Physical and mental comorbidity of headache in a nationally representative sample of US adults

Managing and Preventing Migraine in the Emergency Department: A Review

Migraine is a leading cause of disability worldwide, and acute migraine attacks are a common reason for patients to seek care in the emergency department (ED). There have been recent advancements in the care of patients with migraine, specifically emerging evidence for nerve blocks and new pharmacological classes of medications like gepants and ditans. This article serves as a comprehensive review of migraine in the ED, including diagnosis and management of acute complications of migraine (eg, status migrainosus, migrainous infarct, persistent aura without infarction, and aura-triggered seizure) and use of evidence-based migraine-specific treatments in the ED. It highlights the role of migraine preventive medications and provides a framework for emergency physicians to prescribe them to eligible patients. Finally, it evaluates the evidence for nerve blocks in the treatment of migraine and introduces the possible role of gepants and ditans in the care of patients with migraine in the ED.

Migraine and risk of rheumatoid arthritis: A systematic review and meta-analysis of observational studies

Background

Exposure to Migraine may be one of the risk factors for the onset of rheumatoid arthritis (RA), while the relationship between the two is debatable. In this study, the connection between migraine and the risk of RA was investigated using a systematic review and meta-analysis of the pertinent literature.

Methods

Up to July 2022, the PubMed, EMBASE, Web of Science (WOS), and scopus databases were employed to search for observational studies on the risk of RA in migraineurs. The effect sizes were pooled using a random-effects model or a fixed-effects model.

Results

Out of 2345 records, 5 studies (3 case and control studies and 2 cohort studies) were identified and included in the meta-analysis. According to a pooled analysis, migraine sufferers had a higher chance of developing RA (pooled adjusted effect estimate: 1.94, 95% confidence interval: 1.74-2.17; p < 0.01).

Conclusions

Migraine can be legitimately regarded as a risk factor for RA since this study demonstrated a relationship between migraine and RA. This conclusion should be treated with caution due to low power and precision. Rigorous design and larger sample sizes of studies are needed to verify the findings.

Utilization of a neurology specialty service by primary care providers for headache management at a tertiary care hospital

Background

Recent data indicate that the three-month prevalence of severe headaches or migraines in the US general population is close to 25%. Participation of primary care providers will therefore be critical in providing care to affected individuals.

Objective

To determine the number of headache disorder consult requests to a neurology outpatient service in a tertiary medical center, the appropriateness of the consult requests, and the effectiveness of a lecture series on headache diagnosis and management in preventing inappropriate consult requests from non-neurology providers.

Methods

Clinical data on US Veterans is captured and documented in the Veterans Health Information Systems and Technology Architecture (VISTA). The Computerized Patient Record System (CPRS) electronic medical record (EMR) was used for data entry and retrieval. All consult requests for the study period within the VA North Texas Health Care System were identified in VISTA, and the clinical information reviewed in CPRS. Based on a defined algorithm, headache consult request were categorized as appropriate or inappropriate. A board-certified neurologist provided four in-person/virtual lectures to ambulatory care providers, primary care providers, internal medicine residents, and emergency room providers within the VA North Texas Health Care System on the diagnosis and management of headaches. Prior and post the lecture series, the total number of headache consults per day was assessed over 45-day periods.

Results

The number of daily headache consult requests in the 45-day period prior to the lecture series was 3.6 per day (standard deviation 2.7), and 6.0 per day after the lecture series (standard deviation 2.1). The difference was not statistically significant. There were as many inappropriate headache consult requests after the lecture series as appropriate ones (50% each).

Conclusion

We found that a short-term educational initiative that instructed primary care providers on the diagnosis and management of common headache disorders did not reduce the number of consultation requests and, surprisingly, it did not improve the appropriateness of the consults. Given the prevalence of headaches in the general population, better training of all primary care providers in headache management should be pursued.

Potential Mechanisms and Clinical Effectiveness of Acupuncture in Depression

Major depressive disorder is the most common mental disorder with significant economic burden and limited treatments. Acupuncture has emerged as a promising non-pharmacological treatment for reducing depressive symptoms. However, the potential mechanisms and clinical effectiveness of acupuncture are not fully understood. This review aimed to: (1) summarize the available evidence on the mechanisms and clinical effectiveness of acupuncture for depression, and then (2) compare with pharmacological interventions, guiding future studies. Studies with animal models of depression and patients have shown that acupuncture could increase hippocampal and network neuroplasticity and decrease brain inflammation, potentially to alleviating depressive disorders. Overall clinical studies indicated that acupuncture could relieve primary depression, particularly milder cases, and was helpful in the management of post-stroke depression, pain-related depression, and postpartum depression both as an isolated and adjunct treatment. It was emphasized that acupuncture combined with antidepressant pharmacological treatment not only enhanced the improvement of primary and secondary depressive symptoms but also reduced the side effects of the medical treatment, which is the main cause for high dropout rates with drug treatment. In summary, substantial evidence from animal and human researches supported the beneficial effect of acupuncture in depression. However, most clinical trials of acupuncture were small, and it is unclear whether their findings can be generalized, so more studies are needed.

Headache and mental disorders in a nationally representative sample of American youth

The objective of this study is to examine the association between headache and mental disorders in a nationally representative sample of American youth. We used the National Comorbidity Survey-Adolescent Supplement to assess sex-specific prevalence of lifetime migraine and non-migraine headache using modified International Headache Society criteria and examine associations between headache subtypes and DSM-IV mental disorders. Adolescent report (n = 10,123) was used to identify headache subtypes and anxiety, mood, eating, and substance use disorders. ADHD and behavior disorder were based on parent report (n = 6483). Multivariate logistic regression analyses controlling for key demographic characteristics were used to examine associations between headache and mental disorders. Headache was endorsed by 26.9% (SE = 0.7) of the total sample and was more prevalent among females. Youth with headache were more than twice as likely (OR 2.74, 95% CI 1.94-3.83) to meet criteria for a DSM-IV disorder. Migraine, particularly with aura, was associated with depression and anxiety (adjusted OR 1.90-2.90) and with multiple classes of disorders. Adolescent headache, particularly migraine, is associated with anxiety, mood, and behavior disorders in a nationally representative sample of US youth. Headache is highly prevalent among youth with mental disorders, and youth with headache should be assessed for comorbid depression and anxiety that may influence treatment, severity, and course of both headache and mental disorders.

Headache and immunological/autoimmune disorders: a comprehensive review of available epidemiological evidence with insights on potential underlying mechanisms

Several lines of evidence support a role of the immune system in headache pathogenesis, with particular regard to migraine. Firstly, alterations in cytokine profile and in lymphocyte subsets have been reported in headache patients. Secondly, several genetic and environmental pathogenic factors seem to be frequently shared by headache and immunological/autoimmune diseases. Accordingly, immunological alterations in primary headaches, in particular in migraine, have been suggested to predispose some patients to the development of immunological and autoimmune diseases. On the other hand, pathogenic mechanisms underlying autoimmune disorders, in some cases, seem to favour the onset of headache. Therefore, an association between headache and immunological/autoimmune disorders has been thoroughly investigated in the last years. The knowledge of this possible association may have relevant implications in the clinical practice when deciding diagnostic and therapeutic approaches. The present review summarizes findings to date regarding the plausible relationship between headache and immunological/autoimmune disorders, starting from a description of immunological alteration of primary headaches, and moving onward to the evidence supporting a potential link between headache and each specific autoimmune/immunological disease.

Bidirectional association between migraine and rheumatoid arthritis: two longitudinal follow-up studies with a national sample cohort

OBJECTIVE

To investigate the bidirectional association between migraine and rheumatoid arthritis (RA).

DESIGN

Two longitudinal follow-up studies.

SETTING

Data collected from a national cohort between 2002 and 2013 by the Korean National Health Insurance Service-Health Screening Cohort.

