The comorbidity of migraine

Association Between Electronic Diary-Rated Sleep, Mood, Energy, and Stress With Incident Headache in a Community-Based Sample

BACKGROUND AND OBJECTIVES

The aim of this study was to examine the diurnal links between average and changes in average levels of prospectively rated mood, sleep, energy, and stress as predictors of incident headache in a community-based sample.

METHODS

This observational study included structured clinical diagnostic assessment of both headache syndromes and mental disorders and electronic diaries that were administered 4 times per day for 2 weeks yielding a total of 4,974 assessments. The chief outcomes were incident morning (am) and later-day (pm) headaches. Generalized linear mixed-effects models were used to evaluate the average and lagged values of predictors including subjectively rated mood, anxiety, energy, stress, and sleep quality and objectively measured sleep duration and efficiency on incident am and pm headaches.

RESULTS

The sample included 477 participants (61% female), aged 7 through 84 years. After adjusting for demographic and clinical covariates and emotional states, incident am headache was associated with lower average (ß = -0.206*; confidence intervals: -0.397 to -0.017) and a decrease in average sleep quality on the prior day (ß = -0.172*; confidence interval: -0.305, -0.039). Average stress and changes in subjective energy levels on the prior day were associated with incident headaches but with different valence for am (decrease) (ß = -0.145* confidence interval: -0.286, -0.005) and pm (increase) (ß = 0.157*; confidence interval: 0.032, 0.281) headache. Mood and anxiety disorders were not significantly associated with incident headache after controlling for history of a diagnosis of migraine.

DISCUSSION

Both persistent and acute changes in arousal states manifest by subjective sleep quality and energy are salient precursors of incident headaches. Whereas poorer sleep quality and decreased energy on the prior day were associated with incident morning headache, an increase in energy and greater average stress were associated with headache onsets later in the day. Different patterns of predictors of morning and later-day incident headache highlight the role of circadian rhythms in the manifestations of headache. These findings may provide insight into the pathophysiologic processes underlying migraine and inform clinical intervention and prevention. Tracking these systems in real time with mobile technology provides a valuable ancillary tool to traditional clinical assessments.

The Migraine-Anxiety Comorbidity Among Migraineurs: A Systematic Review

Background: Migraine is recognized as a neurological condition that is often associated with comorbid psychiatric symptoms such as anxiety, depression, bipolar disorder and/or panic disorder. Though some studies have demonstrated the link between migraine and anxiety disorders, there are no systematic reviews that have been published in this area to summarize the evidence. The aim of the present study is to systematically review the literature associated with comorbidity of migraine and anxiety disorders among migraineurs compared to non-migraineurs.

Methods: The present systematic review included population-based, cohort and cross-sectional studies if they were reporting the frequency of migraine with either anxiety or depression as diagnosed by a medical practitioner according to the International Classification of Headache Disorders (ICHD-2/3).

Results: Eight eligible studies from 2060 relevant citations were included in the review. All participants were migraine patients from both primary care and outpatient settings, as well as tertiary headache and anxiety centers, and were compared to non-migraineurs. The results of the systematic review showed that there is a strong and consistent relationship between migraine and anxiety. The co-morbidity of co-occurrence for migraine and anxiety has an average OR of 2.33 (2.20–2.47) among the prevalence and cross sectional studies and an average RR of 1.63 (1.37–1.93) for two cohort studies; The major limitations of included studies were small sample sizes and a lack of adjusting of confounding factors.

Conclusion: The results highlight the need for inclusion of an anxiety screening tool during initial assessments of migraine patients by medical practitioners and/or physicians and may explain why some anxiolytic medications work better than others for migraine mitigation.

Vascular Contributions to Migraine: Time to Revisit?

Migraine is one of the most prevalent and disabling neurovascular disorders worldwide. However, despite the increase in awareness and research, the understanding of migraine pathophysiology and treatment options remain limited. For centuries, migraine was considered to be a vascular disorder. In fact, the throbbing, pulsating quality of the headache is thought to be caused by mechanical changes in vessels. Moreover, the most successful migraine treatments act on the vasculature and induction of migraine can be accomplished with vasoactive agents. However, over the past 20 years, the emphasis has shifted to the neural imbalances associated with migraine, and vascular changes have generally been viewed as an epiphenomenon that is neither sufficient nor necessary to induce migraine. With the clinical success of peripherally-acting antibodies that target calcitonin gene-related peptide (CGRP) and its receptor for preventing migraine, this neurocentric view warrants a critical re-evaluation. This review will highlight the likely importance of the vasculature in migraine.

Human mast cells release the migraine-inducing factor pituitary adenylate cyclase-activating polypeptide (PACAP)

Background Many patients with migraines suffer from allergies and vice versa, suggesting a relationship between biological mechanisms of allergy and migraine. It was proposed many years ago that mast cells may be involved in the pathophysiology of migraines. We set out to investigate the relationship between mast cell activation and known neurogenic peptides related to migraine. Methods Cultured human mast cells were assayed for the presence of neuropeptides and their receptors at the RNA and protein level. Immunohistochemistry analyses were performed on tissue resident and cultured mast cells. Mast cell degranulation assays were performed and pituitary adenylate cyclase-activating polypeptide (PACAP) activity was measured with a bioassay. Results We found that cultured and tissue resident human mast cells contain PACAP in cytoplasmic granules. No other neurogenic peptide known to be involved in migraine was detected, nor did mast cells express the receptors for PACAP or other neurogenic peptides. Furthermore, mast cell degranulation through classic IgE-mediated allergic mechanisms led to the release of PACAP. The PACAP released from mast cells was biologically active, as demonstrated using PACAP receptor reporter cell lines. We confirmed existing literature that mast cell degranulation can also be induced by several neurogenic peptides, which also resulted in PACAP release. Conclusion Our data provides a potential biological explanation for the association between allergy and migraine by demonstrating the release of biologically active PACAP from mast cells.

