatment PMM (n=15) MRM (n=18) MM (n=33) ort±S.S. ort±S.S. ort±S.S VAS Baseline VAS 8,6±1,5 8,9±0,9 8,7±1,2 VAS at the end of 3 month 3,6±2,5 4,4±1,7 4,0±2,1 Vas at the end of 6 month 4,6±2,6 5,1±2,3 4,8±2,4 p* P<0,001 P<0,001 P<0,001 MIDAS Baseline MIDAS 31,0±15,2 45,3±27,0 41,8±26,6 MIDAS at the end of 3 month 12,5±13,8 16,1±12,3 14,5±13,0 MIDAS at the end of 6 month 14,4±12,2 12,1±6,6 13,1±9,5 p** P=0,002 P<0,001 P<0,001 HIT-6 Baseline HIT-6 66,7±16,7 66,3±8,1 65,9±11,8 HIT-6 at the end of 3 month 44,6±10,5 48,3±8,7 46,6±9,6 HIT-6 at the end of 6 month 49,6±10,7 52,7±10,6 51,3±10,6 p* P<0,001 P<0,001 P<0,001 BDI Baseline BDI 13,8±6,1 15,2±8,8 15,0±7,8 BDI at the end of 3 month 8,1±4,9 10,3±6,9 9,3±6,1 BDI at the end of 6 month 12,2±9,7 12,1±9,9 12,1±9,7 P* P=0,005 P=0,02 P= 0,03 In both diagnostic groups, the initially measured VAS, HIT-6, MIDAS, and BDI scores were significantly higher than the measurements at 3 and 6 months (p<0.001 for both groups). There was no significant difference between the 3-month and 6-month results. No significant effect of diagnostic groups on treatment outcomes was observed. Table 4: Temporal changes in VAS, HIT-6, and MIDAS scores based on initial BDI scores Baseline BDI Category 1 (n=19) Baseline BDI Category 2 (n=14) P values ort±S.S. ort±S.S. VAS Baseline VAS 8,6±1,3 8,9±1,0 0,585 VAS at the end of 3 month 3,4±1,9 4,9±2,1 0,054 Vas at the end of 6 month 4,2±2,2 5,7±2,5 0,070 P* P<0,001 P<0,001 MIDAS Baseline MIDAS 30,1±15,7 50,6±27,1 0,010 MIDAS at the end of 3 month 10,1±9,8 20,5±14,6 0,021 MIDAS at the end of 6 month 11,3±10,0 15,7±8,4 0,194 p* P<0,001 P<0,001 HIT-6 Baseline HIT-6 64,4±10,3 69,2±15,0 0,283 HIT-6 at the end of 3 month 46,1±11,2 47,4±7,1 0,703 HIT-6 at the end of 6 month 50,9±12,5 51,7±7,6 0,827 p* P<0,001 P<0,001 When participants were grouped according to BDI categories, baseline measurements of VAS, HIT-6, and MIDAS scores in both groups were significantly higher than those at the 3rd and 6th months. No significant differences were observed between the results at the 3rd and 6th months. The BDI category did not have a significant impact on treatment outcomes. The only significant difference among the categories was that participants in BDI categories 1–2 had significantly lower baseline and 3rd-month MIDAS measurements compared to those in BDI categories 3–4 (p = 0.010 and 0.021, respectively). Table 5: Baseline, 3rd-month, and 6th-month VAS, HIT-6, and MIDAS measurement results according to MO status. MO patients (n=19) wMO patients (n=14) P values ort±S.S. ort±S.S. VAS Baseline VAS 9,0±0,9 8,4±1,5 0,157 VAS at the end of 3 month 4,7±1,6 3,1±2,4 0,028 Vas at the end of 6 month 5,5±1,9 3,9±2,8 0,057 P* P<0,001 P<0,001 MIDAS Baseline MIDAS 47,0±24,8 27,7±15,7 0,016 MIDAS at the end of 3 month 18,2±13,1 9,5±11,4 0,056 MIDAS at the end of 6 month 15,1±8,0 10,5±10,8 0,168 p* P<0,001 P<0,001 HIT-6 Baseline HIT-6 71,4±12,9 59,8±8,4 0,007 HIT-6 at the end of 3 month 49,6±9,1 42,5±9,0 0,034 HIT-6 at the end of 6 month 53,3±10,3 48,5±10,7 0,211 p* P<0,001 P<0,001 When participants were grouped according to MO status; baseline measurements of VAS, HIT-6, and MIDAS scores in both groups were significantly higher than those at the 3rd and 6th months. The 3rd-month VAS measurements of participants with MO were significantly higher than those without medication overuse (wMO) (p = 0.028). The baseline MIDAS measurement values of those with MO were also significantly higher than those wMO (p = 0.016). Regarding the HIT-6 scores, among participants wMO, measurements at each time point were significantly different (0–3 months p <0.001, 0–6 months p = 0.031, 3–6 months p = 0.032). The baseline and 3rd-month HIT-6 scores of those with MO were significantly higher than those wMO (p = 0.007 and p = 0.034, respectively). No significant effect of MO status on treatment was detected. Table 6: Comparison of BDI scores over time between patients who responded and did not respond to treatment, and the between-group effects Nonresponders to Treatment (n=9) Responders to Treatment (n=24) P values ort±S.S. ort±S.S. BDI Baseline BDI 14,1±9,0 14,8±7,3 0,815 BDI at the end of 3 month 11,2±8,0 8,6±5,2 0,284 BDI at the end of 6 month 13,2±10,1 11,7±9,7 0,712 P* P=0,388 P<0,001 There was no statistically significant difference in BDI measurement scores among those who did not benefit from treatment (p=0.388). For those who benefited from treatment, the initial measurement was significantly higher than at the 3rd month (p<0.001). The benefit from treatment did not have a statistically significant effect on the change in measurement results (p=0.576). Discussion In this study, GON blockade was administered as a short-term prophylactic intervention for MM and was found to reduce the severity and frequency of headaches, as well as enhance quality of life. Moreover, it has been observed that the improvement in headaches persisted over an extended period, and patients also demonstrated improvement in their depression scores. In addition to hormones and neurotransmitters involved in migraine pathogenesis, demographic factors have also been observed to influence headaches. Consistent with previous research, our study observed a higher prevalence of overweight/obese patients in both MM groups (Lillis et al., 2017). This finding suggests that elevated BMI may be associated with increased migraine severity and frequency (Gelaye et al., 2017). There was no significant difference between the groups in terms of age and education level. Similarly, in accordance with previous studies, MRM patients exhibited a lower age of migraine onset, higher headache frequency, and increased MO (Silberstein & Patel, 2014). This observation supports the hypothesis that the MRM group experiences more refractory and severe headaches compared to the PMM group. The occurrence of headaches in MRM patients during non-menstrual periods may contribute to an elevated risk of MO. In our study, the characteristics of headaches were examined; it was determined that headache intensity did not show a significant change throughout the day in both groups, but became more pronounced with fasting. This finding may support the role of metabolic factors in migraine pathophysiology. Additionally, stress and fatigue were identified as the most frequent triggering factors in both groups. Thus, the importance of lifestyle factors on migraine headaches has been emphasized once again (Kelman, 2007). Throbbing headache and nausea were the most frequently observed symptoms, which are consistent with the typical clinical features of migraine (Olesen, 2018). In recent years, GON blockade has been proposed as an effective method for migraine treatment (Inan et al., 2019b). Consequently, significant improvements were observed in patients' VAS, HIT-6, MIDAS, and BDI scores following GON blockade administered over a three-month period. During medication-free follow-ups from the third to the sixth month, this improvement persisted, although no statistically significant temporal difference was noted. These findings indicate that GON blockade is effective in short-term prophylaxis, and this effect is maintained in the long term. The improvement in depression scores during treatment follow-up has been associated with the psychogenic aspects of migraine therapy. Notably, the significant improvement in MIDAS scores among patients with initially low BDI scores indicates that quality of life increases more substantially in patients with mild or no accompanying depression. This finding emphasizes the bidirectional relationship between migraine and depression, suggesting that this factor should be considered in treatment strategies. (Breslau et al., 2003). It is known that excessive medication use complicates migraine treatment and increases headache severity. (Diener & Limmroth, 2004). In our study, the higher VAS scores at the third month for patients with MO indicate that these patients experience more severe headaches. Furthermore, the higher initial MIDAS scores in this group support the presence of increased migraine-related disability. Analysis of the HIT-6 scores revealed significant improvements sustained during the 0–3 month, 3–6 month, and 0–6 month follow-up periods. This finding demonstrates that the positive effects of GON blockade on quality of life persist in the long term. Finally, the observation of significant improvement in BDI scores at baseline and third month among patients experiencing a 50% reduction in the number of days with headaches further demonstrates the positive impact of effective migraine treatment on mood (Buse et al., n.d.) Our study is the first to evaluate the efficacy of GON blockade in MM patients, offering an effective option in cases where other prophylactic treatments are unsuitable or intolerable. However, significant limitations include the small sample size and the absence of a placebo control group. Considering the potential for a high placebo effect in migraine studies (Finniss et al., 2010), it is necessary to conduct