PARTICIPANTS

In cohort 1, matching resulted in the inclusion of 31 589 migraine patients and 126 356 control I participants. In cohort 2, matching resulted in the inclusion of 9287 RA patients and 37 148 control II participants.

PRIMARY AND SECONDARY OUTCOME MEASURES

The HRs for RA in patients with migraine (cohort 1) and migraine in patients with RA (cohort 2) were analysed using stratified Cox proportional hazard models after adjusting for autoimmune disease, Charlson Comorbidity Index scores without rheumatoid diseases, obesity (body mass index), smoking and history of alcohol intake. Subgroup analyses stratified by age, sex, income and region of residence were also performed.

RESULTS

The incidence of RA in the migraine group (2.0% (640/31 589)) was higher than that in the control I group (1.4% (1709/126 356), p<0.001). The adjusted HR for RA in the migraine without aura group was 1.48 (95% CIs=1.34 to 1.63, p<0.001).The incidence of migraine in the RA group (6.4% (590/9287)) was higher than that in the control II group (4.6% (1721/37 148), p<0.001). The adjusted HR for migraine without aura in the RA group was 1.35 (95% CI=1.23 to 1.49, p<0.001).

CONCLUSION

Migraine increases the risk of RA, and RA is also associated with an increased risk of migraine.

Healthcare Expenditures Associated With Comorbid Anxiety and Depression Among Adults With Migraine

Introduction: Depression and anxiety are common among patients with migraine and usually associated with a humanistic and financial burden. This study aims to examine the direct healthcare expenditures among adults with migraine alone or with comorbid anxiety and/or depression. Methods: This was a retrospective cross-sectional study using 2012, 2014, and 2016 Medical Expenditure Panel Survey data. Adult patients aged ≥22 years with migraine headache were included in the study. The direct healthcare expenditures of four migraine groups (migraine alone, migraine and anxiety, migraine and depression, and migraine and both conditions) were compared. Results: There were 1,556 patients who met the inclusion criteria and eventually enrolled in the study. Approximately 42% of the study sample had migraine with comorbid depression and/or anxiety (16.1% have depression, 12.3% have anxiety disorder, and 13.9% have both). The mean total healthcare expenditures of adults with migraine alone ($6,461) were significantly lower than those with comorbid depression and anxiety ($11,102), comorbid anxiety ($10,817), and comorbid depression ($14,577). Migraine with comorbid anxiety and depression was significantly associated with incremental costs of $1,027 in outpatient and $662 emergency room healthcare expenditures and prescription drug compared to the migraine alone group. Conclusions: The healthcare expenditures associated with migraine with comorbid depression and/or anxiety are significantly higher than those without mental health comorbidities. Therefore, regular depression and anxiety screening for patients with migraine may help reduce the healthcare expenditures associated with depression and/or anxiety comorbidities and improve the quality of care.

Pathophysiological Bases of Comorbidity in Migraine

Despite that it is commonly accepted that migraine is a disorder of the nervous system with a prominent genetic basis, it is comorbid with a plethora of medical conditions. Several studies have found bidirectional comorbidity between migraine and different disorders including neurological, psychiatric, cardio- and cerebrovascular, gastrointestinal, metaboloendocrine, and immunological conditions. Each of these has its own genetic load and shares some common characteristics with migraine. The bidirectional mechanisms that are likely to underlie this extensive comorbidity between migraine and other diseases are manifold. Comorbid pathologies can induce and promote thalamocortical network dysexcitability, multi-organ transient or persistent pro-inflammatory state, and disproportionate energetic needs in a variable combination, which in turn may be causative mechanisms of the activation of an ample defensive system with includes the trigeminovascular system in conjunction with the neuroendocrine hypothalamic system. This strategy is designed to maintain brain homeostasis by regulating homeostatic needs, such as normal subcortico-cortical excitability, energy balance, osmoregulation, and emotional response. In this light, the treatment of migraine should always involves a multidisciplinary approach, aimed at identifying and, if necessary, eliminating possible risk and comorbidity factors.

Migraine Features in Patients with Persistent Postural-Perceptual Dizziness

OBJECTIVES

To evaluate the presence of migraine features in patients with persistent postural-perceptual dizziness (PPPD).

METHODS

In a retrospective survey study, consecutive patients presenting to a tertiary care neurotology clinic during an 18-month period were given questionnaires about headache and dizziness symptoms. The survey responses plus history and examination of the patient were used to diagnose patients with PPPD. The prevalence of migraine headache, vestibular migraine (VM), and migraine characteristics was evaluated.

RESULTS

In total, 36 subjects with PPPD were included in the study. The mean age of the subjects was 56 ± 16 years with a female (72%) predominance. A total of 19 (53%) patients met the International Classification of Headache Disorders criteria for migraine headache, and 6 of those (17%) met the criteria for definite VM. Of the patients who did not meet full migraine headache criteria, 6 (17%) patients met 4 of 5 criteria, and 5 (14%) patients met 3 of 5 criteria. There was no significant difference between PPPD patients who fulfilled full migraine headache criteria and those who did not in sensitivity to light, sound, smells, weather changes, feelings of mental fog/confusion, and sinus pain/facial pressure.

CONCLUSIONS

This study demonstrates that a majority of patients with PPPD fulfill the criteria for migraine headache. A large proportion of PPPD patients who do not meet the full criteria for migraine headache still meet a majority of the migraine headache criteria. This suggests an association between the 2 conditions. PPPD may be a part of the spectrum of otologic migraine, where migraine manifests as otologic symptoms.

The Relationships Between Self-reported Pain Intensity, Pain Interference, and Quality of Life Among Injured U.S. Service Members With and Without Low Back Pain

Low back pain is a prevalent military and veteran health problem and individuals injured on deployment may be at particularly high risk of pain conditions. Given that increasing numbers of active duty and veteran military personnel are seeking care in community settings, it is critical that health care providers are aware of military health issues. The current study examined the prevalence of low back pain among individuals with deployment-related injuries, compared their self-reported pain intensity and interference ratings, and assessed the relationship between low back pain, self-reported pain ratings, and quality of life. Almost half of participants had low back pain diagnoses, and individuals with low back pain reported significantly higher intensity and interference due to their pain than individuals without low back pain. Finally, the relationship between low back pain and quality of life was explained by self-reported pain indices, underscoring the importance of patient-centered metrics in pain treatment.

Acupuncture for Psychological Disorders Caused by Chronic Pain: A Review and Future Directions

Accumulating evidence supports an association between chronic pain and psychological disorders, a connection that seems to be bidirectional. Treating both the pain and psychological conditions together is essential for effective treatment outcomes. Acupuncture is a somatosensory-guided mind-body therapy that can tackle the multidimensional nature of pain with fewer or no serious adverse effects. In this review, we discuss the use of acupuncture in some conditions with a high incidence of psychological disorders caused by chronic pain: headache, musculoskeletal pain, low back pain, and cancer pain, focusing on the effect and potential mechanisms of acupuncture. Overall clinical studies indicated that acupuncture might effectively contribute to management of psychological disorders caused by chronic pain. Mechanistic studies showed that acupuncture significantly alleviated such psychological disorders by regulating the activity of amygdala and insula, and regulating functional connectivity of insular and limbic regions/medial prefrontal cortex in humans and the corresponding animal models. In addition, 5-HT in the dorsal raphe nucleus, opioid receptors in the cingulate cortex, and plasma met-enkephalin are involved in acupuncture relief of pain and psychological symptoms. Substantial evidences from animal and human research support a beneficial effect of acupuncture in psychological disorders caused by chronic pain.