Allergens might trigger migraine attacks

Migraine is a common primary headache disorder. The mechanisms underlying the onset of a migraine attack are not completely understood. Environmental changes and a number of other factors could induce migraine attacks. The aim of this study was to investigate the relationship between the frequency of migraine attacks and allergens. Migraine patients without aura, and healthy individuals similar in age and gender without a history of headache and allergy were prospectively included in the study. The duration of migraine, the frequency of migraine attacks, the medication history, and the symptoms during attacks were questioned. Migraine disability assessment score (MIDAS) and visual analog scale (VAS) scores were obtained. Allergen extracts including dust, fungi, insect, animal epithelium, pollens, and food allergens were applied for allergy tests. 49 migraine patients and 49 healthy individuals were enrolled in the study. There was no significant difference in terms of age and gender. The median migraine disease duration, the number of attacks in a month, and the duration of attacks were, respectively, 5.5 years (1-44), 4 (1-10) day/month, and 24 (4-72) h. The mean MIDAS grade was 2.45 ± 0.14 (1-4), and mean VAS score was 7.89 ± 0.27 (4-10). The positivity of allergy tests was 55.1 % (27/49) in the migraine group and 32.7 % (16/49) in the control group (p < 0.05). The allergy tests were positive for house dust, red birch, hazel tree, olive tree, nettle, and wheat. The frequency of migraine attacks was higher in allergy-test-positive patients than in negative ones in the migraine group (p = 0.001). The migraine patients who had frequent attacks should be examined for allergies.

Migraine headache and bipolar disorder comorbidity: A systematic review of the literature and clinical implications

BACKGROUND AND AIMS

Psychiatric disorders, e.g., depression, are often comorbid with, and can complicate the treatment of, patients with migraine headache. Although empirical work has increasingly focused on the association between migraine and bipolar disorder, this topic has received little attention in the pain literature. Bipolar disorder is a chronic and recurrent mood disorder characterized by cyclic occurrence of elevated (i.e., manic or hypomanic) and depressed mood states. Bipolar I disorder is diagnosed when patients present with at least one abnormally and persistently elevated manic episode; bipolar II disorder is characterized by the presence of hypomanic episodes. Bipolar disorder warrants attention as depressive phases of the disorder can prevail and are often misconstrued by the unwary clinician as unipolar depression. However, treatment for bipolar disorder is distinct from that of unipolar depression and use of antidepressants, which are often invoked in migraine prophylaxis as well as the treatment of depression, may precipitate significant mood changes among bipolar disorder patients. A systematic review of the literature addressing the co-occurrence of bipolar disorder and migraine was conducted. The treatment of dually affected patients is also discussed.

METHODS

In order to review the literature to date on migraine and bipolar disorder co-occurrence, a comprehensive search of MEDLINE, EMBASE, PubMed, PsycINFO, Web of Science, and CINAHL for clinic-based and epidemiological studies was conducted using terms related to migraine and bipolar disorder. Studies were selected for review if they included subjects meeting validated diagnostic criteria for bipolar disorder as well as migraine headache and if a quantitative description of prevalence rates of comorbid bipolar disorder and migraine were reported. Weighted means of the prevalence rates were calculated to compare with general epidemiological prevalence trends for migraine and bipolar disorder, respectively.

RESULTS

Eleven studies met inclusion criteria. Although findings were constrained by methodological limitations and several low quality studies, clinic- and epidemiological cross-sectional investigations demonstrated a high rate of comorbidity between bipolar disorder and migraine. The weighted mean prevalence rate for migraine headache among bipolar disorder patients was 30.7%; for bipolar disorder among migraineurs, the weighted mean prevalence rates were 9% and 5.9% in clinic-based and epidemiological studies, respectively. The association between bipolar disorder and migraine was most notable among women and patients with the bipolar II disorder subtype.

CONCLUSIONS

High rates of comorbidity exist between migraine and bipolar disorder, exceeding estimated prevalence rates for those conditions in the general population. Comorbidity may portend a more serious clinical course for dually afflicted individuals.

IMPLICATIONS

Clinicians need to structure treatment approaches to address concurrent migraine and bipolar disorder in dually afflicted individuals. Although further evidence-based investigation is warranted to inform optimal treatment approaches for both conditions concurrently, anticonvulsants (e.g., valproate, lamotrigine and topiramate); atypical antipsychotics (e.g., olanzapine or quetiapine); and calcium channel blockers (e.g., verapamil) may be considered.

Vertigo in childhood: a retrospective series of 100 children

OBJECTIVE

Evaluation and management of vertigo in children vary between institutions and medical specialties. The aim of this study is to describe the characteristics of vertigo in children presenting to a pediatric neurology referral center and to investigate the relationship between vertigo and migraine.

STUDY DESIGN

Patients <18 years old presenting with vertigo to Hacettepe University Ihsan Dogramaci Children's Hospital Neurology Unit between January 1996-January 2012 were included (n = 100). Data were obtained from patient files and phone interviews.

