New management strategies for primary headache disorders: Insights from P4 medicine

Primary headache disorder is the main cause of headache attacks, leading to significant disability and impaired quality of life. This disorder is increasingly recognized as a heterogeneous condition with a complex network of genetic, environmental, and lifestyle factors. However, the timely diagnosis and effective treatment of these headaches remain challenging. Precision medicine is a potential strategy based on P4 (predictive, preventive, personalized, and participatory) medicine that may bring new insights for headache care. Recent machine learning advances and widely available molecular biology and imaging data have increased the usefulness of this medical strategy. Precision medicine emphasizes classifying headaches according to their risk factors, clinical presentation, and therapy responsiveness to provide individualized headache management. Furthermore, early preventive strategies, mainly utilizing predictive tools, are critical in reducing headache attacks and improving the quality of life of individuals with headaches. The current review comprehensively discusses the potential application value of P4 medicine in headache management.

Learning headache triggers through experience: A laboratory study

OBJECTIVE

To examine how individuals may learn headache trigger beliefs through sequential symbolic pairings of trigger candidates and headache attacks.

BACKGROUND

Learning from experience may be a major source of information about headache triggers. Little is known about learning-based influences on the establishment of trigger beliefs.

METHODS

This cross-sectional, observational study included N = 300 adults with headache who participated in a laboratory computer task. First, participants rated the chances (0%-100%) that encountering specific triggers would lead to experiencing a headache. Then, 30 sequential images with the presence or absence of a common headache trigger were presented alongside images representing the presence or absence of a headache attack. The primary outcome measure was the cumulative association strength rating (0 = no relationship to 10 = perfect relationship) between the trigger and headache using all previous trials.

RESULTS

A total of N = 296 individuals completed 30 trials for each of three triggers, yielding 26,640 total trials for analysis. The median [25th, 75th] association strength ratings for each of the randomly presented headache triggers were 2.2 [0, 3] for the Color Green, 2.7 [0, 5] for Nuts, and 3.9 [0, 8] for Weather Changes. There was a strong association between the "true" cumulative association strength and corresponding ratings. A 1-point increase on the phi scale (i.e., no relationship to perfect relationship) was associated with a 1.20 (95% CI: 0.81 to 1.49, p < 0.0001) point increase in association strength rating. A participant's prior belief about the potency of a trigger affected their perceived rating of the accumulating evidence, accounting for 17% of the total variation.

CONCLUSION

In this laboratory task, individuals appeared to learn trigger-headache associations through repeated exposures to accumulating symbolic evidence. Prior beliefs about the triggers appeared to influence ratings of the strength of relationships between triggers and headache attacks.

Migraine management: Non-pharmacological points for patients and health care professionals

Migraine is a highly prevalent disorder with an enormous burden on societies. Different types of medications are used for controlling both acute attacks and prevention. This article reviews some non-pharmacological recommendations aiming to manage migraine disorder better and prevent headache attacks. Different triggers of migraine headache attacks, including environmental factors, sleep pattern changes, diet, physical activity, stress and anxiety, some medications, and hormonal changes, are discussed. It is advised that they be identified and managed. Patients should learn the skills to cope with the trigger factors that are difficult to avoid. In addition, weight control, management of migraine comorbidities, lifestyle modification, behavioural treatment and biofeedback, patient education, using headache diaries, and improving patients' knowledge about the disease are recommended to be parts of migraine management. In addition, using neuromodulation techniques, dietary supplements such as riboflavin, coenzyme Q10 and magnesium, and acupuncture can be helpful. Non-pharmacological approaches should be considered in migraine management. Furthermore, the combination of pharmacological and non-pharmacological approaches is more effective than using each separately.

Migraine in physicians and final year medical students: A cross-sectional insight into prevalence, self-awareness, and knowledge from Pakistan

BACKGROUND

Despite its high prevalence, migraine remains underdiagnosed worldwide. A significant reason is the knowledge gap in physicians regarding diagnostic criteria, clinical features, and other clinical aspects of migraine.

AIM

To measure the knowledge deficit in physicians and medical students and to assess the prevalence of migraine in the same population.

METHODS

An online questionnaire was developed and distributed among physicians and final year medical students on duty in various medical and surgical specialties of Allied and DHQ Hospitals, Faisalabad, between October 2018 and October 2019. Inclusion criteria were public practicing physicians who experience headaches, while those who never experienced headaches were excluded. Different questions assessed respondents on their knowledge of triggers, diagnosis, management, and prophylaxis of the migraine headache. They were asked to diagnose themselves using embedded ICHD-3 diagnostic criteria for different types of migraine. Graphs, tables, and figures were made using Microsoft Office 2016 and Microsoft Visio, and data analysis was done in R Studio 1.4.

RESULTS

We had 213 respondents and 175 fulfilled inclusion criteria, with 99 (52%), 58 (30%) and 12 (6.3%) belonging to specialties of medicine, surgery, and others, respectively. Both genders were symmetrically represented (88 male and 87 female). Fifty-two (24.4%) of our 213 respondents were diagnosed with migraine, with 26 (50%) being aware of it. Females had higher prevalence among study participants (n = 28, 32.2%) compared to males (n = 20, 22.7%, P = 0.19). A majority (62%) of subjects never consulted any doctor for their headache. Similarly, a majority (62%) either never heard or did not remember the diagnostic criteria of migraine. Around 38% falsely believed that having any type of aura is essential for diagnosing migraine. The consultation rate was 37% (n = 65), and migraineurs were significantly more likely to have consulted a doctor, and a neurologist in particular (P < 0.001). Consulters and migraineurs fared better in the knowledge of diagnostic aspects of the disease than their counterparts. There was no significant difference in other knowledge aspects between consulters versus non-consulters and migraineurs versus non-migraineurs.

CONCLUSION

Critical knowledge gaps exist between physicians and medical students, potentially contributing to misdiagnosis and mismanagement of migraine.

Triggers of migraine: where do we stand?

