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Aim Evaluate the efficacy and safety of non-invasive vagus nerve stimulation for migraine prevention. Methods After completing a 4-week diary run-in period, adults who had migraine with or without aura were randomly assigned to receive active non-invasive vagus nerve stimulation or sham therapy during a 12-week double-blind period. Results Of 336 enrolled participants, 113 (active, n = 56; sham, n = 57) completed ≥70 days of the double-blind period and were ≥66% adherent with treatment, comprising the prespecified modified intention-to-treat population. The COVID-19 pandemic led to early trial termination, and the population was ∼60% smaller than the statistical target for full power. Mean reduction in monthly migraine days (primary endpoint) was 3.12 for the active group and 2.29 days for the sham group (difference, −0.83; p = 0.2329). Responder rate (i.e. the percentage of participants with a ≥50% reduction in migraine days) was greater in the active group (44.87%) than the sham group (26.81%; p = 0.0481). Prespecified subgroup analysis suggested that participants with aura responded preferentially. No serious device-related adverse events were reported. Conclusions These results suggest clinical utility of non-invasive vagus nerve stimulation for migraine prevention, particularly for patients who have migraine with aura, and reinforce the well-established safety and tolerability profile of this therapy. Trial Registration: ClinicalTrials.gov (NCT03716505).

It is important to ensure that the patient with chronic daily headache has had a thorough evaluation to rule out secondary causes of headache. This includes the use of laboratory studies on serum as well as cerebral spinal fluid (CSF). In this chapter we will walk through the appropriate evaluation in the emergency department as well as the outpatient setting starting with serology, then CSF, and genetic testing. We will end with a discussion of special cases, including pregnancy, immunocompromised patient, traumatic brain injury, and hypercoagulability states.

Background Evaluation of the headache patient in the outpatient clinic and emergency department (ED) has different focuses and goals. The focus of this paper is to review the evaluation of patients in both settings with mention of evaluation in the pediatric and pregnant patient population. The patient's history should drive the practitioner's decision and evaluation choices. We review recommendations made by the American Board of Internal Medicine and American Headache Society through the Choosing Wisely Campaign, which has an emphasis on choosing the right imaging modality for the clinical situation and elimination/prevention of medication overuse headache, as well as the US Headache Consortium guidelines for migraine headache. We will also review focusing on ED evaluation of the pediatric patient and pregnant patient presenting with headache. Conclusion At the end of the review we hope to have provided you with a framework to think about the headache patient and what is the appropriate test in the given clinical setting in order to ensure that the patient gets the right diagnosis and is set on a path to the appropriate management plan.

Migraine and epilepsy are disorders that are common, paroxysmal, and chronic. In many ways they are clearly different diseases, yet there are some pathophysiological overlaps, and overlaps in clinical symptomatology, particularly with regard to visual and other sensory disturbances, pain, and alterations of consciousness. Epidemiological studies have revealed that the two diseases are comorbid in a number of individuals. Both are now recognized as originating from electrical disturbances in the brain, although their wider manifestations involve the recruitment of multiple pathogenic mechanisms. An initial excess of neuronal activity in migraine leads to cortical spreading depression and aura, with the subsequent recruitment of the trigeminal nucleus leading to central sensitization and pain. In epilepsy, neuronal overactivity leads to the recruitment of larger populations of neurons firing in a rhythmic manner that constitutes an epileptic seizure. Migraine aura and headaches may act as a trigger for epileptic seizures. Epilepsy is not infrequently accompanied by preictal, ictal, and postictal headaches that often have migrainous features. Genetic links are also apparent between the two disorders, and are particularly evident in the familial hemiplegic migraine syndromes where different mutations can produce either migraine, epilepsy, or both. Also, various medications are found to be effective for both migraine and epilepsy, again pointing to a commonality and overlap between the two disorders.