larger-scale, randomized, and placebo-controlled trials. Conclusion This study has demonstrated that GON blockade may be an effective option for short-term and long-term prophylaxis in the treatment of MM. GON blockade has reduced the frequency and severity of headaches in MM patients, resulting in significant improvements in quality of life and psychological state. Further research is necessary to validate these findings in larger patient cohorts and to better elucidate the long-term effects of GON blockade. Abbreviations BDI Beck Depression Inventory BMI Body mass index GON Greater occipital nerve HİT-6 Headache Impact Test-6 ICHD-3 International Classification of Headache Disorders -3 MİDAS Migraine Disability Assessment MM Menstrual migraine MO Medication Overuse MRI Magnetic resonance imaging MRM Menstrually related migraine NSAIDs Nonsteroidal anti-inflammatory drugs PMM Pure menstrual migraine wMO Without medication overuse VAS Visual Analog Scale Declarations Ethics approval and consent to participate All patients provided written informed consent after being informed of thestudy protocol. The study was approved by the Ethics Committee of Sancaktepe Prof. Dr. İlhan Varank Research and Training Hospital (File No: 227, Date: 08.11.2023) Consent for publication Not applicable. Competing interests The authors declare no competing interests. Funding The authors received no financial support for the research, authorship, or publication of this article. Author Contribution G.C wrote the main manuscript text. All authors reviewed the manuscript Acknowledgements We gratefully acknowledge the support of the Sancaktepe Şehit Prof. Dr. İlhan Varank Research and Training Hospital and all the participants. Data availability The data supporting the findings of this study is available from thecorresponding author upon reasonable request. References Aguilar-Shea, A. L., & Diaz-de-Teran, J. (2022). Migraine review for general practice. Atencion Primaria , 54 (2). https://doi.org/10.1016/J.APRIM.2021.102208 Breslau, N., Lipton, R. B., Stewart, W. F., Schultz, L. R., & Welch, K. M. A. (2003). Comorbidity of migraine and depression: investigating potential etiology and prognosis. Neurology , 60 (8), 1308–1312. https://doi.org/10.1212/01.WNL.0000058907.41080.54 Buse, D. C., Silberstein, S. D., Manack, A. N., Papapetropoulos, S., & Lipton, R. B. (n.d.). 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Global prevalence of chronic migraine: a systematic review. Cephalalgia : An International Journal of Headache , 30 (5), 599–609. https://doi.org/10.1111/J.1468-2982.2009.01941.X Olesen, J. (2005). The international classification of headache disorders. 2nd edition (ICHD-II). Revue Neurologique , 161 (6–7), 689–691. https://doi.org/10.1016/S0035-3787(05)85119-7 Olesen, J. (2018). International Classification of Headache Disorders. The Lancet Neurology , 17 (5), 396–397. https://doi.org/10.1016/S1474-4422(18)30085-1 Silberstein, S., & Patel, S. (2014). Menstrual migraine: an updated review on hormonal causes, prophylaxis and treatment. Expert Opinion on Pharmacotherapy , 15 (14), 2063–2070. https://doi.org/10.1517/14656566.2014.947959 Tfelt-Hansen, P., Block, G., Dahlöf, C., Diener, H. C., Ferrari, M., Goadsby, P., Guidetti, V., Jones, B., Lipton, R., Massiou, H., Meinert, C., Sandrini, G., Steiner, T., & Winter, P. (2000). Guidelines for controlled trials of drugs in migraine: second edition. Cephalalgia : An International Journal of Headache , 20 (9), 765–786. https://doi.org/10.1046/J.1468-2982.2000.00117.X Vetvik, K. G., & Russell, M. B. (2011). Are Menstrual and Nonmenstrual Migraine Attacks Different? Current Pain and Headache Reports , 15 (5), 339. https://doi.org/10.1007/S11916-011-0212-4 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 13 Feb, 2025 Read the published version in BMC Neurology → Version 1 posted Editorial decision: Revision requested 06 Nov, 2024 Editor assigned by journal 05 Nov, 2024 Submission checks completed at journal 05 Nov, 2024 First submitted to journal 30 Oct, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5362945","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":375116419,"identity":"54c7b538-e837-4240-8fad-1d83eb694e4c","order_by":0,"name":"Guldeniz Cetin","email":"data:image/png;base64,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","orcid":"","institution":"Sancaktepe Prof. Dr. İlhan Varank Research and Training Hospital, Istanbul","correspondingAuthor":true,"prefix":"","firstName":"Guldeniz","middleName":"","lastName":"Cetin","suffix":""},{"id":375116422,"identity":"7462f66e-8a82-467b-a390-8358af801ab6","order_by":1,"name":"Ozlem Totuk","email":"","orcid":"","institution":"Sancaktepe Prof. Dr. İlhan Varank Research and Training Hospital, Istanbul","correspondingAuthor":false,"prefix":"","firstName":"Ozlem","middleName":"","lastName":"Totuk","suffix":""},{"id":375116423,"identity":"7631119b-5cd0-42f1-8b75-a2aa12105490","order_by":2,"name":"Serkan Demir","email":"","orcid":"","institution":"Sancaktepe Prof. Dr. İlhan Varank Research and Training Hospital, Istanbul","correspondingAuthor":false,"prefix":"","firstName":"Serkan","middleName":"","lastName":"Demir","suffix":""},{"id":375116425,"identity":"64e18e4d-8c84-480f-8f4c-0a0600412301","order_by":3,"name":"Sevki Sahin","email":"","orcid":"","institution":"Sancaktepe Prof. Dr. İlhan Varank Research and Training Hospital, Istanbul","correspondingAuthor":false,"prefix":"","firstName":"Sevki","middleName":"","lastName":"Sahin","suffix":""}],"badges":[],"createdAt":"2024-10-30 18:08:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5362945/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5362945/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12883-025-04070-2","type":"published","date":"2025-02-13T15:56:53+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":76487626,"identity":"3370bb98-e073-4108-8e2d-fa4f2f50229c","added_by":"auto","created_at":"2025-02-17 16:10:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1294733,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5362945/v1/189b3c79-ed55-41ac-8a88-b5b26731c80b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evaluation of the Effectiveness of Greater Occipital Nerve Blockade in Menstrual Migraine","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMigraine\u0026nbsp;is estimated to range from 1.4% to 2.2%, impacting millions of people and their families worldwide\u0026nbsp;(Natoli et al., 2010). Migraine is mostly influenced by genetic factors and typically begins in childhood, adolescence, or young adulthood. It is characterized by periodic, often unilateral, throbbing headaches\u0026nbsp;(Olesen, 2018)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe prevalence of migraine in women is three times higher than in men (Aguilar-Shea \u0026amp; Diaz-de-Teran, 2022). The primary factors contributing to the higher prevalence of migraine in women encompass hormonal fluctuations (particularly variations in estrogen levels), genetic predisposition, and environmental influences. Estrogen has been observed to enhance the sensitivity of the trigeminal nerve system, thereby facilitating the initiation of migraine attacks. Moreover, hormonal alterations throughout the female life cycle (adolescence, menstrual cycle, pregnancy, and menopause) can significantly impact the prevalence and severity of migraines. (Vetvik \u0026amp; Russell, 2011).\u003c/p\u003e\n\u003cp\u003eAccording to the International Classification of Headache Disorders (ICHD-3), migraine attacks associated with the menstrual cycle are categorized under the subgroup of Menstrual Migraine (MM). The definition of MM is further subdivided into two distinct categories (Olesen, 2018). Pure MM (PMM) attacks occur exclusively during menstruation and are observed in approximately 1% of the population. Menstrually related migraine (MRM) is more prevalent, with an incidence of approximately 6-7%, and can occur outside of menstruation as well. (Maasumi et al., 2017).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe characteristics of MM attacks significantly differ from those of non-MM attacks (Vetvik \u0026amp; Russell, 2011). Previous research has demonstrated that MM attacks tend to last longer, are more severe and occur more frequently compared to non-MM attacks. (Couturier et al., 2003). As yet, there is no spesific treatment that is designed to MM attacks. \u0026nbsp;Nonsteroidal anti-inflammatory drugs (NSAIDs), triptans, and ergot derivatives, commonly used for general migraine treatment, are also recommended for MM. However, the frequent side effects of these treatments, such as menstrual irregularities, poor patient compliance, pregnancy concerns, and comorbid conditions, highlight the need for alternative therapeutic approaches in MM management (MacGregor, 2015)\u003c/p\u003e\n\u003cp\u003eIn recent years, numerous studies have been conducted on the use of greater occipital nerve (GON) blockade in migraine patients. (Dilli et al., 2015)(Inan et al., 2019a) As an interventional treatment, GON blockade offers an alternative option for patients who do not respond to pharmacological therapies or wish to avoid medication-related side effects. However, research on the efficacy of GON blockade in MM patient groups are limited. To date, no studies in the existing literature have directly compared the effectiveness of GON blockade between PMM and MRM subgroups.