Comorbidity and patterns of familial aggregation in attention-deficit/hyperactivity disorder and bipolar disorder in a family study of affective and anxiety spectrum disorders

The aim of this study is to examine the familial aggregation of Attention-deficit/hyperactivity disorder (ADHD) and its cross-transmission with bipolar disorder (BD) in a community-based family study of mood spectrum disorders. A clinically-enriched community sample of 562 probands recruited from the greater Washington, DC metropolitan area and their 698 directly interviewed relatives were included in analyses. Inclusion criteria were English speaking and consent to contact at least two first-degree relatives. Standard family study methodology was used and DSM-IV classified mental disorders were ascertained through a best-estimate procedure based on direct semi-structured interviews and multiple family history reports. There was specificity of familial aggregation of both bipolar I disorder (BD I) and bipolar II disorder (BD II) (i.e., BD I OR = 6.08 [1.66, 22.3]; BD II OR = 2.98 [1.11, 7.96]) and ADHD (ADHD OR = 2.13 [1.16, 3.95]). However, there was no evidence for cross-transmission of BD and ADHD in first degree relatives (i.e., did not observe increased rates of BD in relatives of those with ADHD and vice versa; all ps > 0.05). The specificity of familial aggregation of ADHD and BD alongside the absence of shared familial risk are consistent with the notion that the comorbidity between ADHD and BD may be attributable to diagnostic artifact, could represent a distinct BD suptype characterized by childhood-onset symptoms, or the possibility that attention problems serve as a precursor or consequence of BD.

Humanistic and economic burden of depression and anxiety among adults with migraine: A systematic review

BACKGROUND

Depression and anxiety are well-recognized comorbid health conditions among adults with migraine due to their humanistic and economic burden. This review was conducted to systematically assess the humanistic and economic burden of comorbid depression and/or anxiety disorder among adults with migraine.

METHODS

A systematic literature search was conducted using MEDLINE and CINAHL via EBSCO, EMBASE, and Cochrane Database of Systematic Reviews via OVID. Studies evaluating the humanistic burden and the economic burden of comorbid depression and anxiety among adults with migraine that were published in peer-reviewed English language journals from inception until January 2020 were included.

RESULTS

Out of the 640 identified articles, 23 studies were found eligible and included in this review. Regarding the humanistic burden, health-related quality of life (HRQoL) was examined by 11 studies, 7 studies examined disability, while 2 studies evaluated both HRQoL and disability measures. These studies reported an association between depression and/or anxiety and lower HRQoL and higher disability among adults with migraine. Regarding the economic burden, only three studies were identified and all concluded that depression and/or anxiety are significantly associated with higher healthcare expenditures and utilization among adults with migraine.

CONCLUSIONS

Results of this review highlight the substantial burden of depression and/or anxiety for adults with migraine. Healthcare providers need to identify and treat anxiety and depression for patients living with migraine.

Understanding the nature of psychiatric comorbidity in migraine: a systematic review focused on interactions and treatment implications

BACKGROUND

Migraine is a highly prevalent and disabling neurological disorder which is commonly linked with a broad range of psychiatric comorbidities, especially among subjects with migraine with aura or chronic migraine. Defining the exact nature of the association between migraine and psychiatric disorders and bringing out the pathophysiological mechanisms underlying the comorbidity with psychiatric conditions are relevant issues in the clinical practice.

METHODS

A systematic review of the most relevant studies about migraine and psychiatric comorbidity was performed using "PubMed", "Scopus", and "ScienceDirect" electronic databases from 1 January 1998 to 15 July 2018. Overall, 178 studies met our inclusion criteria and were included in the current review.

RESULTS

According to the most relevant findings of our overview, the associations with psychiatric comorbidities are complex, with a bidirectional association of major depression and panic disorder with migraine. Importantly, optimizing the pharmacological and non-pharmacological treatment of either migraine or its psychiatric comorbidities might help clinicians to attenuate the burden of both these conditions.

CONCLUSIONS

The available data highlight the need for a comprehensive evaluation of psychiatric disorders in migraine in order to promote an integrated model of care and carefully address the burden and psychosocial impairment related to psychiatric comorbidities in migraine.

Neurological symptoms in Hypophosphatasia

Hypophosphatasia (HPP) typically manifests with fractures, tooth loss, and muscle pain. Although mental health diagnoses and neurological symptoms have not been previously well documented in HPP, they occur commonly. The recognition of non-traditional symptoms may improve patient satisfaction, preempt costly evaluation and misdiagnosis, and lead to further treatment options.

INTRODUCTION

Hypophosphatasia (HPP) is an inborn error of metabolism due to deficiency of tissue non-specific alkaline phosphatase (TNSALP). It is traditionally characterized by rickets in children and osteomalacia in adults, along with fractures, tooth loss, and muscle pain. Neurological symptoms and mental health diagnoses have not been widely reported, and we therefore report their prevalence in a cohort of patients with HPP.

METHODS

A retrospective chart review was performed on a series of 82 HPP patients. Patient charts were reviewed to identify the possible presence and onset of 13 common neurological symptoms.

RESULTS

Median age was 36 years (2 to 79). Seventeen had adult onset HPP (> 18 years) and 65 had pediatric onset HPP (< 18 years). Median time from symptom onset to HPP diagnosis was 8 years (0 to 67). Seventy-four percent had a family history of bone disease, while 17% had a family history of neurologic disease. Bone problems occurred in 89%, dental problems in 77%, and muscle problems in 66%. Fatigue occurred in 66%, headache in 61%, sleep disturbance in 51%, gait change in 44%, vertigo in 43%, depression in 39%, anxiety in 35%, neuropathy in 35%, and hearing loss in 33%.

CONCLUSIONS

The extra-skeletal manifestations of HPP, specifically neurological symptoms, have not been previously well documented. However, mental health diagnoses and neurological symptoms such as headache and sleep disturbance occur commonly in patients with HPP. The recognition of non-traditional symptoms in HPP may improve patient satisfaction, preempt costly evaluation and misdiagnosis, and may lead to further treatment options.

Variations in Patterns of Utilization and Charges for the Care of Headache in North Carolina, 2000-2009: A Statewide Claims' Data Analysis

OBJECTIVES

The purpose of the study was to compare patterns of utilization and charges generated by medical doctors (MDs), doctors of chiropractic (DCs), and physical therapists (PTs) for the treatment of headache in North Carolina.

METHODS

Retrospective analysis of claims data from the North Carolina State Health Plan for Teachers and State Employees from 2000 to 2009. Data were extracted from Blue Cross Blue Shield of North Carolina for the North Carolina State Health Plan using International Classification of Diseases, Ninth Revision, diagnostic codes for headache. The claims were separated by individual provider type, combination of provider types, and referral patterns.

RESULTS

The majority of patients and claims were in the MD-only or MD plus referral patterns. Chiropractic patterns represented less than 10% of patients. Care patterns with single-provider types and no referrals incurred the least charges on average for headache. When care did not include referral providers or services, MD with DC care was generally less expensive than MD care with PT. However, when combined with referral care, MD care with PT was generally less expensive. Compared with MD-only care, risk-adjusted charges (available 2006-2009) for patients in the middle risk quintile were significantly less for DC-only care.

CONCLUSIONS

Utilization and expenditures for headache treatment increased from 2000 to 2009 across all provider groups. MD care represented the majority of total allowed charges in this study. MD care and DC care, alone or in combination, were overall the least expensive patterns of headache care. Risk-adjusted charges were significantly less for DC-only care.