RESULTS

Mean age was 7.5 years. The most common etiological groups were benign paroxysmal vertigo of childhood (BPVC) (39%), psychogenic vertigo (21%), epileptic vertigo (15%), and migraine-associated vertigo (MAV) (11%). BPVC was the most common diagnosis in children ≤5 years of age while psychogenic vertigo prevailed in children >5 years. Staring episodes characterized epileptic vertigo patients (p = 0.021) while headache was more often described by MAV patients (p < 0.001). Vertigo attacks >5 min were uncommon in BPVC patients compared to others (p = 0.013). Twenty percent of BPVC patients contacted through phone interviews were experiencing migraine type headaches that started at a median age of 7.5 years. An algorithm for evaluation of children with vertigo was formed based on data obtained from this study and the literature. When this algorithm was applied to 100 cases of this series, 88 (88%) were correctly diagnosed.

CONCLUSION

While most vertigo cases in children can be diagnosed accurately by a detailed medical history, physical and neurological examination, a standard algorithm can help with the correct classification.

Contributions of epidemiology to our understanding of migraine

BACKGROUND

During the past decade, the introduction of the second edition of the International Classification of Headache Disorders (ICHD-II) and the initiation of active campaigns to increase awareness of the high magnitude, burden, and impact of migraine have stimulated numerous studies of population-based data on the prevalence, correlates, and impact of migraine.

OBJECTIVE

This paper provides an update of the literature on the worldwide epidemiology of migraine from studies that included the ICHD-II criteria. The aims of this paper are: (1) to review evidence regarding the magnitude of migraine; (2) to summarize information on the correlates and impact of migraine; and (3) to discuss the contributions, challenges, and future directions in the epidemiology of migraine. Evidence on the magnitude of migraine is divided into the following types of data: (1) prevalence rates of ICHD-II-defined migraine and tension-type headache from international population-based studies of adults; (2) the magnitude of migraine in U.S. studies; (3) ICHD-II-based international prevalence rates of ICHD-II-defined migraine in children; and (4) incidence rates of migraine from prospective longitudinal studies.

METHODS

A comprehensive review of the literature on the prevalence of migraine subtypes and tension-type headache defined by ICHD-II criteria during the past decade was conducted and aggregate weighted rates across studies were derived.

RESULTS

Across the 19 studies of adults that employed the ICHD-II criteria, the aggregate weighted estimates of the 12-month prevalence of definite migraine are 11.5%, and probable migraine of 7%, yielding a total of 18.5%. The cross-study weighted aggregate rate of migraine with aura is 4.4%, chronic migraine is 0.5%, and of tension-type headache is 13%. There has been even greater growth in international prevalence data on migraine in children, with a total of 21 studies of children that have employed the ICDH-II criteria. The aggregate weighted rate of definite migraine in children is 10.1% and migraine with aura is 1.6%. The well-established demographic correlates of migraine including the equal sex ratio in childhood, with increasing prevalence of migraine in females across adolescence to mid-adulthood were confirmed in these studies. Despite increasing effort to increase awareness of migraine, approximately 50% of those with frequent and/or severe migraine do not receive professional treatment.

CONCLUSIONS

This review demonstrates that the descriptive epidemiology of migraine has reached its maturity. The prevalence rates and sociodemographic correlates have been stable across 50 years. These developments justify a shift in efforts to the application of the designs and methods of analytic epidemiology. Retrospective case-control studies followed by prospective cohort studies that test specific associations are likely to enhance our understanding of the predictors of incidence and progression of migraine, subtypes of migraine with differential patterns of onset and course, and specific environmental exposures that may have either causal or provocative influences on migraine etiology.

Incidental white matter lesions in children presentıng with headache

AIM

We aimed to describe the prevalence and significance of white matter lesions detected on magnetic resonance imaging (MRI) in children with headache.

MATERIAL AND METHODS

Children who were admitted with the complaint of headache and had neuroimaging between December 2007 and June 2012 were included in the study. The clinical and neuroimaging data of the patients were retrospectively evaluated. MRI results of the patients were documented in detail. The patients with non-specific white matter lesions were called for a control visit, and current status of headache and neurological findings were determined.

RESULTS

A total of 941 patients were included in the study. Sixty-one percent of the patients received cranial neuroimaging. 8.2% had only cranial computed tomography (CT), 7.5% had cranial CT and cranial MRI, and 84.3% had only cranial MRI. 22.1% of the patients had abnormal cranial MRI findings. The rate of incidental non-specific white matter changes detected in our study group was 23/527 (4.4%). Among the 23 patients, 12 (52.2%) were male and 11 (47.8%) were female. Fourteen (60.9%) had migraine without aura, 8 (34.8%) had tension-type headache, and 1 (4.3%) had migraine with aura. Mean age of patients at the time of imaging was 12.1 ± 3.4 years (range 4.0-16.0 years). All patients with non-specific white matter changes on MRI showed normal psychomotor development, and there was no history of seizures or head trauma. The physical and neurological examinations of all patients were normal. The mean clinical follow-up period of the patients was 16.8 ± 17.3 months (range 6-80 months). No patients showed neurological deterioration during the follow up. The white matter lesions were supratentorial in all patients. The mean size of the lesions was 5.1 ± 4.5 mm (minimum, 2 mm; maximum, 24 mm). Repeated radiological evaluations were performed in 11 (47.8%) of the patients. No new white matter lesions were detected in control MRI during follow up.