\u003c/p\u003e\n\u003cp\u003eThe goal of the present article is to compare the short-term prophylactic efficacy of GON blockade in different MM subgroups and to evaluate the long-term effects of this treatment on patients\u0026apos; quality of life. For this purpose, we randomly assigned patients from different MM subgroup to receive GON blockade treatment and then compared the frequency, severity, and duration of migraine attacks before and after treatment, as well as the patients\u0026apos; reported quality of life over a follow-up period. We hypothesized that the GON blockade would be effective in MM and that both subgroups would experience an improvement in long-term quality of life.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003ePatients diagnosed with MM who presented to the neurology outpatient clinic between January 2023 and July 2024 were prospectively examined following Ethics Committee approval (File No: 227, Date: 08.11.2023) A total of 41 patients diagnosed with MM were included in the study, of which 8 patients (PMM: 4, MRM: 4) were excluded due to non-compliance with follow-up. The medical data of the remaining 33 patients (PMM: 15, MRM: 18) were analyzed after obtaining informed consent.\u003c/p\u003e\n\u003cp\u003ePatients diagnosed with MM according to ICHD-3, with regular menstrual cycles, who had used at least two prophylactic medications without benefit, were unwilling to use oral medication, and were considering pregnancy were included in the study. Exclusion criteria were determined as the presence of other primary and secondary headaches, use of hormone therapy, breastfeeding, and pregnancy. Cranial MRI was performed on all patients to exclude secondary headaches. Patients\u0026apos; demographic characteristics, body mass index (BMI), headache onset, location, triggers, accompanying symptoms, monthly headache days, and medication overuse status were evaluated. BMI was classified as normal (20-25 kg/m\u0026sup2;), overweight (25-30 kg/m\u0026sup2;), and obese (30 kg/m\u0026sup2; and above).\u003c/p\u003e\n\u003cp\u003eHeadache intensity was assessed using the Visual Analog Scale (VAS) score, ranging from 0 to 10 points. Headache frequency and disability status were measured using Headache Impact Test-6 (HIT-6) -monthly- and Migraine Disability Assessment (MIDAS) -quarterly- scores. Depression assessment was conducted using the Beck Depression Inventory (BDI), with scores divided into two categories: category 1 for scores 0-16 (minimal-mild depressive) and category 2 for scores 17-63 (moderate-severe depressive). The group whose MIDAS scores, which determine the number of painful days, decreased by 50% at months 0 and 3 was identified as treatment responders, while the group without decrease was identified as non-responders (Tfelt-Hansen et al., 2000). Patients utilizing NSAIDs for 15 days or more were categorized as the \u0026lsquo;medication overuse\u0026rsquo; (MO) group, while those without medication overuse were classified as the group \u0026lsquo;without medication overuse\u0026rsquo; (wMO ) (Olesen, 2005).\u003c/p\u003e\n\u003cp\u003eFor short-term prophylaxis, patients received bilateral GON blockade once a month for three months, one week before the expected menstrually bleeding date. For the following three months, participants were monitored without receiving any additional preventive treatments. The GON blockade procedure involved injecting a standard dose of 2 cc (20 mg) lidocaine hydrochloride at each injection site (Inan et al., 2015). Evaluations were conducted before treatment (month 0) and after treatment completion (months 3 and 6).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStatistical analysis:\u003c/strong\u003e The data were analyzed using IBM SPSS.26 software. Descriptive statistics for continuous variables were presented as mean and standard deviation, while descriptive statistics for categorical variables were presented as number (n) and percentage (%). Relationships between categorical variables were examined using the Chi-square test. The Shapiro-Wilk and Kolmogorov-Smirnov normality tests were employed to assess whether continuous variables exhibited normal distribution. The t-test was utilized for comparing continuous variables between groups. Repeated measures analysis was conducted using the GLM repeated measures test to compare measurements across groups. For all analyses, a p-value of \u0026lt;0.05 was considered statistically significant.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eDuring an 18-month study period, 33 patients diagnosed with MM at our hospital\u0026apos;s neurology outpatient clinic who met our study criteria were prospectively evaluated. Table 1 illustrates the demographic characteristics, MM subtype and onset age, headache frequency, medication overuse and treatment benefit status of the examined population.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1:\u003c/strong\u003e Demographic characteristics and headache features of patients\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 32.1192%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.3576%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePMM (n=15)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3642%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMRM (n=18)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.8808%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;MM(n=33)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.27815%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 32.1192%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge (years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.3576%;\"\u003e\n \u003cp\u003e41,3\u0026plusmn;6,4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3642%;\"\u003e\n \u003cp\u003e38,9\u0026plusmn;5,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.8808%;\"\u003e\n \u003cp\u003e40\u0026plusmn;6.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.27815%;\"\u003e\n \u003cp\u003e0,271\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 32.1192%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMİ\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eNormal\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eOverweight/obese\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.3576%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4(%26.7)\u003c/p\u003e\n \u003cp\u003e11(%73.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3642%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6(%33.3)\u003c/p\u003e\n \u003cp\u003e12(%66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.8808%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10(%30.3)\u003c/p\u003e\n \u003cp\u003e23(%69.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.27815%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0,702\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 32.1192%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducational Status\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePrimary school and below\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMiddle school and above\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.3576%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10(%66.7)\u003c/p\u003e\n \u003cp\u003e5(%33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3642%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6(%33.4)\u003c/p\u003e\n \u003cp\u003e12(%66.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.8808%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e16(%48.4)\u003c/p\u003e\n \u003cp\u003e17(%51.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.27815%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0,070\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 32.1192%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge of onset MM (mean \u0026plusmn; SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.3576%;\"\u003e\n \u003cp\u003e31,3\u0026plusmn;7,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3642%;\"\u003e\n \u003cp\u003e24,4\u0026plusmn;9,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.8808%;\"\u003e\n \u003cp\u003e27.58\u0026plusmn;8,8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.27815%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0,024\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 32.1192%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHeadache Frequency (days/month)\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(mean \u0026plusmn; SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.3576%;\"\u003e\n \u003cp\u003e6,0\u0026plusmn;4,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3642%;\"\u003e\n \u003cp\u003e12,2\u0026plusmn;6,9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.8808%;\"\u003e\n \u003cp\u003e9.3\u0026plusmn;6.