PURPOSE OF REVIEW

In this review, we illustrate and discuss the recent findings regarding the epidemiology and pathophysiology of migraine triggers and their implications in clinical practice.

RECENT FINDINGS

Data from the literature suggest that individual triggers fail to provoke migraine attack in experimental settings. It is therefore possible that more triggers acting in combination are needed to induce an attack by promoting some degree of brain dysfunction and thus increasing the vulnerability to migraine. Caution is however needed, because some of the factors rated as triggers by the patients may actually be a component of the clinical picture of migraine attacks.

SUMMARY

Trigger factors of migraine are endogenous or exogenous elements associated with an increased likelihood of an attack in a short period of time and are reported by up to 75.9% of patients. Triggers must be differentiated from premonitory symptoms that precede the headache phase but do not have a causative role in attack provocation, being rather the very first manifestations of the attack. Identification of real triggers is an important step in the management of migraine. Vice versa, promoting an active avoiding behaviour toward factors whose role as triggers is not certain would be ineffective and even frustrating for patients.

Behavioral Management of Episodic Migraine: Maintaining a Healthy Consistent Lifestyle

PURPOSE OF REVIEW

To describe the most recent findings related to lifestyle behaviors and migraine.

RECENT FINDINGS

An individualized conceptualization of how lifestyle factors impact migraine activity has increased our understanding of the role of behavioral interventions for episodic migraine. Healthy diets of several types have been associated with migraine attack reduction, whereas disruptions in diet like skipping meals are associated with migraine attack onset. Both aerobic activity and lower intensity yoga interventions show promise for migraine prevention. Sleep disruption has been associated with migraine day and may have a bi-directional relationship. Both increases and decreases in stress have been associated with migraine activity. Evidence is converging around the principle that highly unusual disruptions in daily routine are particularly associated with migraine attack onset and that a consistent healthy lifestyle is a key feature of effective behavioral migraine prevention strategies.

A Bidirectional View of Migraine and Diet Relationship

Migraine is a common headache with a large negative impact on health. Several endogenous and exogenous factors can influence the severity and frequency of migraine, for example, lifestyle factors including dietary factors. Consequently, lifestyle modifications and dietary considerations have been reported beneficial to moderate clinical features of migraine. Much effort has been invested in determining the lifestyle factors (eg, stress, exercise, sleep, and diet) that trigger migraine to develop recommendations and guidelines for prevention. Diet has also been investigated with a major focus on the content of the diet and to a lesser extent on the amount, pattern, and quality of diet. Identification of dietary factors in migraine has led to nutritional interventions with a major focus on elimination of triggers, and weight control strategies. Several so-called migraine diets have consequently been proposed, for example, the ketogenic diet. Some theories have considered epigenetic diets or functional food to help in altering components of migraine pathogenesis; however, these theories are less investigated. In contrast, evidence is being accumulated to support that some mechanisms underlying migraine may alter dietary choices, for example type, amount, or patterns. Since a causative relationship is not yet established in migraine-diet relationship as to which comes first, this concept is equally valuable and interesting to investigate. Only limited epidemiological data are available to demonstrate that dietary choices are different among patients with migraine compared with individuals without migraine. Differences are reflected on quality, composition, pattern, and the amount of consumption of dietary components. This view emphasizes a potential bidirectional relationship between migraine and diet rather than a one-way influence of one on the other. This targeted review presents examples from current literature on the effects of diet on migraine features and effects of migraine on dietary choices to draw a perspective for future studies.

A Review on the Triggers of Pediatric Migraine with the Aim of Improving Headache Education

Although migraines are common in children and adolescents, they have a robustly negative impact on the quality of life of individuals and their families. The current treatment guidelines outline the behavioral and lifestyle interventions to correct common causative factors, such as negative emotional states, lack of exercise and sleep, and obesity; however, the evidence of their effectiveness is insufficient. To create a plan for disseminating optimal pediatric headache education, we reviewed the current evidence for factors correlated with migraine. We assessed three triggers or risk factors for migraines in children and adolescents: stress, sleep poverty, and alimentation (including diet and obesity). While there is a gradual uptick in research supporting the association between migraine, stress, and sleep, the evidence for diet-related migraines is very limited. Unless obvious dietary triggers are defined, clinicians should counsel patients to eat a balanced diet and avoid skipping meals rather than randomly limiting certain foods. We concluded that there is not enough evidence to establish a headache education plan regarding behavioral and lifestyle interventions. Clinicians should advise patients to avoid certain triggers, such as stress and sleep disorders, and make a few conservative dietary changes.

The Ambiguous Role of Caffeine in Migraine Headache: From Trigger to Treatment

Migraine is a chronic disorder, and caffeine has been linked with migraine for many years, on the one hand as a trigger, and on the other hand as a cure. As most of the population, including migraineurs, consume a considerable amount of caffeine daily, a question arises as to whether it influences their headaches. Indeed, drinking coffee before a migraine attack may not be a real headache trigger, but a consequence of premonitory symptoms, including yawning, diminished energy levels, and sleepiness that may herald a headache. Here, we aim to summarize the available evidence on the relationship between caffeine and migraines. Articles concerning this topic published up to June 2020 were retrieved by searching clinical databases, and all types of studies were included. We identified 21 studies investigating the prevalence of caffeine/caffeine withdrawal as a migraine trigger and 7 studies evaluating caffeine in acute migraine treatment. Among them, in 17 studies, caffeine/caffeine withdrawal was found to be a migraine trigger in a small percentage of participants (ranging from 2% to 30%), while all treatment studies found caffeine to be safe and effective in acute migraine treatment, mostly in combination with other analgesics. Overall, based on our review of the current literature, there is insufficient evidence to recommend caffeine cessation to all migraine patients, but it should be highlighted that caffeine overuse may lead to migraine chronification, and sudden caffeine withdrawal may trigger migraine attacks. Migraine sufferers should be aware of the amount of caffeine they consume and not exceed 200 mg daily. If they wish to continue drinking caffeinated beverages, they should keep their daily intake as consistent as possible to avoid withdrawal headache.