Migraine and Headache Prevalence and Associated Comorbidities in a Large Saudi Sample

Background: We aimed to assess the prevalence of headache and migraine, along with comorbidities, in a large ­Saudi sample. Methods: Self-reported information was collected about headache, migraine and migraine comorbidities including depression, restless legs syndrome (RLS), syncope, bruxism, hypertension and ischaemic disease. The OR was estimated using logistic regression for any associations with headache and migraine. We then analyzed to find a trend of increasing migraine symptoms for each significant comorbidity. Results: Out of 4,943 respondents, 4,158 (84.12%) had recurring headaches. Migraine was present in 1,333 (26.97%), with female predominance (ratio of 1: 2.9). There were statistically significant ORs between migraine and female sex, current smokers, higher income, hypertension, depression, syncope, RLS and bruxism. Non-migraine headaches were significantly associated with female sex, age, RLS and ischaemic disease. Migraine with aura was significantly associated with syncope, ischaemic disease, higher income and BMI. There was an overall significant trend of increasing migraine features in the presence of depression, syncope, RLS, bruxism and hypertension. Conclusions: Headache in general and migraine in particular are associated with multiple comorbidities in comparison to non-headache participants in our cohort, with an estimated prevalence similar to that of western countries.

Drug-drug interactions involving antidepressants: focus on desvenlafaxine

Psychiatric and physical conditions often coexist, and there is robust evidence that associates the frequency of depression with single and multiple physical conditions. More than half of patients with depression may have at least one chronic physical condition. Therefore, antidepressants are often used in cotherapy with other medications for the management of both psychiatric and chronic physical illnesses. The risk of drug-drug interactions (DDIs) is augmented by complex polypharmacy regimens and extended periods of treatment required, of which possible outcomes range from tolerability issues to lack of efficacy and serious adverse events. Optimal patient outcomes may be achieved through drug selection with minimal potential for DDIs. Desvenlafaxine is a serotonin-norepinephrine reuptake inhibitor approved for the treatment of adults with major depressive disorder. Pharmacokinetic studies of desvenlafaxine have shown a simple metabolic profile unique among antidepressants. This review examines the DDI profiles of antidepressants, particularly desvenlafaxine, in relation to drugs of different therapeutic areas. The summary and comparison of information available is meant to help clinicians in making informed decisions when using desvenlafaxine in patients with depression and comorbid chronic conditions.

Long working hours directly and indirectly (via short sleep duration) induce headache even in healthy white-collar men: cross-sectional and 1-year follow-up analyses

OBJECTIVE

Headache in employees may be linked with both overwork and sleep restriction induced by long working hours. Inter-relationships among working hours, sleep duration and headache were investigated.

METHODS

Cross-sectional analyses for prevalent headache (n = 35,908) and 1-year follow-up analyses for incident headache (n = 19,788) were conducted in apparently healthy white-collar men aged 25-59 years. Headache (yes/no), working hours and sleep duration were based on self-administered questionnaire. After determination of relationships between working hours and sleep duration, logistic regression analysis estimated odds ratio (OR) and 95% confidence interval for prevalent and incident headache according to working hours (35-44, 45-49, 50-59 and ≥60 h/week) and sleep duration (≥7, 6-6.9, 5-5.9 and <5 h/day), and tested linear trends in OR. Additionally, interactive effects of working hours and sleep duration on OR were checked. Covariates in the analyses were age, body mass index, drinking, smoking and exercise.

RESULTS

Prevalent and incident headache was found in 1979 (5.5%) men and 707 (3.6%) men, respectively. Working hours were inversely associated with sleep duration. OR for prevalent and incident headache rose with increasing working hours and with reducing sleep duration, regardless of influences of the covariates. Working hours and sleep duration had no interactive effects on OR for prevalent or incident headache.

CONCLUSIONS

The results indicate that long working hours directly and indirectly (via short sleep duration) induce headache even in apparently healthy white-collar men. Headache in employees may be useful for early detection of adverse health effects by long working hours.

The prevalence of depression and the accuracy of depression screening tools in migraine patients

OBJECTIVES

Migraine and depression are common comorbid conditions. The purpose of this study was to assess how well the Patient Health Questionnaire (PHQ-9) and the Hospital Anxiety and Depression Scale (HADS) perform as depression screening tools in patients with migraine.

METHODS

Three hundred consecutive migraine patients were recruited from a large headache center. The PHQ-9 and HADS were self-administered and validated against the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders-IV, a gold standard for the diagnosis of depression. Sensitivity, specificity, positive predictive value, negative predictive value and receiver-operator characteristic curves were calculated for the PHQ-9 and HADS.

RESULTS

At the traditional cut-point of 10, the PHQ-9 demonstrated 82.0% sensitivity and 79.9% specificity. At a cut-point of 8, the HADS demonstrated 86.5% sensitivity and specificity. The PHQ-9 algorithm performed poorly (53.8% sensitivity, 94.9% specificity). The point prevalence of depression in this study was 25.0% (95% CI 19.0-31.0), and 17.0% of patients had untreated depression.

CONCLUSIONS

In this study, the PHQ-9 and HADS performed well in migraine patients attending a headache clinic, but optimal cut-points to screen for depression vary depending on the goals of the assessment. Also, migraine patients attending a headache clinic have a high prevalence of depression and many are inadequately treated. Future studies are needed to confirm these findings and to evaluate the impact of depression screening.

Comorbid pain and migraine chronicity: The Chronic Migraine Epidemiology and Outcomes Study

Objective:

To identify patterns of noncephalic pain comorbidity in people with episodic migraine (EM; <15 headache-days per month) and chronic migraine (CM; ≥15 headache-days per month) and to examine whether the presence of noncephalic pain is an indicator for the 3-month onset or persistence of CM.

Methods:

Data from the Chronic Migraine Epidemiology and Outcomes (CaMEO) Study, a prospective, web-based study with cross-sectional modules embedded in a longitudinal design, were analyzed at baseline and the 3-month follow-up. Relationships between the number of noncephalic pain sites and 3-month onset of CM or persistent CM were assessed.

Results:

Of 8,908 eligible respondents, 8,139 (91.4%) had EM and 769 (8.6%) had CM at baseline. At 3 months, the incidence of CM among those with baseline EM was 3.4%. When adjusted for demographics and headache-day frequency, the odds of CM onset among those with baseline EM increased by 30% (95% confidence interval [CI] 1.21–1.40, p < 0.001) for each additional noncephalic pain site at baseline. Among those with CM at baseline, 50.1% had persistent CM at the 3-month follow-up. After adjustment for demographics, individuals with CM were 15% (95% CI 1.07–1.25, p < 0.001) more likely to have persistent CM for each additional noncephalic pain site at baseline.

Conclusions:

These results suggest that noncephalic pain may be a marker for headache chronicity that could be used to identify people with EM at risk of the onset of CM and people with CM at risk of persistent CM.

The association of generalized anxiety disorder and Somatic Symptoms with frequent attendance to health care services: A cross-sectional study from the Northern Finland Birth Cohort 1966

Objective Generalized anxiety disorder is associated with higher rate of physical comorbities, unexplained symptoms, and health care utilization. However, the role of somatic symptoms in determining health care utilization is unclear. The present study aims to assess the association of frequent attendance of health care services between generalized anxiety disorder symptoms and somatic symptoms. Method This study was conducted cross-sectionally using the material of the 46-year follow-up survey of the Northern Finland Birth Cohort 1966. Altogether, 5585 cohort members responded to the questionnaires concerning health care utilization, illness history, physical symptoms, and generalized anxiety disorder-7 screening tool. Odds ratios belonging to the highest decile in health care utilization were calculated for generalized anxiety disorder symptoms and all (n = 4) somatic symptoms of Hopkins Symptom Checklist-25 controlled for confounding factors. Results Adjusted Odds ratios for being frequent attender of health care services were 2.29 (95% CI 1.58-3.31) for generalized anxiety disorder symptoms and 1.28 (95% CI 0.99-1.64), 1.94 (95% CI 1.46-2.58), 2.33 (95% CI 1.65-3.28), and 3.64 (95% CI 2.15-6.18) for 1, 2, 3, and 4 somatic symptoms, respectively. People with generalized anxiety disorder symptoms had on average a higher number of somatic symptoms (1.8) than other cohort members (0.9). Moreover, 1.6% of people without somatic symptoms tested positive for generalized anxiety disorder, meanwhile 22.6% of people with four somatic symptoms tested positive for generalized anxiety disorder. Conclusions Both generalized anxiety disorder symptoms and somatic symptoms are associated with a higher risk for being a health care frequent attender.