CONCLUSION

Non-specific incidental white matter changes may be seen in children with headache. For normal clinical follow up, in the absence of evident benefits from repeated imaging studies, we suggest that repeated imaging studies are not warranted in every patient and should be tailored according to clinical course.

Comorbidity of migraine and mood episodes in a nationally representative population-based sample

OBJECTIVE

To examine the lifetime comorbidity of migraine with different combinations of mood episodes: (1) manic episodes alone; (2) depressive episodes alone; (3) manic and depressive episodes; (4) controls with no lifetime history of mood episodes, as well as sociodemographic and clinical correlates of migraine for each migraine-mood episode combination.

BACKGROUND

Migraine has been found to be comorbid with bipolar disorder and major depressive disorder in clinical and population-based samples. However, variability in findings across studies suggests that examining mood episodes separately may be fruitful in determining which of these mood episodes are specifically associated with migraine.

METHODS

Using a cross-sectional, population-based sample from the Canadian Community Health Survey 1.2 (n = 36,984), sociodemographic and clinical correlates of migraine were examined in each combination of mood episodes as well as controls. Logistic regression analyses controlling for age, sex, and education level compared the lifetime prevalence of migraine (1) between controls and each combination of mood episodes, and then (2) among the different combinations of mood episodes.

RESULTS

Migraine comorbidity in all combinations of mood episodes was associated with lower socioeconomic status, earlier onset of affective illness, more anxiety, suicidality and use of mental health resources. Compared with controls, the adjusted odds ratio of having migraine was 2.0 (95% confidence interval [CI] 1.4-2.8) for manic episodes alone, 1.9 (95% CI 1.6-2.1) for depressive episodes alone, and 3.0 (95% CI 2.3-3.9) for subjects with both manic and depressive episodes. Compared with those with manic episodes alone and depressive episodes alone, the odds of having migraine were significantly increased in subjects with both manic and depressive episodes (odds ratio 1.5 vs. manic episodes alone; 1.8 vs. depressive episodes alone). In addition, migraine comorbidity was associated with different correlates depending on the specific combination of mood episodes; in subjects with both manic and depressive episodes, migraine comorbidity was associated with an earlier onset of mental illness, while in subjects with either manic or depressive episodes alone, migraine comorbidity was associated with increased suicidality and anxiety.

CONCLUSIONS

Migraine comorbidity appears to delineate a subset of individuals with earlier onset of affective illness and more psychiatric complications, suggesting that migraine assessment in mood disorder patients may be useful as an indicator of potential clinical severity. Differences in the prevalence of migraine as well as sociodemographic and clinical correlates associated with specific combinations of mood episodes underscore the importance of examining this comorbidity by specific type of mood episode.

Behavioral and emotional symptoms and primary headaches in children: A population-based study

Objective:

To investigate behavioral and emotional symptoms in a community-based sample of children as a function of headache status and of headache frequency.

Methods:

Our sample consisted of 1,856 children (5–11 years). Primary headaches were assessed using a validated headache questionnaire. Emotional symptoms were assessed by the Child Behavior Checklist (CBCL). CBCL scores were modeled as a function of headache status after adjustments for demographics and headache frequency.

Results:

Relative to controls, children with migraine were significantly more likely to have abnormalities in the following CBCL domains: somatic, anxiety-depressive, social, attention, internalizing and total score. Children with tension-type headache (TTH) were significantly different from controls in the same domains but at a lower rate than migraine. In children with migraine, impairments significantly varied as a function of headache frequency, race, and income. In children with TTH, gender, age, and headache frequency were significantly associated with abnormal scores.

Conclusions:

Migraine and TTH are significantly associated with behavioral symptoms in several domains, and headache frequency affects the association. Internalizing symptoms are common in children with headaches, while externalizing symptoms (e.g. rule-breaking and aggressivity) are not significantly more common than in controls.

Calcitonin gene-related peptide in migraine: intersection of peripheral inflammation and central modulation

Over the past two decades, a convergence of basic and clinical evidence has established the neuropeptide calcitonin-gene-related peptide (CGRP) as a key player in migraine. Although CGRP is a recognised neuromodulator of nociception, its mechanism of action in migraine remains elusive. In this review, we present evidence that led us to propose that CGRP is well poised to enhance neurotransmission in migraine by both peripheral and central mechanisms. In the periphery, it is thought that local release of CGRP from the nerve endings of meningeal nociceptors following their initial activation by cortical spreading depression is critical for the induction of vasodilation, plasma protein extravasation, neurogenic inflammation and the consequential sensitisation of meningeal nociceptors. Mechanistically, we propose that CGRP release can give rise to a positive-feedback loop involved in localised increased synthesis and release of CGRP from neurons and a CGRP-like peptide called procalcitonin from trigeminal ganglion glia. Within the brain, the wide distribution of CGRP and CGRP receptors provides numerous possible targets for CGRP to act as a neuromodulator.

Potential risk factors for psychiatric disorders in patients with headache

BACKGROUND

Psychiatric comorbidities are common among patients with headache. These can compromise the quality of life of patients and may affect the result of treatment. No available systematic study concerning this problem has been conducted in Thailand.

OBJECTIVE

The study aimed to determine the prevalence and risk factors of psychiatric disorders in patients with headache in tertiary care facility.