Triggers of Primary Headaches: Issues and Pathways Forward

The triggers of primary headaches have considerable significance for our understanding and management of headache and migraine. Triggers explain the variance in headaches - why they occur when they do. Trigger management is generally viewed as an important component of a comprehensive treatment approach for headaches. Historically, however, triggers have not had a prominent place in the headache literature. This situation began to change 20 to 30 years ago, and the pace of change has increased exponentially in recent times. Nevertheless, the field is beset with issues that have held it back from achieving more. This review will focus on elaborating those issues with the goal of suggesting ways forward. The first issue considered will be the definition of a trigger, and how specific triggers are labeled. Consideration will then be given to a classification system for triggers. The review will discuss next the evidence relating to whether self-reported triggers can, indeed, precipitate headaches, and how the capacity to elicit headaches may be acquired or extinguished. Attention will be given to the very important clinical issue of trigger management. Finally, the pathways forward will be proposed. Perhaps the most useful thing to accomplish at this point in time would be agreement on a definition of headache triggers, a list of triggers, and a classification system for triggers. This would greatly assist in comparing research on triggers from different research groups as well as eliminating some of the issues identified in this review. An authoritative body such as the American Headache Society or the International Headache Society, could establish a multidisciplinary committee that would complete these tasks. Consideration should also be given to incorporating triggers into the International Classification of Headache Disorders as an axis or via the use of codes, as this would raise the profile of triggers in assessment and management.

Fear, Avoidance, and Disability in Headache Disorders

PURPOSE OF REVIEW

The purpose of this review is to summarize the role of avoidance behavior in headache-related disability and overview relevant clinical implications.

RECENT FINDINGS

Avoidance occupies a central role in contemporary psychological perspectives on headache disorders and other chronic pain conditions. Several cognitive constructs of relevance to headache are influenced and maintained by avoidance behavior. A growing body of literature attests to the notion that avoidance of headache triggers, of stimuli that exacerbate headache, and of broader life domains can negatively affect headache progression, disability/quality of life, and comorbid psychiatric symptoms. Interventions targeting avoidance behavior, such as therapeutic exposure to headache triggers, mindfulness, and acceptance and commitment therapy (ACT), hold promise for headache disorders but need to be tested in larger trials. Researchers and clinicians are encouraged to attend to functional impairment as a critically important treatment outcome. Comprehensive understanding of headache disorders necessitates attention not merely to diagnostic symptoms and their reduction, but to patterns of avoidance behavior that inadvertently exacerbate headache and contribute to functional impairment.

To Eat or Not to Eat: A Review of the Relationship between Chocolate and Migraines

Migraine is a chronic disorder with episodic attacks, and patients with a migraine often report that certain factors can trigger their headache, with chocolate being the most popular type of food-based trigger. Many studies have suggested a link between chocolate and headaches; however, the underlying physiological mechanisms are unclear. As premonitory symptoms may herald migraine attacks, a question arises regarding whether eating chocolate before a headache is a consequence of a food craving or indeed a real trigger. Here, we aim to summarize the available evidence on the relationship between chocolate and migraines. All articles concerning this topic published up to January 2020 were retrieved by searching clinical databases, including EMBASE, MEDLINE, PubMed, and Google Scholar. All types of studies have been included. Here, we identify 25 studies investigating the prevalence of chocolate as a trigger factor in migraineurs. Three provocative studies have also evaluated if chocolate can trigger migraine attacks, comparing it to a placebo. Among them, in 23 studies, chocolate was found to be a migraine trigger in a small percentage of participants (ranging from 1.3 to 33), while all provocative studies have failed to find significant differences between migraine attacks induced by eating chocolate and a placebo. Overall, based on our review of the current literature, there is insufficient evidence that chocolate is a migraine trigger; thus, doctors should not make implicit recommendations to migraine patients to avoid it.

Mindfulness and Chronic Headache/Migraine: Mechanisms Explored Through the Fear-Avoidance Model of Chronic Pain

OBJECTIVES

To replicate a study by Schutze and colleagues on a headache sample, rather than a heterogenous chronic pain sample, investigating whether level of mindfulness predicts key components in the Fear-Avoidance Model of chronic pain (pain intensity, negative affect, pain catastrophizing, pain-related fear, pain hypervigilance, and functional disability); to investigate the relationships between level of mindfulness and headache/migraine pain intensity, frequency, and duration.

MATERIALS AND METHODS

Participants were 217 individuals who self-reported chronic headache/migraine (51 male, 166 female), aged between 18 and 65 years. Participants completed an online survey measuring demographics, mindfulness, the key components of the Fear-Avoidance Model, and headache pain intensity, duration, and frequency.

RESULTS

Mindfulness had significant negative correlations (P<0.05) with all variables except headache pain intensity and headache frequency. Mindfulness significantly predicted negative affect, pain catastrophizing, fear of pain, pain hypervigilance, and headache duration (P<0.05). Mindfulness remained a significant predictor of negative affect and pain hypervigilance after controlling for other key components and background characteristics (P<0.05). Mindfulness did not moderate the relationship between pain intensity and pain catastrophizing (P=0.204).

DISCUSSION

Findings suggest that mindfulness may be integrated into the Fear-Avoidance Model of chronic pain for individuals with chronic headache/migraine. Directions for future research are discussed.

Psychological therapies for the prevention of migraine in adults

BACKGROUND

Migraine is a common neurological problem associated with the highest burden amongst neurological conditions in terms of years lived with disability. Medications can be used as prophylaxis or rescue medicines, but are costly and not always effective. A range of psychological interventions have been developed to manage migraine.

OBJECTIVES

The objective was to evaluate the efficacy and adverse events of psychological therapies for the prevention of migraine in adults.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsycINFO and CINAHL from their inception until July 2018, and trials registries in the UK, USA, Australia and New Zealand for randomised controlled trials of any psychological intervention for adults with migraine.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of a psychological therapy for people with chronic or episodic migraine, with or without aura. Interventions could be compared to another active treatment (psychological or medical), an attention-placebo (e.g. supportive counselling) or other placebo, routine care, or waiting-list control. We excluded studies where fewer than 15 participants completed each arm.

