Psychological aspects of weekend headache sufferers in comparison with migraine patients

Patterns of Perceived Stress Throughout the Migraine Cycle: A Longitudinal Cohort Study Using Daily Prospective Diary Data

OBJECTIVES

To describe patterns of perceived stress across stages of the migraine cycle, within and between individuals and migraine episodes as defined for this study.

METHODS

Individuals with migraine aged ≥18 years, who were registered to use the digital health platform N1-Headache^TM , and completed 90 days of daily data entry regarding migraine, headache symptoms, and lifestyle factors were eligible for inclusion. Perceived stress was rated once a day at the participant's chosen time with a single question, "How stressed have you felt today?" with response options graded on a 0-10 scale. Days were categorized into phases of the migraine cycle: P_pre  = pre-migraine headache (the 2 days prior to the first day with migraine headache), P₀  = migraine headache days, P_post  = post-migraine headache (the 2 days following the last migraine day with migraine headache), and P_i  = interictal days (all other days). Episodes, defined as discrete occurrences of migraine with days in all 4 phases, were eligible if there was at least 1 reported daily perceived stress value in each phase. Individuals with ≥5 valid episodes, and ≥75% compliance (tracking 90 days in 120 calendar days or less) were eligible for inclusion in the analysis.

RESULTS

Data from 351 participants and 2115 episodes were included in this analysis. Eighty-six percent of the sample (302/351) were female. The mean number of migraine days per month was 6.1 (range 2-13, standard deviation = 2.3) and the mean number of episodes was 6.0 (range 5-10, standard deviation = 1.0) over the 90-day period. Only 8 (8/351, 2.3%) participants had chronic migraine (defined as 15 or more headache days per month with at least 8 days meeting criteria for migraine). Cluster analysis revealed 3 common patterns of perceived stress variation across the migraine cycle. For cluster 1, the "let down" pattern, perceived stress in the interictal phase (P_i ) falls in the pre-headache phase (P_pre ) and then decreases more in the migraine phase (P₀ ) relative to P_i . For cluster 2, the "flat" pattern, perceived stress is relatively unchanging throughout the migraine cycle. For cluster 3, the "stress as a trigger/symptom" pattern, perceived stress in P_pre increases relative to P_i , and increases further in P₀ relative to P_i . Episodes were distributed across clusters as follows: cluster 1: 354/2115, 16.7%; cluster 2: 1253/2115, 59.2%, and cluster 3: 508/2115, 24.0%. Twelve participants (12/351, 3.4%) had more than 50% of their episodes fall into cluster 1, 216 participants (216/351, 61.5%) had more than 50% of their episodes fall into cluster 2, and 25 participants (25/351, 7.1%) had more than 50% of their episodes fall into cluster 3. There were 40 participants with ≥90% of their episodes in cluster 2, with no participants having ≥90% of their episodes in cluster 1 or 3.

CONCLUSIONS

On an aggregate level, perceived stress peaks during the pain phase of the migraine cycle. However, on an individual and episode basis, there are 3 dominant patterns of perceived stress variation across the migraine cycle. Elucidating how patterns of perceived stress vary across the migraine cycle may contribute insights into disease biology, triggers and protective factors, and provide a framework for targeting individualized treatment plans.

Relief Following Chronic Stress Augments Spreading Depolarization Susceptibility in Familial Hemiplegic Migraine Mice

Cortical spreading depolarization (CSD) is the electrophysiological substrate of migraine aura, and a putative trigger of trigeminovascular activation and migraine headache. Many migraineurs report stress or relief after a stress triggers an attack. We tested whether various stress conditions might modulate CSD susceptibility and whether this is dependent on genetic factors. Male and female wild type and familial hemiplegic migraine type1 (FHM1) knock-in mice heterozygous for the S218L missense mutation were subjected to acute or chronic stress, or chronic stress followed by relief (36 h). Acute stress was induced by restraint and exposure to bright light and white noise (3 h). Chronic stress was induced for 28 days by two cycles of repeated exposure of mice to a rat (7 days), physical restraint (3 days), and forced swimming (3 days). Electrical CSD threshold and KCl-induced (300 mM) CSD frequency were determined in occipital cortex in vivo at the end of each protocol. Relief after chronic stress reduced the electrical CSD threshold and increased the frequency of KCl-induced CSDs in FHM1 mutants only. Acute or chronic stress without relief did not affect CSD susceptibility in either strain. Stress status did not affect CSD propagation speed, duration or amplitude. In summary, relief after chronic stress, but not acute or chronic stress alone, augments CSD in genetically susceptible mice. Therefore, enhanced CSD susceptibility may explain why, in certain patients, migraine attacks typically occur during a period of stress relief such as weekends or holidays.