METHODS

The study was conducted at the Headache Clinic, King Chulalongkorn Memorial Hospital in Bangkok, Thailand. One hundred and thirteen patients were enrolled. Diagnosis of headache was made based on International Classification of Headache Disorders II system. Mental disorders were assessed using Primary Care Evaluation of Mental Disorders. Other possible risk factors were extracted using significant physical symptoms count and accumulated risk for mental disorder.

RESULTS

Of the 113 samples analyzed, the prevalence of depression, anxiety, and somatoform disorder was found to be 29.2%, 9.7%, and 27.4%, respectively. No definite relationship between headache types and mental disorders was observed. High number of significant physical complaints and health concerns significantly increased the risk for depression (OR = 4.6, 95% CI = 1.6 to 13.5) while the level of possible risk for mental disorder was associated with an increased risk for somatoform disorder (OR = 1.6, 95% CI = 1.2 to 2.2).

CONCLUSION

The study confirmed high prevalence of psychiatric comorbidities in patients with headache. The results of this study will raise the awareness of physicians to possible underlying mental disorders in patients with headache and facilitate appropriate treatment or psychiatric referral.

Migraine and restless legs syndrome: is there an association?

Occasional clinical reports have suggested a link between migraine and restless legs syndrome. We undertook a systematic review of the evidence, which supports this association, and consider possible shared pathogenic mechanisms and the implications for current clinical practice.

Migraine in women with chronic pelvic pain with and without endometriosis

OBJECTIVE

To examine the prevalence of migraine in women with chronic pelvic pain with and without endometriosis.

DESIGN

Prospective study of headache, pelvic pain, and quality of life before laparoscopic surgery for pelvic pain. Endometriosis was diagnosed pathologically. Headaches were classified as migraine or non-migraine using International Headache Society criteria.

SETTING

Clinical research hospital.

PATIENT(S)

108 women in a clinical trial for chronic pelvic pain (NCT00001848).

INTERVENTION(S)

Laparoscopy to diagnose endometriosis, assessment by neurologist to assess headaches.

MAIN OUTCOME MEASURE(S)

Prevalence of migraine and other headaches in women with chronic pelvic pain with or without endometriosis. Headache frequency, severity and relationship to pelvic pain and endometriosis.

RESULT(S)

Lifetime prevalence of definite or possible migraine was 67% of women with chronic pelvic pain. An additional 8% met criteria for possible migraine. Migraine was no more likely in women with endometriosis than those without. Women with the most severe headaches had a lower quality of life compared with those with pelvic pain alone.

CONCLUSION(S)

Migraine headache is common in women with chronic pelvic pain, regardless of endometriosis, and contributes to disability in those with both conditions. The strong association suggests a common pathophysiology.

Psychological factors in childhood headaches

Recurrent headaches in children are most often migraines and are based in a genetic predisposition with a low headache threshold. As with any pain experience, there is a large emotional component associated with an attack of migraines that grows in amplitude as the headaches become more frequent and resistant to medicine, sleep, or other agents that used to work. Childhood headaches are especially complicated for 3 reasons: (1) the parents' fear (communicated to the child that serious medical pathology underlies the head pain), (2) the lack of evidence-based pharmacologic treatment, and (3) the belief that these headaches are largely psychological. This article addresses the mystery surrounding childhood headaches by delving into the influence of school, friends, and family; the impact of divorce; the coping skills required for a child to manage a migrainous nervous system; the potential secondary gain from headaches; psychiatric comorbidities and how to treat them; and the role of psychological intervention.

The associations of migraines and other headaches with work performance: results from the National Comorbidity Survey Replication (NCS-R)

It is unknown if comorbid conditions account for the association between migraines and work performance. This issue was investigated in the National Comorbidity Survey Replication (n = 9282). Twelve-month severe or persistent migraines and other headaches were assessed with comorbid 12-month mental and physical disorders using the WHO Composite International Diagnostic Interview. Work performance was assessed using the WHO Health and Work Performance Questionnaire. Significant associations of these conditions with work disability disappeared with controls for comorbid disorders, but severe or persistent migraines continued to predict work loss days even with controls. Individual-level and societal-level annual human capital values were $1165 and $9.3 billion for this subset of migraines. Roughly 20% of these associations were due to comorbidity, 60% to direct effects and 20% to indirect effects through temporally secondary comorbidities. These strong associations suggest that workplace interventions for severe or persistent migraines might have a positive return-on-investment for employers.

Long-term use of medications and destructive periodontal disease

BACKGROUND

Knowledge of typical medication use among patients with chronic periodontitis or destructive periodontal disease is limited. The aim of this study was to associate periodontitis severity with the use of different classes of medications.

METHODS

Patients (N=12,631) who had medical, dental, and pharmaceutical coverage with a health maintenance organization and whose severity of destructive periodontal disease was diagnosed by a dentist or specialist were included in the study. The rate of drug use over 7 years was related to the severity of destructive periodontal disease by means of Poisson regression models.

RESULTS

Individuals with moderate to advanced periodontitis had significantly lower fill rates for the respiratory agents (antihistamines: -23%, 95% confidence interval [CI]: -10% to -34%; decongestants: -24%, 95% CI: -13% to -34%; and cough/cold medications: -12%, 95% CI: -3% to -21%) and anti-infective agents (antibiotics: -12%, 95% confidence interval: -6% to -18%; urinary anti-infectives: -36%, 95% CI: -6% to -56%; and topical antibiotics: -18%, 95% CI: -5% to -29%).

CONCLUSIONS

More severe periodontitis was a marker for reduced medication use for allergies and infections. The associations between destructive periodontal disease, infections, allergies, and the hygiene hypothesis need further exploration.