DATA COLLECTION AND ANALYSIS

We extracted study characteristics and outcome data at post-treatment and the longest available follow-up. We analysed intervention versus control comparisons for the primary outcome of migraine frequency. We measured migraine frequency using days with migraines or number of migraine attacks measured in the four weeks after treatment. In addition, we analysed the following secondary outcomes: responder rate (the proportion of participants with a 50% reduction in migraine frequency between the four weeks prior to and the four weeks after treatment); migraine intensity; migraine duration; migraine medication usage; mood; quality of life; migraine-related disability; and proportion of participants reporting adverse events during the treatment. We included these variables, where available, at follow-up, the timing of which varied between the studies. We used the GRADE approach to judge the quality of the evidence.

MAIN RESULTS

We found 21 RCTs including 2482 participants with migraine, and we extracted meta-analytic data from 14 of these studies. The majority of studies recruited participants through advertisements, included participants with migraine according to the International Classification of Headache Disorders (ICHD) criteria and those with and without aura. Most intervention arms were a form of behavioural or cognitive-behavioural therapy. The majority of comparator arms were no treatment, routine care or waiting list. Interventions varied from one 20-minute session to 14 hours of intervention. No study had unequivocally low risk of bias; all had at least one domain at high risk of bias, and 20 had two to five domains at high risk. Reporting of randomisation procedures and allocation concealment were at high or unclear risk of bias. We downgraded the quality of evidence for outcomes to very low, due to very serious limitations in study quality and imprecision. Reporting in trials was poor; we found no preregistrations stipulating the outcomes, or demonstrating equivalent expectations between groups. Few studies reported our outcomes of interest, most only reported outcomes post treatment; follow-up data were sparse.Post-treatment effectsWe found no evidence of an effect of psychological interventions for migraine frequency in number of migraines or days with migraine (standardised mean difference (SMD) -0.02, 95% confidence interval (CI) -0.17 to 0.13; 4 studies, 681 participants; very low-quality evidence).The responder rate (proportion of participants with migraine frequency reduction of more than 50%) was greater for those who received a psychological intervention compared to control: 101/186 participants (54%) with psychological therapy; 37/152 participants (24%) with control (risk ratio (RR) 2.21, 95% CI 1.63 to 2.98; 4 studies, 338 participants; very low-quality evidence). We found no effect of psychological therapies on migraine intensity (SMD -0.13, 95% CI -0.28 to 0.02; 4 studies, 685 participants). There were no data for migraine duration (hours of migraine per day). There was no effect on migraine medication usage (SMD -0.06, 95% CI -0.35 to 0.24; 2 studies, 483 participants), mood (mean difference (MD) 0.08, 95% CI -0.33 to 0.49; 4 studies, 432 participants), quality of life (SMD -0.02, 95% CI -0.30 to 0.26; 4 studies, 565 participants), or migraine-related disability (SMD -0.67, 95% CI -1.34 to 0.00; 6 studies, 952 participants). The proportion of participants reporting adverse events did not differ between those receiving psychological treatment (9/107; 8%) and control (30/101; 30%) (RR 0.16, 95% CI 0.00 to 7.85; 2 studies, 208 participants). Only two studies reported adverse events and so we were unable to draw any conclusions.We rated evidence from all studies as very low quality.Follow-upOnly four studies reported any follow-up data. Follow-ups ranged from four months following intervention to 11 months following intervention. There was no evidence of an effect on any outcomes at follow-up (very low-quality evidence).

AUTHORS' CONCLUSIONS

This review identified 21 studies of psychological interventions for the management of migraine. We did not find evidence that psychological interventions affected migraine frequency, a result based on four studies of primarily brief treatments. Those who received psychological interventions were twice as likely to be classified as responders in the short term, but this was based on very low-quality evidence and there was no evidence of an effect of psychological intervention compared to control at follow-up. There was no evidence of an effect of psychological interventions on medication usage, mood, migraine-related disability or quality of life. There was no evidence of an effect of psychological interventions on migraine frequency in the short-term or long-term. In terms of adverse events, we were unable to draw conclusions as there was insufficient evidence. High and unclear risk of bias in study design and reporting, small numbers of participants, performance and detection bias meant that we rated all evidence as very low quality. Therefore, we conclude that there is an absence of high-quality evidence to determine whether psychological interventions are effective in managing migraine in adults and we are uncertain whether there is any difference between psychological therapies and controls.

Headache Triggers as Surprise

OBJECTIVES

To examine the hypothesis that surprising experiences of headache triggers are associated with daily headache activity.

BACKGROUND

Little is known about the specific environmental or behavioral interactions that might trigger a headache attack in a prone individual. We propose that headache trigger exposures can be usefully characterized, not only by their mechanisms of action, but also on the degree of "surprise" they present to the individual. This hypothesis is based on elements of information theory: that unusual events and experiences carry more information than common events and experiences and that headache attacks are associated with reactions to uncommon or unexpected biopsychosocial exposures.

METHODS

A secondary analysis of the Headache Prediction Study, this prospective cohort study followed N = 95 individuals with episodic migraine who contributed 4195 days of diary data. Information was collected on daily levels of several common headache triggers: number of caffeinated beverages, number of alcoholic beverages, stress (Daily Stress Inventory), and mood disturbance (Profile of Mood States). The probability of observing variations in each trigger was used to estimate the "surprisal" of experiencing each trigger, and this information, measured in bits, was used to predict headache attacks.