Frequency of Perceived Poststress Symptoms in Inpatients, Outpatients and Healthy Controls: The Role of Perceived Exhaustion and Stress

BACKGROUND

Poststress symptoms occur as a consequence of stress, most commonly during leisure periods such as weekends and vacations. However, the prevalence and the pathological mechanisms of poststress symptoms are poorly understood.

METHODS

Here, we compared the frequency of poststress symptoms in healthy controls (n = 984), outpatients (n = 420), and inpatients (n = 101). In outpatients, demographic factors, psychosocial stress, and perceived exhaustion were tested as predictors of poststress symptoms with multivariate regression analysis. Poststress symptoms and perceived exhaustion were assessed using 2 Neuropattern Questionnaires (the NPQ - Patient Questionnaire and the NPQ - Symptom List), and psychosocial stress was evaluated using the Patient Health Questionnaire (PHQ).

RESULTS

Poststress symptoms appeared in 2.9% of healthy controls, 20.0% of outpatients, and 34.7% of inpatients. Predictors were educational level, psychosocial stress, and perceived exhaustion. Poststress symptoms differed primarily between exhausted (75.0%) and nonexhausted patients (25.0%).

CONCLUSION

Poststress symptoms are rather common in clinical populations, and they are primarily associated with the degree of perceived exhaustion. Preliminary evidence suggests that poststress symptoms are possibly related to depletion of norepinephrine stores, which may facilitate a stratified preventive and therapeutic treatment of these subjects.

Influence of Therapeutic Approach in the TENS-induced Hypoalgesia

INTRODUCTION

The present study aimed to determine how the therapist's approach about intervention may influence transcutaneous electrical nerve stimulation (TENS)-induced hypoalgesia.

METHODS

One hundred and sixty-one pain-free individuals agreed to participate in this study and had their demographics, perceived pain intensity, pressure pain threshold, anxiety level, and the state of anxiety inventory score measured. Subsequently, participants were randomly assigned into 6 study groups, 3 active and 3 placebo TENS associated with positive, negative, or neutral approaches about electrical stimulation, as given by the investigator. After the treatment, all parameters were reassessed.

RESULTS

Active TENS-treated participants receiving either positive or neutral expectations about intervention showed a significant increase in pressure pain threshold (P<0.02) compared with pretreatment; however, this was not observed in the active TENS group when associated with negative expectations. The intensity of perceived pain was significantly reduced (P<0.02) only in the active TENS groups in association with either positive or neutral expectations. There was no significant difference in any of the variables assessed in the groups receiving placebo TENS intervention.

DISCUSSION

The negative expectations induced prior to the proposed intervention promoted unfavorable outcomes with respect to the analgesic properties of TENS, suggesting that the approach taken by the physical therapist should be used to convey positive expectations and avoid those negatives, to promote more efficacious treatment.

Reduction in perceived stress as a migraine trigger: testing the "let-down headache" hypothesis

OBJECTIVE

To test whether level of perceived stress and reductions in levels of perceived stress (i.e., "let-down") are associated with the onset of migraine attacks in persons with migraine.

METHODS

Patients with migraine from a tertiary headache center were invited to participate in a 3-month electronic diary study. Participants entered data daily regarding migraine attack experience, subjective stress ratings, and other data. Stress was assessed using 2 measures: the Perceived Stress Scale and the Self-Reported Stress Scale. Logit-normal, random-effects models were used to estimate the odds ratio for migraine occurrence as a function of level of stress over several time frames.

RESULTS

Of 22 enrolled participants, 17 (median age 43.8 years) completed >30 days of diaries, yielding 2,011 diary entries including 110 eligible migraine attacks (median 5 attacks per person). Level of stress was not generally associated with migraine occurrence. However, decline in stress from one evening diary to the next was associated with increased migraine onset over the subsequent 6, 12, and 18 hours, with odds ratios ranging from 1.5 to 1.9 (all p values < 0.05) for the Perceived Stress Scale. Decline in stress was associated with migraine onset after controlling for level of stress for all time points. Findings were similar using the Self-Reported Stress Scale.