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.27815%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0,004\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 32.1192%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMedication Overuse (MO)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.3576%;\"\u003e\n \u003cp\u003e5(%33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3642%;\"\u003e\n \u003cp\u003e14(%77.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.8808%;\"\u003e\n \u003cp\u003e19(%57.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.27815%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0,027\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 32.1192%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eResponse to Treatment\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 21.3576%;\"\u003e\n \u003cp\u003e12 (%88.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.3642%;\"\u003e\n \u003cp\u003e12(%66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 17.8808%;\"\u003e\n \u003cp\u003e24(%72.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 8.27815%;\"\u003e\n \u003cp\u003e0,458\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAnalysis of the demographic data revealed that the mean age of 33 patients was 40.0\u0026plusmn;6.1 years. The mean age, BMI, and educational status of patients diagnosed with MM did not demonstrate significant differences among MM subgroups. However, the age of MM onset was significantly lower (p=0.024) in MRM patients, compared to the PMM patient group, while headache frequency (p=0.004) and MO were significantly higher (p=0.027). Both subgroups exhibited improvement following treatment, with no significant differences observed between the groups.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eTable 2:\u003c/strong\u003e Headache characteristics, triggers, and associated symptoms of the patients, as well as the total number of patients.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"106%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.4694%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.6735%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.2857%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePMM (n=15)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.2857%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMRM (n=18)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.2857%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMM\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=33)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.4694%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003ePresentation of the headache\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 33.6735%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eProminent during fasting\u003c/p\u003e\n \u003cp\u003eProminent in the night\u003c/p\u003e\n \u003cp\u003eProminent during exercise\u003c/p\u003e\n \u003cp\u003eProminent with laughing\u003c/p\u003e\n \u003cp\u003eSame during daytime\u003c/p\u003e\n \u003cp\u003eProminent with straining\u003c/p\u003e\n \u003cp\u003eProminent in the mornings\u003c/p\u003e\n \u003cp\u003eProminent in the cough\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.2857%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5(%33.3)\u003c/p\u003e\n \u003cp\u003e1 (%6.6)\u003c/p\u003e\n \u003cp\u003e3 (%20)\u003c/p\u003e\n \u003cp\u003e2(%13.3)\u003c/p\u003e\n \u003cp\u003e12 (%80)\u003c/p\u003e\n \u003cp\u003e1 (%6.6)\u003c/p\u003e\n \u003cp\u003e1 (%6.6)\u003c/p\u003e\n \u003cp\u003e1 (%6.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.2857%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6(%33.3)\u003c/p\u003e\n \u003cp\u003e8(%44.4)\u003c/p\u003e\n \u003cp\u003e3(%16.6)\u003c/p\u003e\n \u003cp\u003e1(%5.5)\u003c/p\u003e\n \u003cp\u003e8(%44.4)\u003c/p\u003e\n \u003cp\u003e1(%5.5)\u003c/p\u003e\n \u003cp\u003e2(%11.1)\u003c/p\u003e\n \u003cp\u003e1(%5.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.2857%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e11(%33.3)\u003c/p\u003e\n \u003cp\u003e9 (%27.7)\u003c/p\u003e\n \u003cp\u003e6 (%18.1)\u003c/p\u003e\n \u003cp\u003e3 (%9)\u003c/p\u003e\n \u003cp\u003e20(%60.6)\u003c/p\u003e\n \u003cp\u003e2 (%6)\u003c/p\u003e\n \u003cp\u003e3 (%9)\u003c/p\u003e\n \u003cp\u003e2 (%6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.4694%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eHeadache triggers\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 33.6735%;\"\u003e\n \u003cp\u003eStress\u003c/p\u003e\n \u003cp\u003eFatigue\u003c/p\u003e\n \u003cp\u003eSeasonal relationship\u003c/p\u003e\n \u003cp\u003eAlcohol\u003c/p\u003e\n \u003cp\u003eFasting\u003c/p\u003e\n \u003cp\u003eOdor\u003c/p\u003e\n \u003cp\u003eLoud noise\u003c/p\u003e\n \u003cp\u003eHigh-intensity light\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.2857%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15 (%100)\u003c/p\u003e\n \u003cp\u003e15 (%100)\u003c/p\u003e\n \u003cp\u003e1 (%6.6)\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e11(%73.3)\u003c/p\u003e\n \u003cp\u003e7 (%46.6)\u003c/p\u003e\n \u003cp\u003e13(%86.6)\u003c/p\u003e\n \u003cp\u003e10(%66.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.2857%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e18(%100)\u003c/p\u003e\n \u003cp\u003e16(%88.8)\u003c/p\u003e\n \u003cp\u003e4(%22.2)\u003c/p\u003e\n \u003cp\u003e2(%11.1)\u003c/p\u003e\n \u003cp\u003e14(%77.7)\u003c/p\u003e\n \u003cp\u003e11(%61.1)\u003c/p\u003e\n \u003cp\u003e13(%72.2)\u003c/p\u003e\n \u003cp\u003e11(%61.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.2857%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e33 (%100)\u003c/p\u003e\n \u003cp\u003e31(%93.9)\u003c/p\u003e\n \u003cp\u003e5 (%15.1)\u003c/p\u003e\n \u003cp\u003e2 (%6)\u003c/p\u003e\n \u003cp\u003e25(%75.7)\u003c/p\u003e\n \u003cp\u003e18(%54.5)\u003c/p\u003e\n \u003cp\u003e26(%78.7)\u003c/p\u003e\n \u003cp\u003e21(%63.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.4694%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eFeatures of headache\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"bottom\" style=\"width: 33.6735%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003ePenetrating-Jabbing\u003c/p\u003e\n \u003cp\u003eDull\u003c/p\u003e\n \u003cp\u003eCompressive\u003c/p\u003e\n \u003cp\u003eThrobbing\u003c/p\u003e\n \u003cp\u003eLightning\u003c/p\u003e\n \u003cp\u003eSudden\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.2857%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (%6.6)\u003c/p\u003e\n \u003cp\u003e2 (%13.3)\u003c/p\u003e\n \u003cp\u003e3 (%20)\u003c/p\u003e\n \u003cp\u003e14(%93.3)\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e6 (%40)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.2857%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1 (%5.5)\u003c/p\u003e\n \u003cp\u003e1 (%5.5)\u003c/p\u003e\n \u003cp\u003e5 (%27.7)\u003c/p\u003e\n \u003cp\u003e16(%88.8)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;-\u003c/p\u003e\n \u003cp\u003e6 (%33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.2857%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2 (%6)\u003c/p\u003e\n \u003cp\u003e3 (%9)\u003c/p\u003e\n \u003cp\u003e8 (%24.2)\u003c/p\u003e\n \u003cp\u003e30(%90.9)\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e12(%36.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.4694%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eAssociated symptoms\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.6735%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eNausea\u003c/p\u003e\n \u003cp\u003eVomiting\u003c/p\u003e\n \u003cp\u003ePhotophobia\u003c/p\u003e\n \u003cp\u003ePhonophobia\u003c/p\u003e\n \u003cp\u003eDizziness\u003c/p\u003e\n \u003cp\u003eVertigo\u003c/p\u003e\n \u003cp\u003eAllodynia\u003c/p\u003e\n \u003cp\u003eTinnitus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.2857%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15 (%100)\u003c/p\u003e\n \u003cp\u003e7 (%46.6)\u003c/p\u003e\n \u003cp\u003e13(%86.6)\u003c/p\u003e\n \u003cp\u003e13 (%86.6\u003c/p\u003e\n \u003cp\u003e12 (%80)\u003c/p\u003e\n \u003cp\u003e1 (%6.6)\u003c/p\u003e\n \u003cp\u003e3 (%20)\u003c/p\u003e\n \u003cp\u003e2 (%13.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.2857%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e16(%88.8)\u003c/p\u003e\n \u003cp\u003e11(%61.1)\u003c/p\u003e\n \u003cp\u003e16(%88.8)\u003c/p\u003e\n \u003cp\u003e16(%88.8)\u003c/p\u003e\n \u003cp\u003e16(%88.8)\u003c/p\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003cp\u003e6 (%33.3)\u003c/p\u003e\n \u003cp\u003e1 (%5.