RESULTS

Participants experienced a headache attack on 1613 of 4195 days (38.5%). Each of the triggers was modestly related to the probability of experiencing a future headache in a complex manner that involved interactions between current headache status, current levels of the trigger, and lagged (previous) levels of the trigger. However, when expressed as a surprisal, the associations were simplified and strengthened. For example, each of the individual trigger surprisals exhibited a meaningful association with the development of a future headache attack (expressed as a 1 SD change in surprisal), with odds ratios ranging from a low of 1.11 (95%CI: 1.00 to 1.24) for alcohol to a high of 1.30 (95%CI: 1.14 to 1.46) for stress. The individual surprisals could be summed for total trigger surprise and exhibited a reliable association with new onset headache, OR 1.35 (95%CI: 1.17 to 1.49). This score exhibited superior discrimination between headache and non-headache days from all of the individual triggers (ignoring base rate, AUC: 0.61; AUC: 0.71 with base rate).

CONCLUSIONS

Diverse headache triggers can be uniformly described using their probability distributions. Rare values of headache triggers, or surprising values, were found to have consistent associations with headache activity across a variety of triggers. This finding, if validated in external data using other triggers, has potential to be used to conceptualize the influence of a wide range of headache triggers.

Relating Photophobia, Visual Aura, and Visual Triggers of Headache and Migraine

OBJECTIVE

This study investigated a potential association between visual factors and symptoms related to migraine. It was predicted that photophobia and visual aura would be positively associated with interictal light sensitivity and visual headache triggers (flicker, glare, and eyestrain), and that these 2 visual symptoms would also be associated.

BACKGROUND

Previous studies have found independent neurophysiological associations between several visual factors and symptoms related to headache disorders. Many of these connections appear to be associated with increased cortical hypersensitivity, a phenomenon that might be in part due to repeated avoidance and reduced tolerance to triggers. If true, and if associations between visual factors and symptoms can be established, this may have implications for an exposure-based treatment for migraine symptoms.

METHODS

Four hundred and ninety-one participants (411 female, 80 male) were recruited through Griffith University (AUS), Headache Australia, Pain Australia, and through social media. Participants were grouped based on the presence of headache disorder symptoms and the presence or absence of photophobia and/or visual aura. A cross-sectional online survey design was utilized to gather information pertaining to interictal light sensitivity, visual triggers, and visual symptoms.

RESULTS

With respect to interictal light sensitivity and photophobia, a significant difference (P < .001, eta squared [η² ] = 0.084) was found between the 3 groups, where headache disorder participants with photophobia (group A1; mean [M] = 2.5, standard deviation [SD] = 0.97) reported significantly greater light sensitivity than participants with headache disorder and no photophobia (A2; M = 1.68, SD = 0.62) and control group participants (A3; M = 1.82, SD = 0.85). This pattern was repeated for participants reporting flicker as a headache trigger (P < .001, η² = 0.061), with group A1 (M = 2.45, SD = 1.24) significantly higher than groups A2 (M = 1.68, SD = 0.83) and A3 (M = 1.68, SD = 0.89), and was also seen for glare as a headache trigger (P < .001, η² = 0.092), with group A1 (M = 2.92, SD = 0.96) significantly higher than A2 (M = 2.31, SD = 0.89) and A3 (M = 2.09, SD = 0.93). This pattern of results was not replicated for headache disorder participants with and without visual aura. A significant association (P < .001) was found between photophobia and visual aura in headache disorder participants based on a chi-square test of independence, with 86/136 participants reporting either both or neither visual symptom.

CONCLUSIONS

This study supports a link between certain visual phenomena in headache disorder populations, and supports future research into exposure-based treatments for migraine symptoms.

The Role of Negative Affect on Headache-Related Disability Following Traumatic Physical Injury

OBJECTIVE

Acute postinjury negative affect (NA) may contribute to headache pain following physical injury. Early psychiatric-headache comorbidity conveys increased vulnerability to chronic headache-related disability and impairment. Yet, it is unknown whether NA is involved in the transition to chronic headache related-disability after injury. This prospective observational study examined the role of acute postinjury NA on subacute and chronic headache-related disability above and beyond nonpsychiatric factors.

METHODS

Eighty adult survivors of single-incident traumatic physical injury were assessed for negative affect (NA): a composite of depression and anxiety symptoms, and symptoms of posttraumatic stress disorder (PTSS) during the acute 2-week postinjury phase. NA was examined as the primary predictor of subacute (6-week) and chronic (3-month) headache-related disability; secondary analyses examined whether the individual NA components differentially impacted the outcomes.

RESULTS

Hierarchical linear regression confirmed NA as a unique predictor of subacute (Cohen's f ²  = 0.130; P = .005) and chronic headache related-disability (Cohen's f ²  = 0.160; P = .004) beyond demographic and injury-related factors (sex, prior headaches, and closed head injury). Upon further analysis, PTSS uniquely predicted greater subacute (Cohen's f ²  = 0.105; P = .012) and chronic headache-related disability (Cohen's f ²  = 0.103; P = .022) above and beyond demographic and injury-related factors, depression, and anxiety. Avoidance was a robust predictor of subacute headache impairment (explaining 15% of the variance) and hyperarousal was a robust predictor of chronic headache impairment (10% of the variance).

CONCLUSION

Although NA consistently predicted headache-related disability, PTSS alone was a unique predictor above and beyond nonpsychiatric factors, depression, and anxiety. These results are suggestive that early treatment of acute postinjury PTSS may correlate with reductions in disability and negative physical health sequelae associated with PTSS and chronic headache.

Influences on headache trigger beliefs and perceptions

Background Previous headache trigger studies have primarily utilized checklists to measure beliefs about triggers. While this work has defined the diversity of beliefs across headache sufferers, the strength of association and the frequency at which these triggers are encountered remain unexplored. Objective To measure the strength of association, frequency of encounter, and influences on trigger beliefs and perceptions using a laboratory assessment task. Methods This cross-sectional observational study, part of the HACOGS project, included adult current migraine, tension-type, or cluster headache sufferers. Participants rated the chances they would experience a headache if they were to encounter a specific trigger and the number of days per month they experience that trigger for 33 common triggers. Results All 300 participants contributed data on all triggers, with little missing data (1.2%). All triggers exhibited a high degree of inter-individual variability on the strength of association and encounter perceptions. Many triggers were perceived to be encountered daily (e.g., caffeine, air conditioning), and a full range of perceptions were observed for each trigger. Stress (75% chance of headache), missing a meal (60%), and dehydration (60%) were the triggers with the greatest potency beliefs. Only 8-15% of these beliefs were related to individual differences and 26-27% to the triggers themselves. Conclusions Participants expressed diverse beliefs and perceptions about the strength of many common headache triggers. Variation in these beliefs was not associated with individual differences or the triggers themselves. This finding supports the importance of measuring more than just the presence-absence of trigger beliefs.