Background Oxygen is the standard of care for acute treatment of cluster headache. CMS, the US Centers for Medicaid and Medicare Services, has made the indefensible decision to not cover oxygen for cluster headache for patients with Medicaid and Medicare insurance, despite the evidence and professional guidelines. Commercial insurance generally covers oxygen for cluster headache. Objective This is a “how-to” guide for successfully prescribing oxygen in the US. Summary Prescription information is provided that can be incorporated as dot phrases, smart sets, or other standard templates for prescribing oxygen for cluster patients. In many states, oxygen is affordable and can be prescribed for Medicaid and Medicare patients who wish to pay cash. Welding or nonmedical grade industrial oxygen is almost the same cost as medical oxygen. However, it is less pure, lacks the same inspection of tanks, and is delivered without regulators to provide appropriate flow rates. Patients who pay cash should be strongly encouraged to buy medical oxygen.

Recent research from randomized experiments on class size points to positive effects of small classes that persist for several years, but the evidence about the social distribution of effects is less clear. Some scholars have contended that the immediate effects of small classes are larger for minorities and for disadvantaged persons (e.g., J. D. Finn & C. M. Achilles, 1990). Those claims have led to policies of class size reduction specifically to reduce inequality in educational outcomes. The authors used data from a 5-year follow-up to Project STAR to investigate whether differential effects of small classes on achievement for minority students persist. A repeated measures analysis suggested that there was a statistically significant, positive differential lasting benefit of 4 years for minorities enrolled in small classes in reading, and a negative differential lasting benefit for girls enrolled in small classes in mathematics over 5 years following the experiment. Thus, it appears that the lasting be...

Recent evidence about the effects of class size on academic achievement from randomized experiments points to positive effects of small classes. However, the evidence about the mechanism producing these effects is less clear. Some scholars have argued for mechanisms that would imply greater effects of small classes for low-achieving students. This article investigates possible differential effects of small classes on achievement using data from Project STAR, a four-year, large-scale randomized experiment on the effects of class size. We examined the differential effects of small classes for students in the bottom half and bottom quarter, respectively, of their class's achievement distribution in kindergarten. Although small class effects are somewhat larger for low-achieving students in reading, the differential effects (interactions) are not statistically significant. Moreover, the small class effects for low-achieving students in mathematics are actually smaller than those for higher achieving students. Thus while there are unambiguous positive effects of small classes on achievement, there is no evidence for differentially larger effects of small classes for lower achieving students.

Some scholars argue that the effects of small classes in the early grades are not cumulative—that the benefits of small classes accrue in the 1st year of small classes. That argument suggests both policy implications and scientific questions of why additional benefits should not accrue from additional exposure to small classes. In this article, the cumulative effects of small classes on achievement were investigated with data from Project STAR, a 4-year, large-scale randomized experiment on the effects of class size. Controlling for achievement in the previous-year small classes in Grades 1, 2, and 3 yielded additional positive effects on reading and mathematics achievement. Thus, there are additional (cumulative) effects of small classes after the 1st year that may be large enough to be important for education policy.

This study was the first to test a model of the influence of homework on classroom performance using a sample of elementary school students. A total of 28 teachers in Grades 2 and 4 took part in the study, along with 428 students and parents. The authors used structural equation modeling to examine relationships among variables. Student norms were positively related to the elimination of distractions from homework by parents. Positive student norms, higher student ability, and positive parent attitudes toward homework were all related to greater parent facilitation. Student's attitude toward homework was unrelated to home and community factors but was related positively to parent attitudes toward homework. Classroom grades were unrelated to student's attitude toward homework but were predicted by how much homework the student completed (even after the use of homework in grading was controlled), by student ability, and by the amount of parent facilitation. More generally, parent facilitation was a...

Reducing class size to increase academic achievement is a policy option currently of great interest. Although the results of small-scale randomized experiments and some interpretations of large-scale econometric studies point to positive short-term effects of small classes, some scholars view the evidence as ambiguous. Project STAR in Tennessee-a 4-year, large-scale randomized experiment on the effects of class size—provided persuasive evidence that small classes have immediate positive effects on academic achievement. Unlike most other early education interventions, these effects persisted for several years after the children returned to regular-sized classes. The authors of the present article report analyses of a 6-year follow-up of the students in that experiment. Class-size effects persisted for at least 6 years and remained large enough to be important for educational policy. The results suggest that small classes in early grades have lasting benefits and that those benefits are greater for...