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.2857%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e32(%96.9)\u003c/p\u003e\n \u003cp\u003e18(%54.5)\u003c/p\u003e\n \u003cp\u003e29(%87.8)\u003c/p\u003e\n \u003cp\u003e29(%87.8)\u003c/p\u003e\n \u003cp\u003e28(%84.8)\u003c/p\u003e\n \u003cp\u003e1 (%3)\u003c/p\u003e\n \u003cp\u003e9 (%27.7)\u003c/p\u003e\n \u003cp\u003e3 (%9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eIn the evaluation of the presentation, triggers, features, and associated symptoms of headache, no significant difference was observed between MM groups. (Table 2)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eTablo 3:\u0026nbsp;\u003c/strong\u003eVAS, HIT-6, MIDAS and BDI scores by the groups and total number of the patients before and after treatment\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePMM\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=15)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMRM\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=18)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;MM\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=33)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eort\u0026plusmn;S.S.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eort\u0026plusmn;S.S.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eort\u0026plusmn;S.S\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eVAS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline VAS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e8,6\u0026plusmn;1,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e8,9\u0026plusmn;0,9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e8,7\u0026plusmn;1,2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVAS at the end of 3 month\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e3,6\u0026plusmn;2,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e4,4\u0026plusmn;1,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e4,0\u0026plusmn;2,1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVas at the end of 6 month\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e4,6\u0026plusmn;2,6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e5,1\u0026plusmn;2,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e4,8\u0026plusmn;2,4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u0026lt;0,001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u0026lt;0,001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u0026lt;0,001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMIDAS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline MIDAS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e31,0\u0026plusmn;15,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e45,3\u0026plusmn;27,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e41,8\u0026plusmn;26,6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMIDAS at the end of 3 month\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e12,5\u0026plusmn;13,8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e16,1\u0026plusmn;12,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e14,5\u0026plusmn;13,0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMIDAS at the end of 6 month\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e14,4\u0026plusmn;12,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e12,1\u0026plusmn;6,6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e13,1\u0026plusmn;9,5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP=0,002\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u0026lt;0,001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u0026lt;0,001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eHIT-6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline HIT-6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e66,7\u0026plusmn;16,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e66,3\u0026plusmn;8,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e65,9\u0026plusmn;11,8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHIT-6 at the end of 3 month\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e44,6\u0026plusmn;10,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e48,3\u0026plusmn;8,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e46,6\u0026plusmn;9,6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHIT-6 at the end of 6 month\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e49,6\u0026plusmn;10,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e52,7\u0026plusmn;10,6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e51,3\u0026plusmn;10,6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u0026lt;0,001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u0026lt;0,001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u0026lt;0,001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eBDI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline BDI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e13,8\u0026plusmn;6,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e15,2\u0026plusmn;8,8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e15,0\u0026plusmn;7,8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBDI at the end of 3 month\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e8,1\u0026plusmn;4,9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e10,3\u0026plusmn;6,9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e9,3\u0026plusmn;6,1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBDI at the end of 6 month\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e12,2\u0026plusmn;9,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e12,1\u0026plusmn;9,9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e12,1\u0026plusmn;9,7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP=0,005\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP=0,02\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP=\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;0,03\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eIn both diagnostic groups, the initially measured VAS, HIT-6, MIDAS, and BDI scores were significantly higher than the measurements at 3 and 6 months (p\u0026lt;0.001 for both groups). There was no significant difference between the 3-month and 6-month results. No significant effect of diagnostic groups on treatment outcomes was observed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4:\u0026nbsp;\u003c/strong\u003eTemporal changes in VAS, HIT-6, and MIDAS scores based on initial BDI scores\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline BDI Category 1 (n=19)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline BDI Category 2 (n=14)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP values\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003eort\u0026plusmn;S.S.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003eort\u0026plusmn;S.S.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eVAS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline VAS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e8,6\u0026plusmn;1,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e8,9\u0026plusmn;1,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e0,585\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVAS at the end of 3 month\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e3,4\u0026plusmn;1,9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e4,9\u0026plusmn;2,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e0,054\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVas at the end of 6 month\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e4,2\u0026plusmn;2,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e5,7\u0026plusmn;2,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e0,070\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;P*\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u0026lt;0,001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u0026lt;0,001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMIDAS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline MIDAS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e30,1\u0026plusmn;15,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e50,6\u0026plusmn;27,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0,010\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMIDAS at the end of 3 month\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e10,1\u0026plusmn;9,8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e20,5\u0026plusmn;14,6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0,021\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMIDAS at the end of 6 month\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e11,3\u0026plusmn;10,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e15,7\u0026plusmn;8,4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e0,194\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u0026lt;0,001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u0026lt;0,001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eHIT-6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline HIT-6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e64,4\u0026plusmn;10,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e69,2\u0026plusmn;15,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e0,283\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHIT-6 