Variability in measures of health and health behavior among emerging adults 1 year after high school according to college status

OBJECTIVE

To examine changes in health behaviors among US emerging adults 1 year after high school.

PARTICIPANTS

The national sample of participants (N = 1,927), including those attending 4-year college/university (n = 884), 2-year colleges/technical schools (n = 588), and no college (n = 455), participated in annual spring surveys 2013-2014.

METHODS

Health behaviors were assessed the last year of high school and first year of college; differences by college status controlling for previous-year values were estimated using regression analyses.

RESULTS

Relative to 4-year college attendees, those attending technical school/community college were less likely to binge drink (odds ratio [OR] = 0.57, confidence interval [CI] = 0.38-0.86) but more likely to speed (OR = 1.26, CI = 1.0-2.84), consume sodas (OR = 1.57, CI = 1.0-2.47), and report lower family satisfaction (p < .01), with marginally more physical and depressive symptoms. College nonattendees reported more DWI (driving while intoxicated; OR = 1.60, CI = 1.05-2.47), soda drinking (OR = 2.51, CI = 1.76-3.59), oversleeping (OR = 4.78, CI = 3.65-8.63), and less family satisfaction (p < .04).

CONCLUSIONS

Health risk behaviors among emerging adults varied by college status.

Behavioral health in young adults with epilepsy: Implications for transition of care

AIM

Neurodevelopmental and behavioral health disorders commonly occur with epilepsy, yet risk for young adults is unknown. The aim of this study was to determine the distribution and risk characteristics of neurodevelopmental and behavior health comorbidities among young adults with epilepsy compared with those among young adults with migraine and healthy controls.

METHOD

A case-control study examining hospital admission, outpatient, and emergency department (ED) visits for young adults with an ICD-9-CM diagnosis of epilepsy, migraine, or lower extremity fracture (LEF) was conducted. The association of epilepsy, migraine, or LEF with comorbidities was evaluated with univariate and multivariate polytomous logistic regression.

RESULTS

From 2000 to 2013, 29,139 young adults ages 19 to 25years were seen in hospitals and EDs for epilepsy (5666), migraine (17,507), or LEF (5966). Young adults with epilepsy had higher proportions of behavioral health comorbidities (51.8%) compared with controls with migraine (37.6%) or LEF (21.6%). In young adults with epilepsy compared with migraine, the increased risk of having any behavioral health comorbidity was 76%, and neurodevelopmental comorbidity was 297%. After adjustment, young adults with epilepsy showed significantly higher odds of each behavioral health comorbidity compared with controls with migraine and LEF.

INTERPRETATION

Young adults with epilepsy are particularly susceptible to behavioral health and neurodevelopmental disorders. Results are discussed within the context of transition to adult care.

Increased risk of rheumatoid arthritis in patients with migraine: a population-based, propensity score-matched cohort study

Previous cross-sectional studies have suggested an association between migraine and rheumatoid arthritis (RA), but no longitudinal study has been performed to evaluate the temporal relationship between the two conditions. The purpose of the present population-based, propensity score-matched cohort study was to investigate whether migraineurs are at a higher risk of developing RA. A total of 58,749 subjects aged between 20 and 90 years with at least two ambulatory visits with a diagnosis of migraine were recruited in the migraine group. We fit a logistic regression model that included age, sex, comorbid conditions, and socioeconomic status as covariates to compute the propensity score. The non-migraine group consisted of 58,749 propensity score-matched, randomly sampled subjects without migraine. The RA-free survival curves were generated using the Kaplan-Meier method. Stratified Cox proportional hazard regression was used to estimate the effect of migraine on the risk of RA. During follow-up, 461 subjects in the migraine group and 220 in the non-migraine group developed RA. The incidence rate of RA was 3.18 (95% confidence interval [CI] 2.90-3.49) per 1000 person-years in the migraine group and 1.54 (95% CI 1.34-1.76) per 1000 person-years in the non-migraine group. Compared to the non-migraine group, the crude hazard ratio of RA for the migraine group was 2.15 (95% CI 1.82-2.56, P < 0.0001), and the multivariable-adjusted hazard ratio was 1.91 (95% CI 1.58-2.31, P < 0.0001). This study showed that patients with migraine had an increased risk of developing RA.

Increased migraine risk in osteoporosis patients: a nationwide population-based study

BACKGROUND

Osteoporosis and migraine are both important public health problems and may have overlapping pathophysiological mechanisms. The aim of this study was to use a Taiwanese population-based dataset to assess migraine risk in osteoporosis patients.

METHODS

The Taiwan National Health Insurance Research Database was used to analyse data for 40,672 patients aged ≥20 years who had been diagnosed with osteoporosis during 1996-2010. An additional 40,672 age-matched patients without osteoporosis were randomly selected as the non-osteoporosis group. The relationship between osteoporosis and migraine risk was estimated using Cox proportional hazard regression models.

RESULTS

During the follow-up period, 1110 patients with osteoporosis and 750 patients without osteoporosis developed migraine. After controlling for covariates, the overall incidence of migraine was 1.37-fold higher in the osteoporosis group than in the non-osteoporosis group (3.72 vs. 1.24 per 1000 person-years, respectively). Migraine risk factors included high Charlson Comorbidity Index score, female gender, hypertension, depression, asthma, allergic rhinitis, obesity, and tobacco use disorder.

CONCLUSIONS

Our results indicate that patients with a history of osteoporosis had a higher risk of migraine.

Prevalence of migraine in a diverse community--electronic methods for migraine ascertainment in a large integrated health plan

INTRODUCTION

The growing availability of electronic health data provides an opportunity to ascertain diagnosis-specific cases via systematic methods for sample recruitment for clinical research and health services evaluation. We developed and implemented a migraine probability algorithm (MPA) to identify migraine from electronic health records (EHR) in an integrated health plan.

METHODS

We identified all migraine outpatient diagnoses and all migraine-specific prescriptions for a five-year period (April 2008-March 2013) from the Kaiser Permanente, Northern California (KPNC) EHR. We developed and evaluated the MPA in two independent samples, and derived prevalence estimates of medically-ascertained migraine in KPNC by age, sex, and race.

RESULTS

The period prevalence of medically-ascertained migraine among KPNC adults during April 2008-March 2013 was 10.3% (women: 15.5%, men: 4.5%). Estimates peaked with age in women but remained flat for men. Prevalence among Asians was half that of whites.

CONCLUSIONS

We demonstrate the feasibility of an EHR-based algorithm to identify cases of diagnosed migraine and determine that prevalence patterns by our methods yield results comparable to aggregate estimates of treated migraine based on direct interviews in population-based samples. This inexpensive, easily applied EHR-based algorithm provides a new opportunity for monitoring changes in migraine prevalence and identifying potential participants for research studies.

Childhood somatic complaints predict generalized anxiety and depressive disorders during young adulthood in a community sample

BACKGROUND

Children with somatic complaints are at increased risk for emotional disorders during childhood. Whether this elevated risk extends into young adulthood - and to which specific disorders - has rarely been tested with long-term prospective-longitudinal community samples. Here we test whether frequent and recurring stomach aches, headaches, and muscle aches during childhood predict emotional disorders in adulthood after accounting for childhood psychiatric and physical health status and psychosocial adversity.

METHOD

The Great Smoky Mountains Study is a community representative sample with 1420 participants. Children/adolescents were assessed 4-7 times between ages 9-16 years. They were assessed again up to three times between ages 19-26 years. Childhood somatic complaints were coded when subjects or their parents reported frequent and recurrent headaches, stomach aches, or muscular/joint aches at some point when children were aged 9-16 years. Psychiatric disorders were assessed with the Child and Adolescent Psychiatric Assessment and the Young Adult Psychiatric Assessment.