Association of posttraumatic stress disorder symptoms with migraine and headache after a natural disaster

OBJECTIVE

Previous research shows that migraine and general headache symptoms increase after traumatic events. Questions remain about whether posttraumatic stress disorder (PTSD) produces migraine/headache symptoms, or if individuals afflicted by migraine/headache are especially likely to develop PTSD. We test whether PTSD symptoms following a natural disaster are associated with higher odds of reporting frequent headaches/migraines postdisaster. We decompose PTSD into intrusion, avoidance, and hyperarousal symptom clusters to examine which, if any, are uniquely related to headache/migraine postdisaster.

METHOD

We use prospectively collected pre- and postdisaster data to explore whether overall PTSD symptoms and symptom clusters are associated with migraine/headache in a sample of Hurricane Katrina survivors. We account for severity of hurricane exposure and control for baseline migraine and headache problems to reduce the probability that heightened PTSD susceptibility among those who already suffered from the conditions could explain observed associations.

RESULTS

PTSD symptoms were associated with higher odds of experiencing frequent headaches or migraines with a standard deviation change in PTSD score corresponding to over twice the odds (95% confidence interval [1.64, 2.68]) of having trouble with frequent headaches or migraines in the post-Katrina period. Each additional point on the intrusion subscale (sample M [SD] = 1.6 [1.1]) was associated with 55% higher odds of reporting frequent headache/migraine (95% confidence interval [1.03, 2.33]), but we found no association with avoidance or hyperarousal symptoms.

CONCLUSIONS

Clinicians and disaster planners should be aware that disaster survivors might be at heightened risk of migraine/headache episodes, and those experiencing intrusive reminders may be most affected. (PsycINFO Database Record

American pediatric surgical association journal of pediatric surgery lecture

Every year in the United States, 1.6 to 3.8 million concussions occur secondary to injuries sustained during sports and recreational activities. Major advances have been made in terms of identifying specific clinical profiles following concussion. Nevertheless, there are continued misunderstandings regarding this injury and variable clinical management strategies being employed that may result in protracted recovery periods for youth athletes. Therefore, it is essential that individualized treatment plans target the particular clinical profile(s) present following concussion. Further progress related to management of this injury depends on medical professionals working as part of multidisciplinary teams to provide appropriate education, accurate information, and treatments based on the identified clinical profiles. It is also important for medical professionals of all disciplines to stay vigilant toward future research and practice guidelines given the evolving nature of this injury.

The Headache Triggers Sensitivity and Avoidance Questionnaire: Establishing the Psychometric Properties of the Questionnaire

OBJECTIVE

The purpose of this study was to evaluate the psychometric properties of the newly developed Headache Triggers Sensitivity and Avoidance Questionnaire (HTSAQ) designed to measure variables relating to the Trigger Avoidance Model of Headaches.

BACKGROUND

The Trigger Avoidance Model of Headaches proposes that one pathway to developing a primary headache disorder is through the avoidance of headache triggers, resulting in an increase in trigger potency through sensitization. Conversely, prolonged exposure to certain triggers may reduce a potential trigger's ability to precipitate a headache. This model has led to an alternative approach to trigger management being proposed called Learning to Cope with Triggers, which advocates the desensitization of certain headache triggers through controlled exposure, while supporting avoidance of those triggers that are detrimental to health and wellbeing. To be able to evaluate predictions based on the Trigger Avoidance Model of Headaches and to investigate the effectiveness of Learning to Cope with Triggers, psychometrically sound measures of trigger sensitivity and trigger avoidance are needed.

METHOD

A convenience sample of 376 participants (87.5% female; 64.1% European descent) was recruited for the online study which consisted of a battery of measures including the HTSAQ, Brief Headache Screen, Pain Anxiety Symptoms Scale, Pain Sensitivity Questionnaire, Chronic Pain Acceptance Questionnaire, and demographic items. With an interval of 2-6 weeks, a subsample of participants (n = 201) completed the HTSAQ for a second time. The mean age of the sample was 31.4 years (SD = 12.8). The most common headache diagnoses (based on the Brief Headache Screen) were migraine (chronic = 62; episodic = 160), followed by medication-overuse headache (n = 87). The remaining participants (n = 67) were diagnosed as having episodic less severe headache (most likely tension-type headache).

RESULTS

Reliability was assessed through internal consistency and test-retest reliability over a period of 2-6 weeks, and both were excellent (alpha > .80). Strong construct validity was demonstrated by the measure's scale scores being significantly correlated in theoretically consistent ways with the Pain Sensitivity Questionnaire, Pain Anxiety Symptoms Scale, and Chronic Pain Acceptance Questionnaire. As the Trigger Avoidance Model of Headaches would predict, correlations between the HTSAQ Sensitivity scales and the Avoidance scale were strong (P < .001), and participants with chronic migraine had significantly higher HTSAQ scores than those with episodic headaches.

CONCLUSION

The findings support the use of the HTSAQ as a valid and reliable tool for assessing sensitivity to headache triggers and avoidance of headache triggers. Further research examining the factor structure of the HTSAQ is warranted.