at the end of 3 month\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e46,1\u0026plusmn;11,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e47,4\u0026plusmn;7,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e0,703\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHIT-6 at the end of 6 month\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e50,9\u0026plusmn;12,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e51,7\u0026plusmn;7,6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e0,827\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 114px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u0026lt;0,001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u0026lt;0,001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eWhen participants were grouped according to BDI categories, baseline measurements of VAS, HIT-6, and MIDAS scores in both groups were significantly higher than those at the 3rd and 6th months. No significant differences were observed between the results at the 3rd and 6th months. The BDI category did not have a significant impact on treatment outcomes. The only significant difference among the categories was that participants in BDI categories 1\u0026ndash;2 had significantly lower baseline and 3rd-month MIDAS measurements compared to those in BDI categories 3\u0026ndash;4 (p = 0.010 and 0.021, respectively).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 5:\u0026nbsp;\u003c/strong\u003eBaseline, 3rd-month, and 6th-month VAS, HIT-6, and MIDAS measurement results according to MO status.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMO patients\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(n=19)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ewMO patients\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(n=14)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP values\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eort\u0026plusmn;S.S.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eort\u0026plusmn;S.S.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eVAS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline VAS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e9,0\u0026plusmn;0,9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e8,4\u0026plusmn;1,5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e0,157\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVAS at the end of 3 month\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e4,7\u0026plusmn;1,6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e3,1\u0026plusmn;2,4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0,028\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVas at the end of 6 month\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e5,5\u0026plusmn;1,9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e3,9\u0026plusmn;2,8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e0,057\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;P*\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u0026lt;0,001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u0026lt;0,001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMIDAS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline MIDAS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e47,0\u0026plusmn;24,8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e27,7\u0026plusmn;15,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0,016\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMIDAS at the end of 3 month\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e18,2\u0026plusmn;13,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e9,5\u0026plusmn;11,4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e0,056\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMIDAS at the end of 6 month\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e15,1\u0026plusmn;8,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e10,5\u0026plusmn;10,8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e0,168\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u0026lt;0,001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u0026lt;0,001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 75px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eHIT-6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline HIT-6\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e71,4\u0026plusmn;12,9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e59,8\u0026plusmn;8,4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0,007\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHIT-6 at the end of 3 month\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e49,6\u0026plusmn;9,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e42,5\u0026plusmn;9,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0,034\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHIT-6 at the end of 6 month\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e53,3\u0026plusmn;10,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e48,5\u0026plusmn;10,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e0,211\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ep*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u0026lt;0,001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u0026lt;0,001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eWhen participants were grouped according to MO status; baseline measurements of VAS, HIT-6, and MIDAS scores in both groups were significantly higher than those at the 3rd and 6th months. The 3rd-month VAS measurements of participants with MO were significantly higher than those without medication overuse (wMO) (p = 0.028). The baseline MIDAS measurement values of those with MO were also significantly higher than those wMO (p = 0.016). Regarding the HIT-6 scores, among participants wMO, measurements at each time point were significantly different (0\u0026ndash;3 months p \u0026lt;0.001, 0\u0026ndash;6 months p = 0.031, 3\u0026ndash;6 months p = 0.032). The baseline and 3rd-month HIT-6 scores of those with MO were significantly higher than those wMO (p = 0.007 and p = 0.034, respectively). No significant effect of MO status on treatment was detected.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 6:\u0026nbsp;\u003c/strong\u003eComparison of BDI scores over time between patients who responded and did not respond to treatment, and the between-group effects\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNonresponders to Treatment\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(n=9)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eResponders to Treatment\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e(n=24)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP values\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eort\u0026plusmn;S.S.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003eort\u0026plusmn;S.S.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\" valign=\"top\" style=\"width: 74px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eBDI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline BDI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e14,1\u0026plusmn;9,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e14,8\u0026plusmn;7,3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0,815\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBDI at the end of 3 month\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e11,2\u0026plusmn;8,0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e8,6\u0026plusmn;5,2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0,284\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBDI at the end of 6 month\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003e13,2\u0026plusmn;10,1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e11,7\u0026plusmn;9,7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e0,712\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 200px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;P*\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 133px;\"\u003e\n \u003cp\u003eP=0,388\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 113px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eP\u0026lt;0,001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 85px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eThere was no statistically significant difference in BDI measurement scores among those who did not benefit from treatment (p=0.388). For those who benefited from treatment, the initial measurement was significantly higher than at the 3rd month (p\u0026lt;0.001). The benefit from treatment did not have a statistically significant effect on the change in measurement results (p=0.576).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, GON blockade was administered as a short-term prophylactic intervention for MM and was found to reduce the severity and frequency of headaches, as well as enhance quality of life. Moreover, it has been observed that the improvement in headaches persisted over an extended period, and patients also demonstrated improvement in their depression scores.