RESULTS

Frequent and recurrent somatic complaints in childhood predicted adulthood emotional disorders. After controlling for potential confounders, predictions from childhood somatic complaints were specific to later depression and generalized anxiety disorder. Long-term predictions did not differ by sex. Somatic complaints that persisted across developmental periods were associated with the highest risk for young adult emotional distress disorders.

CONCLUSIONS

Children from the community with frequent and recurrent physical distress are at substantially increased risk for emotional distress disorders during young adulthood. Preventions and interventions for somatic complaints could help alleviate this risk.

Evaluation of dynamic weight bearing for measuring nonevoked inflammatory hyperalgesia in mice

BACKGROUND

Animal models in pain research have suggested that inclusion of both evoked and nonevoked behavioral measures is needed to better reflect the human pain experience. Individuals with chronic pain are known to experience spontaneous pain, in addition to pain after exposure to an external stimulus. Recently, the dynamic weight bearing (DWB) apparatus was developed to assess for nonevoked hyperalgesia by capturing weight bearing and surface distribution in the paws of mice after acute inflammation.

OBJECTIVES

The aim of this study was to evaluate the DWB test as a measure of nonevoked hyperalgesia.

METHODS

The experimental group received an intraplantar injection in the left hind paw of the inflammatory agent--complete Freund's adjuvant (CFA)--whereas the vehicle control group received a saline injection and the naive control group had no treatment. Calipers and a plethysmometer were used to verify inflammation and the hot-plate test was used as a measure for stimulus-evoked hyperalgesia. Data were collected at baseline; 3 hours; and 1, 3, and 7 days after injection.

RESULTS

Mice injected with CFA showed a statistically significant higher mean paw thickness and volume displacement compared with the vehicle and naive control groups. In the hot-plate testing, CFA-treated mice showed lower response temperature at 7 days compared with the other groups. On the DWB test, CFA-treated mice showed a reduction in the ipsilateral paw load and surface area compared with the contralateral paw load at Days 1, 3, and 7.

DISCUSSION

Mice with inflammation showed alterations in weight bearing as well as increased thermal hyperalgesia in comparison with control groups. These findings support the use of the DWB test as a tool for measuring nonevoked inflammatory hyperalgesia in a mouse model.

Depression, anxiety and stress among pregnant migraineurs in a pacific-northwest cohort

BACKGROUND

The co-occurrence of migraine and unipolar psychiatric disorders has been well documented in non-pregnant populations, however little is known in pregnant populations.

METHODS

A cohort of 1321 women was interviewed during the first trimester of pregnancy. At the time of interview lifetime migraine status was ascertained using International Classification of Headache Disorders diagnostic criteria (ICHD-II). Information regarding unipolar depression, anxiety and stress during pregnancy was collected using the Patient Health Questionnaire Depression Module-9 (PHQ-9), and the Depression Anxiety Stress Scales 21-item Short Form (DASS-21). Multivariable logistic regression procedures were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the association of migraine and mood disorders during pregnancy.

RESULTS

Approximately 28.2% (N=372) were classified as having a lifetime history of migraine; among migraineurs 122 were classified as migraineurs with aura and 250 as migraineurs without aura. Compared with non-migraineurs, migraineurs were associated with 1.60-fold increased odds of depression as measured by a PHQ-9 score ≥10 (AOR=1.60; 95% CI: 1.12-2.31). Overall, migraine with aura was more strongly associated with depression than was migraine without aura. Migraineurs, as compared with non-migraineurs, also had higher odds of mood disorders as measured by the DASS-21.

CONCLUSIONS

The comorbidity of mood and migraine disorders in pregnant populations supports the need for integrated mental and physical clinical evaluation, increased vigilance, and treatment of patients with such disorders.

Lifetime prevalence and correlates of migraine among women in a pacific northwest pregnancy cohort study

BACKGROUND

Migraine is a common neurological disorder, ranked among the world's leading causes of years lived with disability by the World Health Organization. The burden of migraine is highest in women of reproductive age.

METHODS

We characterized the prevalence, symptoms, and correlates of migraine and other headaches among 500 women enrolled in a pregnancy cohort study. Migraine diagnoses (eg, definitive migraine and probable migraine) were based on the International Classification of Headache Disorders-II criteria. Headache-related disability, before and during early pregnancy, was determined using the Migraine Disability Assessment questionnaire. Logistic regression models were used to estimate adjusted odds ratios and 95% confidence intervals.

RESULTS

The lifetime prevalence of definitive migraine was 20.0% (95% confidence interval 16.6-23.8%). When probable migraine was included, the lifetime prevalence of any migraine (definitive migraine plus probable migraine) increased to 29.8% (95% confidence interval 25.9-34.0%). An additional 16.6% (95% confidence interval 13.5-20.2%) of women in the cohort were classified as having non-migraine headaches. Over 26% of migraineurs experienced moderate or severe headache-related disability during early pregnancy. Migraine headaches were associated with a family history of headache or migraine (odds ratio = 3.47; 95% confidence interval 2.14-5.63), childhood car sickness (odds ratio = 8.02; 95% confidence interval 4.49-14.35), pre-pregnancy obesity status (odds ratio = 3.83; 95% confidence interval 1.77-8.26), and a high frequency of fatigue (odds ratio = 2.01; 95% confidence interval 1.09-3.70).

CONCLUSION

Migraine- and headache-related disability are prevalent conditions among pregnant women. Diagnosing and treating migraine and headaches during pregnancy are essential.

Agreement of self-reported physician diagnosis of migraine with international classification of headache disorders-II migraine diagnostic criteria in a cross-sectional study of pregnant women

BACKGROUND

Migraine, a common chronic-intermittent disorder among reproductive age women, has emerged as a novel risk factor for adverse perinatal outcomes. Diagnostic reliability of self-report of physician-diagnosed migraine has not been investigated in pregnancy cohort studies. We investigated agreement of self-report of physician-diagnosed migraine with the diagnostic criteria promoted by the International Classification of Headache Disorders, 2nd edition (ICHD-II).

METHODS

The cross-sectional study was conducted among 500 women who provided information on a detailed migraine questionnaire that allowed us to apply all ICHD-II diagnostic criteria.

RESULTS

Approximately 92% of women reporting a diagnosis of migraine had the diagnosis between the ages of 11 and 40 years (<10 years 6.8%; 11-20 years 38.8%; 21-30 years 42.7%; 31-40 years 10.7%; and >40 years 1.0%). We confirmed self-reported migraine in 81.6% of women when applying the ICHD-II criteria for definitive migraine (63.1%) and probable migraine (18.5%).

CONCLUSION

There is good agreement between self-reported migraine and ICHD-II-based migraine classification in this pregnancy cohort. We demonstrate the feasibility of using questionnaire-based migraine assessment according to full ICHD-II criteria in epidemiological studies of pregnant women.

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.

Comorbidity of migraine and psychiatric disorders among substance-dependent inpatients

BACKGROUND

Limited and conflicting data exist regarding the prevalence of psychiatric disorders, particularly substance use disorders (SUDs), among migraineurs in inpatient clinical settings.

METHODS

As part of a larger cross-sectional study, 181 substance-dependent inpatients completed a structured psychiatric interview and measures of psychiatric symptoms and migraine. Standardized mean differences were used to quantify differences between inpatients with and without migraine across 4 domains of predictors (demographic variables, non-SUD psychiatric diagnoses, specific SUDs, and self-reported psychiatric symptoms). The predictors within each domain that best discriminated between the migraine and no-migraine groups were identified using a classification tree approach with Bonferroni corrections. These candidate predictors were subsequently entered into a multivariate logistic regression to predict migraine status, which was then replicated using bootstrapping of 500 samples. Associations between migraine status and SUD treatment dropout were also examined.