The effects of class size on academic achievement have been studied for decades. Although recent research from randomized experiments points to positive effects of small classes, the evidence about the social distribution of effects is less clear. Some scholars have contended that the effects of small classes are larger for minorities and the disadvantaged. These claims have led to policy decisions to implement small classes to reduce inequality in educational outcomes. This article investigates possible differential effects of small classes on achievement using data from Project STAR, a four-year, large-scale randomized experiment on the effects of class size. The small class effects on both reading and mathematics achievement are somewhat larger for minorities and low socioeconomic status (SES) students. However, the differential effects for minority students (interactions) are statistically significant only for reading achievement in one of the models examined, but not others. None of the differential ...

The effects of class size on academic achievement have been studied for decades. Although the results of small scale randomized experiments and large-scale econometric studies point to positive effects of small classes, some scholar have seen the evidence as ambiguous. This paper reports analyses of a 4-year, large-scale randomized experiment on the effects of class size, project STAR in Tennessee. Although implementation was not perfect, these analyses suggest that shortcomings in implementation probably led to underestimates of the effects of class size. The analyses reported here suggest class size effects that are large enough to be important for educational policy and that are quite consistent across schools. Thus, small classes appear to benefit all kinds of students in all kinds of schools.

Four hundred twenty-four students in Grades 6 through 12 and 1 parent of each completed a questionnaire concerning student participation in 5 types of after-school activities: homework, television viewing, extracurricular activities, other types of structured after-school groups, and jobs. Student standardized achievement test scores and class grades were also obtained. After-school activities contributed significantly to the prediction of achievement even after the student's gender, grade level, ethnicity, free-lunch eligibility, and level of adult supervision after school were statistically controlled. Generally, more time in extracurricular activities and other structured groups and less time in jobs and television viewing were associated with higher test scores and class grades. More time on homework was associated with better grades. The joint effects of all 5 after-school activities nearly doubled the predictive ability of any single activity.

Four explanations were tested for why the correlation between homework and achievement is weaker in elementary school than secondary school. Eighty-two teachers answered questions about their homework practices, and their responses were related to their students' achievement test scores. No evidence was found to suggest the weaker correlation in elementary school associated with a restricted variation in amounts of homework in early grades nor that teachers assigned more homework to poor-performing classes. Evidence did suggest that teachers in early grades assigned homework more often to develop young students' management of time, a skill rarely measured on standardized achievement tests. Also consistent with this hypothesis, elementary school teachers were more likely to use homework to review class material and to go over homework in class, while secondary school teachers more often used homework to prepare for and enrich class lessons. Finally, there was weak evidence that young students who were struggling in school took more time to complete homework assignments.

Students (n = 709), parents, and teachers (n = 82) completed a questionnaire concerning amount of homework assigned by teachers, portion of assignments completed by students, and attitudes about homework. Student achievement measures were also collected. Weak relations were found between the amount of homework assigned and student achievement. Positive relations were found between the amount of homework students completed and achievement, especially at upper grades (6-12). At lower grades (2 and 4), teacher-assigned homework was related to negative student attitudes. At upper grades, teachers with more positive attitudes toward homework and those whose students performed more poorly on stantlardized tests reported assigning more homework. A path analysis for lower grades indicated that class grades were predicted only by standardized test scores and the proportion of homework completed by students. At upper grades, class grade predictors also included parent, teacher, and student attitudes.

A review of 39 studies indicated that achievement test scores decline over summer vacation. The results of the 13 most recent studies were combined using meta-analytic procedures. The meta-analysis indicated that the summer loss equaled about one month on a grade-level equivalent scale, or one tenth of a standard deviation relative to spring test scores. The effect of summer break was more detrimental for math than for reading and most detrimental for math computation and spelling. Also, middle-class students appeared to gain on grade-level equivalent reading recognition tests over summer while lower-class students lost on them. There were no moderating effects for student gender or race, but the negative effect of summer did increase with increases in students’ grade levels. Suggested explanations for the findings include the differential availability of opportunities to practice different academic material over summer (with reading practice more available than math practice) and differences in the material’s susceptibility to memory decay (with fact- and procedure-based knowledge more easily forgotten than conceptual knowledge). The income differences also may be related to differences in opportunities to practice and learn. The results are examined for implications concerning summer school programs and proposals concerning school calendar changes