\u003c/p\u003e \u003cp\u003eIn addition to hormones and neurotransmitters involved in migraine pathogenesis, demographic factors have also been observed to influence headaches. Consistent with previous research, our study observed a higher prevalence of overweight/obese patients in both MM groups (Lillis et al., 2017). This finding suggests that elevated BMI may be associated with increased migraine severity and frequency (Gelaye et al., 2017). There was no significant difference between the groups in terms of age and education level.\u003c/p\u003e \u003cp\u003eSimilarly, in accordance with previous studies, MRM patients exhibited a lower age of migraine onset, higher headache frequency, and increased MO (Silberstein \u0026amp; Patel, 2014). This observation supports the hypothesis that the MRM group experiences more refractory and severe headaches compared to the PMM group. The occurrence of headaches in MRM patients during non-menstrual periods may contribute to an elevated risk of MO.\u003c/p\u003e \u003cp\u003eIn our study, the characteristics of headaches were examined; it was determined that headache intensity did not show a significant change throughout the day in both groups, but became more pronounced with fasting. This finding may support the role of metabolic factors in migraine pathophysiology. Additionally, stress and fatigue were identified as the most frequent triggering factors in both groups. Thus, the importance of lifestyle factors on migraine headaches has been emphasized once again (Kelman, 2007). Throbbing headache and nausea were the most frequently observed symptoms, which are consistent with the typical clinical features of migraine (Olesen, 2018).\u003c/p\u003e \u003cp\u003eIn recent years, GON blockade has been proposed as an effective method for migraine treatment (Inan et al., 2019b). Consequently, significant improvements were observed in patients' VAS, HIT-6, MIDAS, and BDI scores following GON blockade administered over a three-month period. During medication-free follow-ups from the third to the sixth month, this improvement persisted, although no statistically significant temporal difference was noted. These findings indicate that GON blockade is effective in short-term prophylaxis, and this effect is maintained in the long term.\u003c/p\u003e \u003cp\u003eThe improvement in depression scores during treatment follow-up has been associated with the psychogenic aspects of migraine therapy. Notably, the significant improvement in MIDAS scores among patients with initially low BDI scores indicates that quality of life increases more substantially in patients with mild or no accompanying depression. This finding emphasizes the bidirectional relationship between migraine and depression, suggesting that this factor should be considered in treatment strategies. (Breslau et al., 2003).\u003c/p\u003e \u003cp\u003eIt is known that excessive medication use complicates migraine treatment and increases headache severity. (Diener \u0026amp; Limmroth, 2004). In our study, the higher VAS scores at the third month for patients with MO indicate that these patients experience more severe headaches. Furthermore, the higher initial MIDAS scores in this group support the presence of increased migraine-related disability. Analysis of the HIT-6 scores revealed significant improvements sustained during the 0\u0026ndash;3 month, 3\u0026ndash;6 month, and 0\u0026ndash;6 month follow-up periods. This finding demonstrates that the positive effects of GON blockade on quality of life persist in the long term.\u003c/p\u003e \u003cp\u003eFinally, the observation of significant improvement in BDI scores at baseline and third month among patients experiencing a 50% reduction in the number of days with headaches further demonstrates the positive impact of effective migraine treatment on mood (Buse et al., n.d.)\u003c/p\u003e \u003cp\u003eOur study is the first to evaluate the efficacy of GON blockade in MM patients, offering an effective option in cases where other prophylactic treatments are unsuitable or intolerable. However, significant limitations include the small sample size and the absence of a placebo control group. Considering the potential for a high placebo effect in migraine studies (Finniss et al., 2010), it is necessary to conduct larger-scale, randomized, and placebo-controlled trials.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study has demonstrated that GON blockade may be an effective option for short-term and long-term prophylaxis in the treatment of MM. GON blockade has reduced the frequency and severity of headaches in MM patients, resulting in significant improvements in quality of life and psychological state. Further research is necessary to validate these findings in larger patient cohorts and to better elucidate the long-term effects of GON blockade.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eBDI \u003c/strong\u003eBeck Depression Inventory \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBMI \u003c/strong\u003eBody mass index \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGON \u003c/strong\u003eGreater occipital nerve \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHİT-6 \u003c/strong\u003eHeadache Impact Test-6 \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eICHD-3\u003c/strong\u003e International Classification of Headache Disorders -3\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMİDAS \u003c/strong\u003eMigraine Disability Assessment\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMM \u003c/strong\u003e Menstrual migraine\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMO \u003c/strong\u003e Medication Overuse\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMRI \u003c/strong\u003e Magnetic resonance imaging \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMRM \u003c/strong\u003e Menstrually related migraine\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNSAIDs \u003c/strong\u003eNonsteroidal anti-inflammatory drugs\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePMM\u003c/strong\u003e Pure menstrual migraine \u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ewMO \u003c/strong\u003e Without medication overuse\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eVAS\u003c/strong\u003e Visual Analog Scale\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e\n\u003cp\u003eAll patients provided written informed consent after being informed of thestudy protocol. The study was approved by the Ethics Committee of Sancaktepe Prof. Dr. İlhan Varank Research and Training Hospital (File No: 227, Date: 08.11.2023)\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eThe authors received no financial support for the research, authorship, or publication of this article.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eG.C wrote the main manuscript text. All authors reviewed the manuscript\u003c/p\u003e\n\u003ch2\u003eAcknowledgements\u003c/h2\u003e\n\u003cp\u003eWe gratefully acknowledge the support of the Sancaktepe Şehit Prof. Dr. İlhan Varank Research and Training Hospital and all the participants.\u003c/p\u003e\n\u003ch2\u003eData availability\u003c/h2\u003e\n\u003cp\u003eThe data supporting the findings of this study is available from thecorresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAguilar-Shea, A. L., \u0026amp; Diaz-de-Teran, J. (2022). Migraine review for general practice. \u003cem\u003eAtencion Primaria\u003c/em\u003e, \u003cem\u003e54\u003c/em\u003e(2). https://doi.org/10.1016/J.APRIM.2021.102208\u003c/li\u003e\n \u003cli\u003eBreslau, N., Lipton, R. B., Stewart, W. F., Schultz, L. R., \u0026amp; Welch, K. M. A. (2003). Comorbidity of migraine and depression: investigating potential etiology and prognosis. \u003cem\u003eNeurology\u003c/em\u003e, \u003cem\u003e60\u003c/em\u003e(8), 1308\u0026ndash;1312. https://doi.org/10.1212/01.WNL.0000058907.41080.54\u003c/li\u003e\n \u003cli\u003eBuse, D. C., Silberstein, S. D., Manack, A. N., Papapetropoulos, S., \u0026amp; Lipton, R. B. (n.d.). \u003cem\u003ePsychiatric comorbidities of episodic and chronic migraine\u003c/em\u003e. https://doi.org/10.1007/s00415-012-6725-x\u003c/li\u003e\n \u003cli\u003eCouturier, E. G. M., Bomhof, M. A. M., Neven, A. K., \u0026amp; Van Duijn, N. P. (2003). Menstrual migraine in a representative Dutch population sample: prevalence, disability and treatment. \u003cem\u003eCephalalgia : An International Journal of Headache\u003c/em\u003e, \u003cem\u003e23\u003c/em\u003e(4), 302\u0026ndash;308. https://doi.org/10.1046/J.1468-2982.2003.00516.X\u003c/li\u003e\n \u003cli\u003eDiener, H. C., \u0026amp; Limmroth, V. (2004). Medication-overuse headache: A worldwide problem. \u003cem\u003eLancet Neurology\u003c/em\u003e, \u003cem\u003e3\u003c/em\u003e(8), 475\u0026ndash;483. https://doi.org/10.1016/S1474-4422(04)00824-5\u003c/li\u003e\n \u003cli\u003eDilli, E., Halker, R., Vargas, B., Hentz, J., Radam, T., Rogers, R., \u0026amp; Dodick, D. (2015). Occipital