Towards a definition of comorbidity in the light of clinical complexity

Clinical complexity encompasses multiple levels, including all the disorders and conditions experienced by a person along cross-sectional and longitudinal contexts, the diversity of severity levels and courses of clinical conditions, but also the plurality of values of people experiencing health problems and seeking help for them. The term comorbidity refers to the association of two distinct diseases in the same individual at a rate higher than expected by chance. Looking systematically to comorbidity represents the main road to approach patients' clinical complexity. Once epidemiologically established through population or community surveys, the study of the comorbidity direction and of the chronological patterns of associated clinical entities may offer relevant information from both a clinical and a scientific point of view. Comorbidity profiles of migraine and tension-type headache offer a paradigmatic example to appraise and highlight headache patient clinical complexity, allowing the conversion of diagnosis from a validated cluster of symptoms to a person-centred clinical diagnosis.

Allergy: a risk factor for suicide?

The rates of depression, anxiety, and sleep disturbance (suicide risk factors) are greater in patients with allergic rhinitis than in the general population. The rate of allergy is also greater in patients with depression. Preliminary data suggest that patients with a history of allergy may have an increased rate of suicide. Clinicians should actively inquire to diagnose allergy in patients with depression and depression in patients with allergy. Spring peaks of suicide are highly replicated, but their origin is poorly understood. Preliminary epidemiologic data suggest that seasonal spring peaks in aeroallergens are associated with seasonal spring peaks in suicide. Our research in Brown Norway rats demonstrates that sensitization and exposure to aeroallergens induces anxiety-like and aggressive behaviors as well as allergy-related helper T-cell type 2 (Th2) cytokine gene expression in the prefrontal cortex. Thus, it is possible that sensitization and exposure to aeroallergens, which peak in spring, may be conducive to seasonal exacerbation of suicide risk factors such as anxiety, depression, hostility/aggression, and sleep disturbance. Connecting allergy with suicide and suicide risk factors adds to previous neurologic literature connecting allergy with migraines and seizure disorders. Our recent report of Th2 (allergy-mediating) cytokine expression in the orbitofrontal cortex of suicide victims should lead to future studies to test the hypothesis that mediators of allergic inflammation in the nasal cavities may result in Th2 cytokine expression in the brain, influencing affect and behavioral modulation. Certain medications used to treat allergy can exacerbate suicide risk factors, potentially worsening suicide risk and even triggering suicide. Systemic (but not topical) corticosteroids have been associated with manic and depressive episodes and mixed mood states. Recently, the US Food and Drug Administration started investigating the possibility that montelukast may trigger suicide. Although this association requires further exploration and confirmation, clinicians should err on the side of caution, inquiring about past suicide attempts; hopelessness; reasons for living; and suicidal ideation, intent, or plan; and referring the patient to a mental health professional for evaluation if appropriate.

Family-based analysis of serotonin transporter gene polymorphisms in migraine with and without aura

Genetic epidemiological twin studies have demonstrated a significant heritability for migraine, with > 60% of liability to migraine either with or without aura coming from additive genetic factors. Because of the essential role of serotonin in the pathophysiology and treatment of migraine, genes of the serotonin system are candidates for involvement in migraine. Consequently, we examined two functional VNTR polymorphisms in the serotonin transporter gene, the 5-HTTLPR and the intron 2 VNTR, in a sample of 212 family trios each with a proband with childhood migraine, 153 with migraine without aura (MoA) and 59 with migraine with aura (MA). For the first time, we used transmission disequilibrium test analysis with the program TDTPHASE to examine the transmission of these two markers and their haplotypes to offspring affected by migraine. We found no significant transmission distortion of any marker, with the common L allele of the 5-HTTLPR transmitted 170 times and not transmitted 178 times, and the S allele 130 vs. 122 times. Likewise, the common 12 allele of the intron 2 VNTR was transmitted 201 times and not transmitted 188 times, and the 10 allele 107 vs. 120 times. The markers were not associated with MoA and MA and none of the haplotypes was associated with overall migraine, MoA or MA. The 5-HTTLPR and the intron 2 VNTRs do not play a major role in susceptibility to migraine.

Mood and anxiety disorders in chronic headache

Although most individuals with recurrent headache disorders in the general population do not experience severe psychopathology, population-based studies and clinical investigations find high rates of comorbidity between headache and mood and anxiety disorders. When present, psychiatric disorders may complicate headache treatment and portend a poorer treatment response. The negative prognosis associated with psychiatric comorbidity emphasizes the importance of the identification of psychopathology among those with headache beginning at an early age, and suggests that the treatment of psychiatric comorbidity is warranted to improve the outcome of headache management. In this article we describe the mood and anxiety disorders most commonly associated with migraine, tension-type headache, and chronic daily headache. We provide recommendations for the assessment of comorbid mood and anxiety disorders as well as a brief overview of treatment options. Last, we discuss the clinical implications of mood and anxiety disorders on the treatment and outcome of headache.

Is headache related to asthma, hay fever, and chronic bronchitis? The Head-HUNT Study

OBJECTIVES

To examine the relationship between migraine and nonmigrainous headache and asthma, hay fever, and chronic bronchitis in a large cross-sectional population-based study.

BACKGROUND

Associations between prevalence of migraine and asthma or allergy have been demonstrated in clinic-based and epidemiologic studies whereas studies on chronic bronchitis are scarce.