Parents (n = 709) were surveyed about involvement in their child's homework. A factor analysis revealed three dimensions of homework involvement similar to those found in more general studies of parenting style. These dimensions are autonomy support, direct involvement, and elimination of distractions. A fourth dimension, parental interference, differentiated itself from autonomy support for students in higher grades. Two-thirds of parents reported some negative or inappropriate form of involvement. Parenting style for homework was then related to student and family characteristics and student schooling outcomes. Results indicated parents with students in higher grade levels reported giving students more homework autonomy and less involvement of all other types. Parents in poorer families reported less support for autonomy and more interference. Parents reported less elimination of distractions when an adult was not at home after school and, for elementary school students, when there were more than one child living in the home. Elementary school parents of males reported more direct involvement in homework, while high school parents of females reported more direct involvement. More parental support for autonomy was associated with higher standardized test scores, higher class grades, and more homework completed. More positive parent involvement was associated with lower test scores and lower class grades, especially for elementary school students. Student attitudes toward homework were unrelated to parenting style for homework. Stage-environment fit theory and conceptions of families as varying in resources to support children are used to explain the findings and draw implications for parent behavior and educational practice. Copyright 2000 Academic Press. ___

The literature on homework for students with learning disabilities is reviewed. First, a summary of Cooper's (1989a) synthesis of research on homework for students without disabilities is presented, including (a) a definition of homework, (b) a model of the homework process, (c) the results of a meta-analysis of homework studies, and (d) generic policy guidelines. Next, special education research on homework conducted after 1985 is described. The literature is divided into studies that manipulated homework conditions and homework-related surveys of teachers and parents. The results of the literature review suggest that homework policies and practices for students with learning disabilities should emphasize (a) simple, short assignments; (b) careful monitoring by and prominent rewards from teachers; and (c) parental involvement, especially to provide structure, conducive environments, and immediate rewards.

A two‐part follow‐up study was conducted of students in grade 4 who had participated in the reduced class size experiment during the preceding years. Outcome measures included a range of norm referenced and criterion referenced achievement tests and teachers’ ratings of the youngsters’ effort, initiative taking, and disruptive behavior in the fourth grade classroom. Statistically significant carry‐over effects of small classes were found on every achievement measure. Significant differences were also found in participation levels between students who had attended small classes and those in regular classes, but these were not as consistent as the impact on cognitive performance. The confirmed consequences of placing youngsters in classes with 12 to 17 pupils need to be supplemented by research on other outcomes in order to compare the complete range of benefits with the relatively large monetary costs that could be incurred.

Reduction of class size to increase academic achievement is a policy option that is currently of great interest. Although the results of small-scale randomized experiments and some interpretations of large-scale econometric studies point to positive effects of small classes, the evidence has been seen by some scholars as ambiguous. Project STAR in Tennessee, a 4-year, large-scale randomized experiment on the effects of class size, provided persuasive evidence that small classes had immediate effects on academic achievement. However, it was not clear whether these effects would persist over time as the children returned to classes of regular size or would fade, as have the effects of most other early education interventions. This article reports analyses of a 5-year follow-up of the students in that experiment. The analyses described here suggest that class size effects persist for at least 5 years and remain large enough to be important for educational policy. Thus, small classes in early grades appear to have lasting benefits.

It is widely accepted that teachers differ in their effectiveness, yet the empirical evidence regarding teacher effectiveness is weak. The existing evidence is mainly drawn from econometric studies that use covariates to attempt to control for selection effects that might bias results. We use data from a four-year experiment in which teachers and students were randomly assigned to classes to estimate teacher effects on student achievement. Teacher effects are estimated as between-teacher (but within-school) variance components of achievement status and residualized achievement gains. Our estimates of teacher effects on achievement gains are similar in magnitude to those of previous econometric studies, but we find larger effects on mathematics achievement than on reading achievement. The estimated relation of teacher experience with student achievement gains is substantial, but is statistically significant only for 2nd-grade reading and 3rd-grade mathematics achievement. We also find much larger teacher effect variance in low socioeconomic status (SES) schools than in high SES schools.