nerve block for the short-term preventive treatment of migraine: A randomized, double-blinded, placebo-controlled study. \u003cem\u003eCephalalgia : An International Journal of Headache\u003c/em\u003e, \u003cem\u003e35\u003c/em\u003e(11), 959\u0026ndash;968. https://doi.org/10.1177/0333102414561872\u003c/li\u003e\n \u003cli\u003eFinniss, D. G., Kaptchuk, T. J., Miller, F., \u0026amp; Benedetti, F. (2010). Biological, clinical, and ethical advances of placebo effects. \u003cem\u003eLancet (London, England)\u003c/em\u003e, \u003cem\u003e375\u003c/em\u003e(9715), 686\u0026ndash;695. https://doi.org/10.1016/S0140-6736(09)61706-2\u003c/li\u003e\n \u003cli\u003eGelaye, B., Sacco, S., Brown, W. J., Nitchie, H. L., Ornello, R., \u0026amp; Peterlin, B. L. (2017). Body composition status and the risk of migraine: A meta-analysis. \u003cem\u003eNeurology\u003c/em\u003e, \u003cem\u003e88\u003c/em\u003e(19), 1795\u0026ndash;1804. https://doi.org/10.1212/WNL.0000000000003919\u003c/li\u003e\n \u003cli\u003eInan, L. E., Inan, N., Unal-Artık, H. A., Atac, C., \u0026amp; Babaoglu, G. (2019a). Greater occipital nerve block in migraine prophylaxis: Narrative review. \u003cem\u003eCephalalgia : An International Journal of Headache\u003c/em\u003e, \u003cem\u003e39\u003c/em\u003e(7), 908\u0026ndash;920. https://doi.org/10.1177/0333102418821669\u003c/li\u003e\n \u003cli\u003eInan, L. E., Inan, N., Unal-Artık, H. A., Atac, C., \u0026amp; Babaoglu, G. (2019b). Greater occipital nerve block in migraine prophylaxis: Narrative review. \u003cem\u003eCephalalgia\u003c/em\u003e, \u003cem\u003e39\u003c/em\u003e(7), 908\u0026ndash;920. https://doi.org/10.1177/0333102418821669/ASSET/IMAGES/LARGE/10.1177_0333102418821669-FIG1.JPEG\u003c/li\u003e\n \u003cli\u003eKelman, L. (2007). The triggers or precipitants of the acute migraine attack. \u003cem\u003eCephalalgia : An International Journal of Headache\u003c/em\u003e, \u003cem\u003e27\u003c/em\u003e(5), 394\u0026ndash;402. https://doi.org/10.1111/J.1468-2982.2007.01303.X\u003c/li\u003e\n \u003cli\u003eLillis, J., Graham Thomas, J., Seng, E. K., Lipton, R. B., Pavlović, J. M., Rathier, L., Roth, J., O\u0026rsquo;Leary, K. C., \u0026amp; Bond, D. S. (2017). Importance of Pain Acceptance in Relation to Headache Disability and Pain Interference in Women With Migraine and Overweight/Obesity. \u003cem\u003eHeadache\u003c/em\u003e, \u003cem\u003e57\u003c/em\u003e(5), 709\u0026ndash;718. https://doi.org/10.1111/HEAD.13058\u003c/li\u003e\n \u003cli\u003eMaasumi, K., Tepper, S. J., \u0026amp; Kriegler, J. S. (2017). Menstrual Migraine and Treatment Options: Review. \u003cem\u003eHeadache\u003c/em\u003e, \u003cem\u003e57\u003c/em\u003e(2), 194\u0026ndash;208. https://doi.org/10.1111/HEAD.12978\u003c/li\u003e\n \u003cli\u003eMacGregor, E. A. (2015). Migraine Management During Menstruation and Menopause. \u003cem\u003eContinuum (Minneapolis, Minn.)\u003c/em\u003e, \u003cem\u003e21\u003c/em\u003e(4 Headache), 990\u0026ndash;1003. https://doi.org/10.1212/CON.0000000000000196\u003c/li\u003e\n \u003cli\u003eNatoli, J. L., Manack, A., Dean, B., Butler, Q., Turkel, C. C., Stovner, L., \u0026amp; Lipton, R. B. (2010). Global prevalence of chronic migraine: a systematic review. \u003cem\u003eCephalalgia : An International Journal of Headache\u003c/em\u003e, \u003cem\u003e30\u003c/em\u003e(5), 599\u0026ndash;609. https://doi.org/10.1111/J.1468-2982.2009.01941.X\u003c/li\u003e\n \u003cli\u003eOlesen, J. (2005). The international classification of headache disorders. 2nd edition (ICHD-II). \u003cem\u003eRevue Neurologique\u003c/em\u003e, \u003cem\u003e161\u003c/em\u003e(6\u0026ndash;7), 689\u0026ndash;691. https://doi.org/10.1016/S0035-3787(05)85119-7\u003c/li\u003e\n \u003cli\u003eOlesen, J. (2018). International Classification of Headache Disorders. \u003cem\u003eThe Lancet Neurology\u003c/em\u003e, \u003cem\u003e17\u003c/em\u003e(5), 396\u0026ndash;397. https://doi.org/10.1016/S1474-4422(18)30085-1\u003c/li\u003e\n \u003cli\u003eSilberstein, S., \u0026amp; Patel, S. (2014). Menstrual migraine: an updated review on hormonal causes, prophylaxis and treatment. \u003cem\u003eExpert Opinion on Pharmacotherapy\u003c/em\u003e, \u003cem\u003e15\u003c/em\u003e(14), 2063\u0026ndash;2070. https://doi.org/10.1517/14656566.2014.947959\u003c/li\u003e\n \u003cli\u003eTfelt-Hansen, P., Block, G., Dahl\u0026ouml;f, C., Diener, H. C., Ferrari, M., Goadsby, P., Guidetti, V., Jones, B., Lipton, R., Massiou, H., Meinert, C., Sandrini, G., Steiner, T., \u0026amp; Winter, P. (2000). Guidelines for controlled trials of drugs in migraine: second edition. \u003cem\u003eCephalalgia : An International Journal of Headache\u003c/em\u003e, \u003cem\u003e20\u003c/em\u003e(9), 765\u0026ndash;786. https://doi.org/10.1046/J.1468-2982.2000.00117.X\u003c/li\u003e\n \u003cli\u003eVetvik, K. G., \u0026amp; Russell, M. B. (2011). Are Menstrual and Nonmenstrual Migraine Attacks Different? \u003cem\u003eCurrent Pain and Headache Reports\u003c/em\u003e, \u003cem\u003e15\u003c/em\u003e(5), 339. https://doi.org/10.1007/S11916-011-0212-4\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-neurology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurl","sideBox":"Learn more about [BMC Neurology](http://bmcneurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurl","title":"BMC Neurology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"menstrual migraine, pure menstrual migraine, menstrually related migraine, GON blockade, short term prophylacy","lastPublishedDoi":"10.21203/rs.3.rs-5362945/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5362945/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e This study aimed to compare the short-term prophylactic efficacy of greater occipital nerve (GON) blockade in menstrual migraine (MM) subgroups and evaluate the long-term effects on patients' quality of life.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e In this prospective study, 33 patients diagnosed with MM (15 with pure menstrual migraine [PMM] and 18 with menstrually related migraine [MRM]) received bilateral GON blockade once a month, one week before menstrual bleeding, for three months. Patients were evaluated before treatment (month 0) and after treatment completion (months 3 and 6) using the Visual Analog Scale (VAS), Headache Impact Test-6 (HIT-6), Migraine Disability Assessment (MIDAS), and Beck Depression Inventory (BDI) scores.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e MRM patients had a lower age of MM onset (p=0.024), higher headache frequency (p=0.004), and increased medication overuse (p=0.027) compared to PMM patients. After GON blockade, significant improvements were observed in VAS, HIT-6, MIDAS, and BDI scores in both subgroups, with no significant differences between them. The improvement persisted during the medication-free follow-up period (months 3-6). Patients with mild or no depression showed a more substantial increase in quality of life. Patients experiencing a 50% reduction in headache days demonstrated significant improvement in BDI scores.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e GON blockade may be an effective option for short-term and long-term prophylaxis in the treatment of MM, reducing the frequency and severity of headaches and improving quality of life and psychological state. Further research with larger patient cohorts and placebo-controlled trials is necessary to validate these findings.\u003c/p\u003e","manuscriptTitle":"Evaluation of the Effectiveness of Greater Occipital Nerve Blockade in Menstrual Migraine","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-19 06:22:43","doi":"10.21203/rs.3.rs-5362945/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-11-07T04:58:24+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-11-05T17:05:07+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-11-05T17:04:55+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Neurology","date":"2024-10-30T18:02:58+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-neurology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurl","sideBox":"Learn more about [BMC Neurology](http://bmcneurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurl","title":"BMC Neurology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"50074d6c-797f-4f99-86af-2d2ec04a5186","owner":[],"postedDate":"November 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-02-17T16:04:42+00:00","versionOfRecord":{"articleIdentity":"rs-5362945","link":"https://doi.org/10.1186/s12883-025-04070-2","journal":{"identity":"bmc-neurology","isVorOnly":false,"title":"BMC Neurology"},"publishedOn":"2025-02-13 15:56:53","publishedOnDateReadable":"February 13th, 2025"},"versionCreatedAt":"2024-11-19 06:22:43","video":"","vorDoi":"10.1186/s12883-025-04070-2","vorDoiUrl":"https://doi.org/10.1186/s12883-025-04070-2","workflowStages":[]},"version":"v1","identity":"rs-5362945","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5362945","identity":"rs-5362945","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}