METHODS

A total of 51,383 subjects completed a headache questionnaire and constituted the "Head-HUNT" Study. Of these 50,401 (98.1%) answered the questions about asthma and chronic bronchitis, and 47,029 (91.5%) answered the question about hay fever. Associations were assessed in multivariate analyses, estimating prevalence odds ratios (ORs) with 95% confidence intervals (CI).

RESULTS

Both migraine and nonmigrainous headache were approximately 1.5 times more likely among those with current asthma, asthma related symptoms, hay fever, and chronic bronchitis than those without. The association increased with increasing headache frequency.

CONCLUSIONS

This large questionnaire-based study confirms that migraine and other headaches are associated with respiratory and allergic disorders. The magnitude of the association between headache and asthma, hay fever, and chronic bronchitis tended to be in the same order. Headache frequency seems to have a greater impact on the association with respiratory or allergic conditions than headache diagnoses. Whether it is a causal relationship is uncertain, but the results underline the importance of considering comorbid disorders among patients with frequent headache.

Anger, depression and personality dimensions in patients with migraine without aura

BACKGROUND

Migraine without aura causes acute and chronic pain and partially compromises patients' social functioning and work performance. Over the past years, psychiatric comorbidities were frequently observed in these patients, together with coping difficulties and typical personality traits. The aim of this study was to identify whether migraine patients and controls share distinctive personality traits.

METHODS

105 consecutive patients suffering from migraine without aura referred to the Headache Center of Turin University were enrolled in the study and compared to a control group of 79 healthy subjects. Patients and controls completed several psychometric questionnaires, including the Temperament and Character Inventory, the Beck Depression Inventory and the State-Trait Anger Expression Inventory.

RESULTS

Patients suffering from migraine show more depressive symptoms, difficult anger management with a tendency to hypercontrol, and a distinctive personality profile with high harm avoidance, high persistence and low self-directedness. When a logistic regression was performed, the only significant predictors of migraine were temperament variables.

CONCLUSIONS

The results suggest that the personality traits and psychosomatic mechanisms of migraine patients may make them vulnerable to stress and less skilled in coping with pain. These traits correlate with dysregulated neurotransmitter systems which may also be part of the psychobiological components of personality, depressive disorders and migraine itself.

Prevalence of migraine headaches in patients with allergic rhinitis

BACKGROUND

Histamine has been implicated in the pathogenesis of migraine headaches. Because allergic rhinitis (AR) is a histamine-driven syndrome and the nasal passage is in close proximity to the central nervous system, we hypothesize that AR may trigger migraine headaches.

OBJECTIVE

To determine the prevalence of migraine headaches in patients with and without AR.

METHODS

Allergic rhinitis was diagnosed based on skin or radioallergosorbent test results, clinical history, and physical examination findings. The diagnosis of migraine headache was made if patients fulfilled the International Headache Society criteria. Surveys were obtained from hospital-based allergy, pediatric, and internal medicine clinics, all serving the same inner-city population.

RESULTS

A total of 294 surveys were completed. Of 76 patients in the AR group, 26 (34%) had headaches meeting the International Headache Society criteria for migraines, and of the 57 patients in the non-AR group, only 2 (4%) had headaches that met the criteria. A Fisher exact test showed P = 8.2 x 10(-6). The odds ratio was 14.3, which signifies that the odds of having migraine headaches is 14.3 times higher in the AR group than in the non-AR group.

CONCLUSIONS

There is a high prevalence of migraine headaches in patients with AR compared with those without AR. We propose that histamine plays a key role in triggering migraines by means of vasodilation and inflammation in the pathogenesis of migraine headaches.

Population-based U.S. study of severe headaches in adults: psychological distress and comorbidities

OBJECTIVE

To examine the associations between severe headaches (SH), psychological distress, and comorbid conditions among U.S. adults.

BACKGROUND

The lifetime prevalence of headaches is over 90% and headaches, particularly migraines, have been associated with disability, increased healthcare costs, and mood disorders.

METHODS

We analyzed data obtained from adults aged 18 years or older (n = 29,828) who participated in the 2002 National Health Interview Survey, an ongoing, computer-assisted personal interview of a representative sample of the U.S. population.

RESULTS

Approximately 15.1% of adults aged 18 years or older reported SH in the previous 3 months. Those reporting such headaches were significantly more likely, than those who did not, to report insomnia, excessive sleepiness, recurrent pain, and depressive or anxiety symptoms during the preceding 12 months. Approximately 88% of those who reported having had SH within the previous 3 months also indicated that they had at least one comorbid medical condition, relative to 67% of those without SH.

CONCLUSION

Despite their episodic nature, our results suggest that SH are associated with impairments in both physical and mental health. As the presence of SH may serve as an indicator of significant psychological distress and medical comorbidities, eliciting information about their occurrence during a standard medical examination appears to be warranted.