Behavioural Management of Headache Triggers: Three Case Examples Illustrating a New Effective Approach (Learning to Cope with Triggers)

The traditional approach to headache trigger management is to advise avoidance of all triggers, but we have advocated an alternative approach called ‘Learning to Cope with Triggers’ (LCT), in which the objective is to desensitise headache sufferers to some triggers or to build up tolerance for the triggers, using exposure techniques. A recent publication established the efficacy of this approach to trigger management. Reported here are three cases to illustrate how LCT is used in practice. Two cases were male and one was female, with ages ranging from 32 to 67 years. The headache diagnoses were frequent episodic tension-type headache, migraine without aura, and chronic tension-type headache; all had had headaches since childhood/adolescence. The headache triggers that were the focus of the intervention were heat, tiredness, and stress/anger. Post-treatment, changes in the capacity of the triggers to elicit headaches were reported in all three cases. Reductions in headaches from pre- to post-treatment, and from pre- to 4-month follow-up, were: case 1, 69% and 60% respectively; case 2, 76% and 80% respectively; and case 3, 73% and 61% respectively. Decreases in medication consumption, and enhanced self-efficacy were also recorded.

Enhancing cognitive-behavioural therapy for recurrent headache: design of a randomised controlled trial

Background

We have argued against the traditional approach of counselling avoidance of all triggers of headaches and migraine. Problems with this approach include the impossibility of avoiding all triggers and the high costs associated with trying to do so, and that avoidance could lead to reduced tolerance for the triggers. We have developed an alternative approach called Learning to Cope with Triggers (LCT) that encourages avoidance of triggers that are detrimental to health and wellbeing, but uses exposure to other triggers to desensitise headache sufferers to the triggers. This approach has been shown to be more effective than advising avoidance of all triggers. Trigger management is only one component of a comprehensive treatment program and the current study is designed to evaluate a new approach to treating headaches in which LCT has been integrated into an established cognitive-behavioural therapy (CBT) package (LCT/CBT).

Methods/Design

A target sample of 120 adult participants who suffer from migraine or tension-type headache, at least six days per month, and have done so for at least 12 months will be recruited. Participants will be randomly assigned to one of three groups: LCT/CBT; Avoid/CBT (CBT combined with instructions to avoid all triggers); and waiting-list control. Measures will include: daily diaries for recording headaches, triggers and medication consumption; headache disability and quality of life; trigger avoidance; locus of control and self-efficacy; and coping strategies. Treatment will involve 12 60-minute sessions scheduled weekly. Assessment will be completed before and after treatment, and at 4 and 12 month follow-up. The data will be analysed to determine which approach is most effective, and predictors of response to treatment.

Discussion

Migraine and tension-type headache are common and can be disabling. CBT has been demonstrated to be an efficacious treatment for both disorders. However, there is room for improvement. This study aims to increase the efficacy of behavioural approaches and identify factors predictive of a positive response.

Trial registration

Australian and New Zealand Clinical Trials Registry ACTRN12614000435684.

Religiousness and headache: is there a relation? Results from a representative sample of adults living in a low-income community

BACKGROUND

The use of religious behaviors to alleviate the consequences of stressful life circumstances is a frequent strategy employed by pain sufferers. Specifically in the field of headache research, to date, few studies have assessed spiritual and religious beliefs.

OBJECTIVE

The objective of this article is to investigate the relation between religiousness (organizational, non-organizational and intrinsic) and headache disorders in a representative sample of adults living in a low-income community.

METHODS

This was a cross-sectional, population-based study. In 2005, we conducted door-to-door interviews with 439 people, aged more than 18 years, randomly selected from a low-income community in Brazil. Four regression models were created to explain the relationships between religious involvement and headache, controlling for demographics, depression/anxiety and alcohol use and smoking.

RESULTS

Of the 439 households contacted, at least one member from 383 (87.2%) households participated. We interviewed more women (74.4%) and more subjects aged 18-39 years. The mean age was 41.7 (SD 8.5) years. Bivariate analysis shows that high religious attendance, non-organizational religiousness and intrinsic religiousness were associated with presence of headache and presence of migraine. After the logistic regression models, only high non-organizational religiousness remained associated with presence of headache (odds ratio (OR): 1.22 (1.01-1.49)). All other religious variables were unrelated to the presence of headache and its types.

CONCLUSION

There is a modest relationship between high non-organizational religiousness and presence of headache. Headache sufferers may use coping strategies such as private religious behaviors to try to overcome suffering.

Migraine and triggers: post hoc ergo propter hoc?

The influence of environmental factors on the clinical manifestation of migraine has been a matter of extensive debate over the past decades. Migraineurs commonly report foods, alcohol, meteorologic or atmospheric changes, exposure to light, sounds, or odors, as factors that trigger or aggravate their migraine attacks. In the same way, physicians frequently follow this belief in their recommendations in how migraineurs may reduce their attack frequency, especially with regard to the consumption of certain food components. Interestingly, despite being such a common belief, most of the clinical studies have shown conflicting results. The aim of the review is to critically analyze clinical and pathophysiological facts that support or refute a correlation between certain environmental stimuli and the occurrence of migraine attacks. Given the substantial discrepancy between patients' reports and objective clinical data, the methodological difficulties of investigating the link between environmental factors and migraine are highlighted.

Causality and headache triggers

OBJECTIVE

The objective of this study was to explore the conditions necessary to assign causal status to headache triggers.

BACKGROUND

The term "headache trigger" is commonly used to label any stimulus that is assumed to cause headaches. However, the assumptions required for determining if a given stimulus in fact has a causal-type relationship in eliciting headaches have not been explicated.

METHODS

A synthesis and application of Rubin's Causal Model is applied to the context of headache causes. From this application, the conditions necessary to infer that 1 event (trigger) causes another (headache) are outlined using basic assumptions and examples from relevant literature.

RESULTS

Although many conditions must be satisfied for a causal attribution, 3 basic assumptions are identified for determining causality in headache triggers: (1) constancy of the sufferer, (2) constancy of the trigger effect, and (3) constancy of the trigger presentation. A valid evaluation of a potential trigger's effect can only be undertaken once these 3 basic assumptions are satisfied during formal or informal studies of headache triggers.

