12 Chapter 1 such as cognitive deficits and fatigue.2, 5 The extent of inter-personal and inter-attack variations in the preictal/postictal phases remains unknown. Therefore, a single, clear-cut definition (48 hours) may not apply to all patients or attacks. MONITORING WITH ELECTRONIC E-DIARIES Electronic headache diaries (E-diaries), which are based on AI algorithms that analyse headache characteristics rather than relying on patient-reported migraine days (as seen in commercial apps), are highly useful in the monitoring and treatment of migraine.6 For effective implementation in clinical practice, an e-tool must meet several key requirements.6 The e-tool must be validated to ensure accuracy and reliability in measuring, diagnosing, or monitoring the intended condition or health issue. Consistency in performance is important, providing the same results across repeated measurements. Clinical relevance is essential, ensured by providing information that aids in decision-making and treatment. Privacy and security standards must be upheld to protect patient data. E-tools should be user-friendly to promote acceptance among both healthcare providers and patients. Seamless integration with existing clinical systems and electronic medical records is necessary, alongside compliance with regulatory guidelines and obtaining the required approvals. Finally, adequate support, including training and technical assistance, should be available for healthcare providers. Using unvalidated E-tools demonstrates a lack of understanding and recognition of the complexity of migraine as a condition. The combination of validated questionnaires and an E-diary has high sensitivity and specificity for diagnosing migraine.7 However, clinical assessment remains essential for diagnosing aura.7 E-diaries are useful for monitoring sex-specific aspects of migraine8-10 and for tracking the effectiveness of new therapeutic options for migraine, such as anti-CGRP(-R)-mAbs.11, 12 With an estimated average cost of CGRP monoclonal antibodies of €6,000 per patient per year, these treatments are expensive and require careful monitoring.13 In fact, the Dutch Healthcare Institute (Zorginstituut Nederland, ZIN) has specifically recommended that patients receiving treatment with anti-CGRP(-R) monoclonal antibodies be closely monitored.13 Without adequate monitoring of the number of migraine days, it is impossible to assess whether the criteria for continuing CGRP-mAbs treatment (≥30% reduction in migraine days) are met, which could result in unexpectedly high unwanted costs. By using an E-diary, both patients and healthcare providers can obtain reliable insights into the effectiveness of this treatment. This helps to avoid continuing ineffective medication and contributes to cost savings. Additionally,
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