Kinesiophobia in migraine

Pain aggravation by movement and avoidance of movement (kinesiophobia) is often reported by patients during migraine attacks. Yet its specific contribution to migraine diagnosis is undetermined. To characterize the frequency and severity of kinesiophobia during migraine and its role in the diagnosis of primary headaches, we questioned 150 patients (126 women and 24 men, average age 38.5 yrs) with migraine (n = 111) or tension-type headache (TTH) (n = 39) about aggravation of pain by bending forward, brisk head movements (jolt), and avoidance of movement during the attacks. The degree of pain worsening by each stimulus was measured through a visual analog scale and compared to worsening produced by other sensory stimuli such as light, sound, and smell. The discrimination power of kinesiophobia between migraine and TTH was calculated, using the International Classification of Headache Disorders criteria as gold standard. Sensitivity/specificity of studied symptoms was high in differentiating the 2 headache types: bending forward: 98%/85.7%; jolt: 96.3%/81.6%; and immobility during the attacks: 100%/70%. The degree of kinesiophobia was identical to photo- and phonophobia in migraine patients. We conclude that kinesiophobia discriminates between migraine and TTH. Bending forward and jolt may be useful additional questions to ask patients for the differentiation of headache attacks.

PERSPECTIVE

This article evaluates the specific role of movement (movement-induced pain aggravation and avoidance of movement) in primary headaches. Kinesophobia is an easy symptom to screen, explained by migraine pathophysiology, and proved to be a sensitive and specific measure to identify migraine attacks when compared to tension-type headache.

Somatoform disorders in neurological practice

PURPOSE OF REVIEW

Patients with medically unexplained symptoms continue to intrigue, fascinate and frustrate clinicians. They are common in general medicine and often present with apparent neurological disorder. This review aims to provide insight into the recent literature that has sought to clarify epidemiology, diagnostic issues, aetiologic understanding and treatment of patients with psychogenic disorders who usually first present to neurologists.

RECENT FINDINGS

Somatoform disorders are common in neurological practice. A number of papers have addressed issues of epidemiology and identified that medically unexplained symptoms in neurological populations are higher than originally thought. A number of recent review papers have served to summarize areas of considerable information (e.g. treatments) and areas of rapid growth in knowledge (e.g. neuroimaging). Studies investigating the role of psychological factors are well represented and clarify our psychopathological understanding of somatoform disorders in patients presenting to neurologists. Treatment studies are few and continue to be limited by population sizes and study designs.

SUMMARY

Somatoform disorders are common in neurological populations. Comorbidity related to somatoform disorders with known organic neurological conditions requires further study. On account of the limitations of treatment studies, evidence-based clinical management of these patients is awaited.

Neuropsychiatric aspects of migraine

Migraine is a common chronic disorder that presents with recurrent attacks of headache and associated symptoms. Various somatic and psychiatric conditions have been reported as comorbid conditions with migraine. Among the psychiatric disorders that have been reported as comorbid with migraine are major depression, anxiety, panic disorder, and bipolar disorder. Recent studies discussing the comorbidity of headache and psychiatric disorders are reviewed here.

The role of mast cells in migraine pathophysiology

Mast cells are critical players in allergic reactions, but they have also been shown to be important in immunity and recently also in inflammatory diseases, especially asthma. Migraines are episodic, typically unilateral, throbbing headaches that occur more frequently in patients with allergy and asthma implying involvement of meningeal and/or brain mast cells. These mast cells are located perivascularly, in close association with neurons especially in the dura, where they can be activated following trigeminal nerve, as well as cervical or sphenopalatine ganglion stimulation. Neuropeptides such as calcitonin gene-related peptide (CGRP), hemokinin A, neurotensin (NT), pituitary adenylate cyclase activating peptide (PACAP), and substance P (SP) activate mast cells leading to secretion of vasoactive, pro-inflammatory, and neurosensitizing mediators, thereby contributing to migraine pathogenesis. Brain mast cells can also secrete pro-inflammatory and vasodilatory molecules such as interleukin-6 (IL-6) and vascular endothelial growth factor (VEGF), selectively in response to corticotropin-releasing hormone (CRH), a mediator of stress which is known to precipitate or exacerbate migraines. A better understanding of brain mast cell activation in migraines would be useful and could lead to several points of prophylactic intervention.

Topiramate monotherapy in epilepsy and migraineprevention

OBJECTIVES

The purposes of this review were to assess the efficacy of topiramate as monotherapy for epilepsy and migraine prevention, describe how it should be used, and give clinical advice on how to manage the practical aspects of dosing, titration, and possible adverse events in these 2 indications.

METHODS

We searched the PubMed and BIOSIS databases using the key words topiramate, epilepsy, and migraine from the year 1987 onward, and subsequently focused the search on larger controlled trial studies of topiramate as monotherapy.

RESULTS

Studies have evaluated the use of topiramate as monotherapy in the treatment of partial-onset and generalized seizures and in the prevention of migraine. In a randomized study, 75% of epilepsy patients treated with 400 mg/d topiramate remained seizure free at 1 year. Patients in the same study treated with a lower dose of topiramate (50 mg/d) also experienced notable seizure reductions, with 59% of patients free of seizures at 1 year. A comparison trial of topiramate (100 or 200 mg/d), valproate, and carbamazepine found that topiramate was associated with a similar time to first posttreatment seizure as the other 2 agents (P = NS). Trials of topiramate monotherapy in migraine prevention found that 100 mg/d was associated with a > or =50% reduction in monthly migraine frequency in 49% to 54% of patients. The migraine prevention trials typically used a starting dose of 25 mg/d, with weekly increases of 25 mg and an initial monotherapy target dose of 100 mg/d. The most common adverse events associated with topiramate are paresthesia, weight loss, and other centrally mediated symptoms, many of which may be ameliorated by proper titration and dosing and by good communication between physician and patient.

CONCLUSIONS

Data from controlled trials suggest that 100 mg/d topiramate as monotherapy is effective in the treatment of partial-onset and generalized seizures and in the prevention of migraine.