CONCLUSIONS

Evaluating these assumptions is extremely difficult or infeasible in clinical practice, and satisfying them during natural experimentation is unlikely. Researchers, practitioners, and headache sufferers are encouraged to avoid natural experimentation to determine the causal effects of headache triggers. Instead, formal experimental designs or retrospective diary studies using advanced statistical modeling techniques provide the best approaches to satisfy the required assumptions and inform causal statements about headache triggers.

Travelling along a road with obstacles: experiences of managing life to feel well while living with migraine

Living a life with migraine can impair one's sense of feeling well, and migraine is a disorder that is associated with substantial disability. Earlier research on how people manage their migraine has given important insight into these people's preventive actions and how they handle their attacks, but there is still a lack of knowledge of how persons with migraine manage their lives to feel well from a more holistic viewpoint. Therefore, the aim of this study was to explore lived experiences of managing life to feel well while living with migraine. Nineteen persons with migraine were interviewed. A hermeneutic-phenomenological approach was used to explore their lived experiences. The findings reveal that persons with migraine not only used preventive strategies to abort and ease the consequences of migraine but also tried to amplify the good in life through increasing their energy and joy and through reaching peace with being afflicted with migraine. The findings of this study can encourage healthcare providers, as well as persons with migraine, to consider channeling their efforts into strategies aiming to amplify the good in life, including reaching peace of mind despite being afflicted.

"It's a balance between letting it influence life completely and not letting it influence life at all"--a qualitative study of migraine prevention from patients' perspective

PURPOSE

The aim of this study was to elucidate migraine prevention from a patient perspective.

METHOD

Twenty-one participants who suffered from migraine were interviewed and the data analysed by means of qualitative content analysis.

RESULTS

The analysis revealed two categories; Avoiding migraine triggers and introducing migraine inhibiting strategies. In both categories, decisions were influenced by an appraisal of the advantages versus disadvantages, attitudes, support and knowledge. An overarching theme: "migraine prevention from the patients' perspective is a balance between letting it influence life completely and not letting it influence life at all" was identified from the interviews.

CONCLUSIONS

As migraine is a chronic disorder that cannot be cured, merely relieved, prevention is of great importance. The present study highlights migraine prevention from the patients' perspective and the important issue of how much prevention is allowed to influence life. Either of the directions involves a risk that life can be controlled by migraine. Acceptance of the disease and allowing migraine prevention to influence life to some degree can be a way of regaining control.

IMPLICATIONS FOR REHABILITATION

• Migraine prevention from the patients' perspective is described as a balance between letting it influence life completely and not letting it influence life at all, which in either direction can lead to a life controlled by migraine. • To take the patients' perspectives of the illness in consideration as well as finding the most suitable treatment, based on an appraisal of individual advantages versus disadvantages is important to meet the need of the patient and to improve migraine prevention. Increased knowledge about migraine prevention is imperative both in health care and for the individual patient. Support during prevention is requested by patients.

Scuba diving is not associated with high prevalence of headache: a cross-sectional study in men

OBJECTIVE

To study the prevalence of cephalalgia in male divers.

BACKGROUND

Scuba divers work in stressing environments and have a high cerebrovascular risk, both conditions which are supposed to contribute to the genesis of cephalalgia. However, no study assessed expressly the prevalence of cephalalgia in divers, to date.

METHODS

We enrolled 201 professional male scuba divers (41.0 ± 7.2 years) and controls (41.1 ± 7.2 years), and the risk ratio and its corresponding 95% confidence of suffering from cephalalgia was calculated.

RESULTS

We found that 16% of divers and 22% of matched controls were affected by cephalalgia (P > .05), accounting for a risk ratio of 0.71 (95% CI 0.47-1.07). Divers reported fewer attacks per month (1.8 ± 0.7, n = 32) with regard to controls (2.5 ± 1.8, n = 45) (P = .02), but no differences concerning age at onset and severity were detected (P > .05). Divers suffered from migraine, migraine with aura and tension headache as much as controls.

CONCLUSION

Scuba diving, an intense physical activity characterized by cerebral micro-vascular distress, is not associated with cephalalgia, as a whole, or migraine, tension headache or migraine with aura, more commonly than in a matched, non-diving, population. A longitudinal study may disclose if diving may act as a protective factor in the occurrence of crises of cephalalgia.

Team players against headache: multidisciplinary treatment of primary headaches and medication overuse headache

Multidisciplinary approaches are gaining acceptance in headache treatment. However, there is a lack of scientific data about the efficacy of various strategies and their combinations offered by physiotherapists, physicians, psychologists and headache nurses. Therefore, an international platform for more intense collaboration between these professions and between headache centers is needed. Our aims were to establish closer collaboration and an interchange of knowledge between headache care providers and different disciplines. A scientific session focusing on multidisciplinary headache management was organised at The European Headache and Migraine Trust International Congress (EHMTIC) 2010 in Nice. A summary of the contributions and the discussion is presented. It was concluded that effective multidisciplinary headache treatment can reduce headache frequency and burden of disease, as well as the risk for medication overuse headache. The significant value of physiotherapy, education in headache schools, and implementation of strategies of cognitive behavioural therapy was highlighted and the way paved for future studies and international collaboration.

Behavioral management of migraine headache triggers: learning to cope with triggers

The literature on migraine triggers is reviewed, including the most common triggers, interactions between triggers, the research evidence related to the capacity of self-reported triggers to precipitate headaches, and the neurobiologic pathways by which triggers induce migraine attacks. An argument is developed against the standard advice to avoid migraine triggers as the best way of preventing attacks, based on conceptual and practical criticisms, and consideration of cognate literatures on chronic pain, stress, and anxiety. A small number of studies suggest that exposure to headache triggers has the same effect as exposure to anxiety-eliciting stimuli, with short exposure associated with increased pain response and prolonged exposure associated with decreased pain response. On the basis of this literature, "learning to cope with triggers" is advocated, where controlled exposure and approach/confront strategies are used to manage migraine triggers, except in cases where such an approach would probably be inappropriate.