RESULTS

Forty-four of the 181 (24.3%) participants met criteria for migraine. Migraineurs were more likely to be female (34.8% vs. 18.3%) and reported higher levels of current anxiety symptoms (mean [standard deviation]: 19.7 [11.0] vs. 11.3 [10.3]). Having a lifetime diagnosis of generalized anxiety disorder (56.8% vs. 27%, odds ratio 3.47, 95% confidence interval [CI] 1.39-10.58) or a current diagnosis of alcohol dependence (45.5% vs. 24.1%, odds ratio 3.79, 95% CI 1.63-13.62) was associated with more than a 3-fold risk of migraine. These 4 variables in combination were forced into the final multivariate model, which differentiated well between those with and without migraine (area under the receiver operating characteristic curve = 0.81; 95% CI 0.73-0.88). Migraine was not differentially associated with increased risk for SUD treatment dropout (13.6% vs. 16.1% dropout among those without migraine).

DISCUSSION

A history of generalized anxiety disorder, high levels of current anxiety symptoms, and current alcohol dependence are the strongest psychiatric predictors of migraine status among substance-dependent inpatients. However, migraine status is not associated with SUD treatment dropout.

The prevalence, impact, and treatment of migraine and severe headaches in the United States: a review of statistics from national surveillance studies

BACKGROUND

Four ongoing U.S. public health surveillance studies gather information relevant to the prevalence, impact, and treatment of headache and migraine: the National Health Interview Survey, the National Health and Nutrition Examination Survey, the National Ambulatory Care Survey, and the National Hospital Ambulatory Medical Care Survey. The American Migraine Prevalence and Prevention (AMPP) study is a privately funded study that provides comparative U.S. population-based estimates of the prevalence and burden of migraine and chronic migraine.

OBJECTIVE

To gather in one place and compare the most current available estimates of the U.S. adult prevalence of headache and migraine, and the number of affected people overall and in various subgroups, and to provide estimates of headache burden and treatment patterns by examining migraine and headache as a reason for ambulatory care and emergency department (ED) visits in the United States.

METHODS

We reviewed published analyses from available epidemiological studies identified through searches of PubMed and the National Center for Health Statistics. We aimed to identify information about migraine and headache burden, and treatment in national surveys conducted over the last decade. For each source, we selected the best available and most current estimate of migraine or headache prevalence, and selected associated measures of disability, health care use, and treatment patterns.

RESULTS

Compared with a slightly higher proportion of 22.7% in the National Health and Nutrition Examination Survey, 16.6% of adults 18 or older reported having migraine or other severe headaches in the last 3 months in the 2011 National Health Interview Survey. In contrast, the AMPP study found an overall prevalence of migraine of 11.7% and probable migraine of 4.5%, for a total of 16.2%. Data from National Ambulatory Medical Care Survey/National Hospital Ambulatory Medical Care Survey showed that head pain was the fifth leading cause of ED visits overall in the U.S. and accounted for 1.2% of outpatient visits. The burden of headache was highest in females 18-44, where the 3-month prevalence of migraine or severe headache was 26.1% and head pain was the third leading cause of ED visits. The prevalence and burden of headache was substantial even in the least affected subgroup of males 75 or older, where 4.6% reported experiencing severe headache or migraine in the previous 3 months. Triptans accounted for almost 80% of antimigraine analgesics prescribed at office visits in 2009, nearly half of which were for sumatriptan. Migraine is associated with increased risk for other physical and psychiatric comorbidities, and this risk increases with headache frequency.

CONCLUSION

This report provides the most current available estimates of the prevalence, impact, and treatment patterns of migraine or severe headache in the United States. Migraine and other severe headaches are a common and major public health problem, particularly among reproductive-aged women. Data about prevalence and disability from the major government-funded surveillance studies are generally consistent with results of studies such as the American Migraine Studies 1 and 2, and the AMPP study.

Personality traits in chronic daily headache patients with and without psychiatric comorbidity: an observational study in a tertiary care headache center

Background

Previous studies suggest that patients with Chronic Daily Headache (CDH) have higher levels of anxiety and depressive disorders than patients with episodic migraine or tension-type headache. However, no study has considered the presence of psychiatric comorbidity in the analysis of personality traits. The aim of this study is to investigate the prevalence of psychiatric comorbidity and specific personality traits in CDH patients, exploring if specific personality traits are associated to headache itself or to the psychiatric comorbidity associated with headache.

Methods

An observational, cross-sectional study. Ninety-four CDH patients with and without medication overuse were included in the study and assessed by clinical psychiatric interview and Mini International Neuropsychiatric Interview (M.I.N.I.) as diagnostic tools. Minnesota Multiphasic Personality Inventory-2 (MMPI-2), Hamilton Depression Rating Scale (HAM-D) were afterwards administered. Patients with and without psychiatric comorbidity were compared. Further analyses were made by splitting the whole group according to the headache diagnosis and the presence or not of medication overuse.

Results

Psychiatric comorbidity was detected in 44 patients (46.8%) (group A) and was absent in the remaining 50 patients (53.2%) (group B). Mood and anxiety disorders were the most frequently diagnosed (43.6%).

In the overall group, mean scores of MMPI-2 showed a high level in the so-called neurotic triad; in particular the mean score in the Hypochondriasis subscale was in the pathologic area (73.55 ± 13.59), while Depression and Hysteria scores were moderate but not severe (62.53 and 61.61, respectively). In content scales, score in Health Concern was also high (66.73).

Group A presented higher scores compared to Group B in the following MMPI-2 subscales: Hypochondriasis (p = .036), Depression (p = .032), Hysteria (p < .0001), Hypomania (p = .030). Group B had a high score only in the Hypochondriasis subscale. No significant differences were found between chronic migraine (CM)-probable CM (pCM) plus probable medication overuse headache (pMOH) and chronic tension-type headache (CTTH)-probable CTTH (pCTTH) plus pMOH patients or between patients with and without drug overuse.

Conclusions

The so-called “Neurotic Profile” reached clinical level only in CDH patients with psychiatric comorbidity while a high concern about their general health status was a common feature in all CDH patients.

Application of density estimation algorithms in analyzing co-morbidities of migraine

In this study, we will propose a density estimation based data analysis procedure to investigate the co-morbid associations between migraine and the suspected diseases. The primary objective of this study has aimed to develop a novel analysis procedure that can discover insightful knowledge from large medical databases. The entire analysis procedure consists of two stages. During the first stage, a kernel density estimation algorithm named relaxed variable kernel density estimation (RVKDE) is invoked to identify the samples of interest. Then, in the second stage, a density estimation algorithm based on generalized Gaussian components and named G²DE is invoked to provide a summarized description of the distribution. The results obtained by applying the proposed two-staged procedure to analyze co-morbidities of migraine revealed that the proposed procedure could effectively identify a number of clusters of samples with distinctive characteristics. The results further revealed that the distinctive characteristics of the clusters extracted by the proposed procedure were in conformity with the observations reported in recently published articles. Accordingly, it is conceivable that the proposed analysis procedure can be exploited to provide valuable clues of pathogenesis and facilitate development of proper treatment strategies.

Panic disorder and migraine: comorbidity, mechanisms, and clinical implications

A growing body of literature suggests that comorbid anxiety disorders are more common and more prognostically relevant among migraine sufferers than comorbid depression. Panic disorder (PD) appears to be more strongly associated with migraine than most other anxiety disorders. PD and migraine are both chronic diseases with episodic manifestations, involving significant functional impairment and shared symptoms during attacks, interictal anxiety concerning future attacks, and an absence of identifiable secondary pathology. A meta-analysis of high-quality epidemiologic study data from 1990 to 2012 indicates that the odds of PD are 3.76 times greater among individuals with migraine than those without. This association remains significant even after controlling for demographic variables and comorbid depression. Other less-rigorous community and clinical studies confirm these findings. The highest rates of PD are found among migraine with aura patients and those presenting to specialty clinics. Presence of PD is associated with greater negative impact of migraine, including more frequent attacks, increased disability, and risk for chronification and medication overuse. The mechanisms underlying this common comorbidity are poorly understood, but both pathophysiological (eg, serotonergic dysfunction, hormonal influences, dysregulation of the hypothalamic-pituitary-adrenal axis) and psychological (eg, interoceptive conditioning, fear of pain, anxiety sensitivity, avoidance behavior) factors are implicated. Means of assessing comorbid PD among treatment-seeking migraineurs are reviewed, including verbal screening for core PD symptoms, ruling out medical conditions with panic-like features, and administering validated self-report measures. Finally, evidence-based strategies for both pharmacologic and behavioral management are outlined. The first-line migraine prophylactics are not indicated for PD, and the selective serotonin re-uptake inhibitors used to treat PD are not efficacious for migraine; thus, separate agents are often required to address each condition. Core components of behavioral treatments for PD are reviewed, and their integration into clinical headache practice is discussed.

Body mass index and migraine: a survey of the Chinese adult population

The objective of this study is to evaluate the association between body mass index (BMI) and migraine in general population Chinese cohort. This was a cross-sectional secondary analysis from a general population Chinese cohort of men and women of reproductive and post-reproductive age ranging between 18 and 65 years. Migraine was defined utilizing ICHD criteria. Body mass indices were calculated using measured height and weight and categorized based on the World Health Organizations criteria. The 1-year period prevalence of migraine was 9.3 %. No association was identified between migraine and those with a BMI < 30.0. Compared to those with normal BMI (18.5-23.0), those with BMI ≥ 30 (morbid obesity) had a greater prevalence of migraine (8.6 vs. 13.8 %, p = 0.000). Multivariate-adjusted odds ratio demonstrated that those with morbid obesity had a greater than twofold increased odds of migraine [OR 2.10 (1.39-3.12)] as compared to those with a BMI between 18.5 and 23.0. No association was found between obesity and migraine severity, frequency, or disability. Morbid obesity was associated with twofold increased odds of migraine in this Chinese men and women cohort of predominantly reproductive age.

Pain and the relationship with mood and anxiety disorders and psychological symptoms

OBJECTIVE

The objective of this study was to investigate the association between pain and mood and anxiety disorders, as well as psychological symptoms, in a population-based sample of women.

METHODS

This study examined the data collected from 1067 women aged 20-93years (median 51years) participating in the Geelong Osteoporosis Study. Mood and anxiety disorders were diagnosed using a clinical interview (SCID-I/NP) and psychological symptomatology was assessed using the General Health Questionnaire. Pain was determined using a Visual Analogue Scale (0-100mm) and deemed present if score≥40mm.

RESULTS

Current mood disorders were associated with an increased likelihood of overall (OR=3.2, 95% CI 2.0-5.1), headache (OR=2.8, 95% CI 1.6-4.8), back (OR=4.0, 95% CI 2.5-6.5) and shoulder pain (OR=2.2, 95% CI 1.2-4.2). In those with current mood disorders, the pain interfered with daily activities (OR=3.2, 95% CI 1.9-5.5) and was present most of their time awake (OR=2.5, 95% CI 1.5-4.1). This pattern was similarly observed for those with past mood disorders. Current anxiety disorders were associated with an increased likelihood for overall (OR=2.2, 95% CI 1.4-3.6), headache (OR=2.2, 95% CI 1.3-4.0), back (OR=1.8, 95% CI 1.1-3.0) and shoulder pain (OR=1.9, 95% CI 1.0-3.5, p=.05). In those with current anxiety disorders, the pain interfered with daily activities (OR=2.4, 95% CI 1.4-4.1) and was present most of their time awake (OR=1.9, 95% CI 1.2-3.2). There was no association between pain and past anxiety. Psychological symptomatology was associated with pain at each site (all p<.001).

CONCLUSIONS

This study is consistent with studies utilising clinical samples in reporting that mood and anxiety disorders, as well as psychological symptoms, are associated with higher levels of perceived pain.

Chronic pain and depression in the quality of life of women with migraine--a controlled study

BACKGROUND

Migraine is comorbid to depression and widespread chronic pain (WCP), but the influence of these conditions on the health-related quality of life (HRQoL) of individuals with episodic (EM) and chronic migraine (CM) is poorly understood.

OBJECTIVE

To assess the prevalence of depressive symptoms and WCP in individuals with EM and CM, as well as to estimate the joint impact of these conditions on the HRQoL of these individuals.

METHODS

All women aged 18 to 65 years with a first diagnosis of EM or CM from September of 2006 to September of 2008 seen in an outpatient headache service were invited to participate. They were asked to attend a separate appointment in the service, and to bring another woman of similar age that also agreed to participate. Depressive symptoms were assessed using the Beck Depression Inventory. Questions about WCP followed the protocol of the American College of Rheumatology. HRQoL was assessed using the Short-Form 36 (SF-36). Multivariate analysis modeled HRQoL as a function of headache status, depressive symptoms, and pain, using quantile regression.

RESULTS

Sample consisted of 179 women, 53 in the EM group, 37 in the CM group and 89 in control group. Groups did not differ by demographics. Mean scores of SF-36 were 53.6 (standard deviation [SD] = 23.5) for EM, 44.2 (SD = 18.5) for CM and 61.8 (SD = 21.5) for controls. In multivariate analysis, SF-36 scores were predicted by a CM status (P = .02; -10.05 [95% CI -18.52; -1.58]) and by a Beck Depression Inventory score (P < .01; -1.27 [95% CI -1.55; -0.99]). The influence of WCP in the SF-36 scores approached significance (P = .08; -0.78 [95% CI -1.64; 0.88]). Age did not contribute to the model.

CONCLUSION

Women with migraine are at an increased chance of WCP, and the chance increases as a function of headache frequency. Both depressive symptoms and CM independently predict HRQoL status.

Consultation-liaison psychiatry for patients with headaches

Screening of headache patients for psychiatric disorders is needed, because of the well-known high rates of comorbidity with depression and anxiety. Screening for both depression and anxiety is highly advisable in order to identify subjects who need psychiatric consultation and therapy. Screening tools for depression and anxiety range from informal questions to self-report instruments to structured interviews and the choice is up to the clinician and the setting of the clinical evaluation. Data on psychiatric disorders and medication overuse are till now not consistent. The treatment of mood and anxiety disorders in headache patients needs to take into account the possible drug interactions with headache therapies. The collaboration between neurologists and consultation-liaison psychiatrists helps the identification of headache patients who need a psychiatric therapeutic program and follow-up.

Migraine and obesity: epidemiology, possible mechanisms and the potential role of weight loss treatment

Migraine and obesity are two public health problems of enormous scope that are responsible for significant quality of life impairment and financial cost. Recent research suggests that these disorders may be directly related with obesity exacerbating migraine in the form of greater headache frequency and severity, or possibly increasing the risk for having migraine. The relationship between migraine and obesity may be explained through a variety of physiological, psychological and behavioural mechanisms, many of which are affected by weight loss. Given that weight loss might be a viable approach for alleviating migraine in obese individuals, randomized controlled trials are needed to test the effect of weight loss interventions in obese migraineurs. Large-scale weight loss trials have shown that behavioural interventions, in particular, can produce sustained weight losses and related cardiovascular improvements in patients who are diverse in body weight, age and ethnicity. Consequently, these interventions may provide a useful treatment model for showing whether weight loss reduces headache frequency and severity in obese migraineurs, and offering further insight into pathways through which weight loss might exert an effect.