CONCLUSIONS

Reduction in stress from one day to the next is associated with migraine onset the next day. Decline in stress may be a marker for an impending migraine attack and may create opportunities for preemptive pharmacologic or behavioral interventions.

Symptomatic or prophylactic treatment of weekend migraine: an open-label, nonrandomized, comparison study of frovatriptan versus naproxen sodium versus no therapy

BACKGROUND

Migraine often occurs during weekends. The efficacy of frovatriptan, naproxen sodium, or no therapy for the acute or prophylactic treatment of weekend migraineurs was tested in an open-label, nonrandomized pilot study.

METHODS

Twenty-eight subjects (mean age 36 ± 12 years, including 18 females) suffering from migraine without aura were followed up for six consecutive weekends. No treatment was administered during the first two weekends. On the third and fourth weekends, patients were given frovatriptan 2.5 mg and on the fifth and sixth weekends naproxen sodium 500 mg. Treatment was taken on Saturday and Sunday morning, regardless of the occurrence of migraine. Efficacy was evaluated through a diary, where patients reported the severity of migraine on a scale from 0 (no migraine) to 10 (severe migraine) and use of rescue medication.

RESULTS

The migraine severity score was significantly lower with frovatriptan (4.8 [95% confidence interval (CI) 3.8-5.9]) than with naproxen sodium (5.7 [CI 5.1-6.4], P< 0.05 versus frovatriptan) or no therapy (6.6 [6.2-7.0], P< 0.01 versus frovatriptan). The difference in favor of frovatriptan was more striking in patients not taking rescue medication (frovatriptan, 1.9 [1.5-2.3]) versus naproxen sodium 3.6 [3.0-4.2], P< 0.001) and versus no therapy (5.1 [4.4-5.8], P< 0.001) and on the second day of treatment. The rate of use of rescue medication was significantly (P< 0.05) lower on frovatriptan (12.5%) than on naproxen sodium (31.3%) or no therapy (56.3%).

CONCLUSION

This pilot study provides the first evidence of the efficacy of a second-generation triptan as symptomatic or prophylactic treatment for weekend migraine.

Triggers of migraine and tension-type headache

Identification of trigger factors or precipitants is frequently recommended as a basic strategy in the treatment of migraine and tension-type headache (TTH). Trigger factors increase the probability of headache in the short term. Potential trigger factors have been examined most frequently in migraine and less often in TTH. Many of these factors are related to migraine as well as to TTH, but their prevalence may differ in the two headache types. In this chapter, we will review the findings of retrospective as well as of prospective and controlled studies. Taken together, virtually all aspects of life have been suspected to trigger migraine or TTH, but scientific evidence for many of these triggers is poor. Menstruation has a prominent unfavorable role in migraine and possibly in TTH. There is at least some evidence that environmental factors such as weather, lights, noise and odors, stress and other psychological factors, sleeping problems, fatigue and tiredness may play a role. In addition, intake of alcohol, caffeine withdrawal, skipping meals, and possibly dehydration may trigger migraine and TTH in some patients. Scientific evidence is lacking that any other food or food additive plays a relevant role as a trigger factor of headaches.

Weekend migraine

It is a general belief that migraine attacks are prone to occur on days off. Only a few studies, however, have addressed this issue. The objective of this study was to investigate the periodicity of migraine with respect to weekly (circaseptan) variations. Eighty-nine females of fertile age who had participated in a previous questionnaire-based study volunteered to record in detail every migraine attack for 12 consecutive months. Eighty-four patients completed recordings for a mean of 311 days (s.d. = 95.9, range 30-365). A total of 2314 attacks were recorded. Migraine occurrence was almost equally distributed during the week, except on Sundays, when there were significantly fewer attacks (t = -4.42, d.f. = 83, P < 0.001). A Mantel-Haenszel estimate of the relative risk of having an attack on a holiday vs. another day, not Sundays included, was 0.64 (95% CI 0.49-0.85). Our study suggests that days off protect against migraine.

The biochemical and neuroendocrine bases of the hyperalgesic nocebo effect

Despite the increasing research on placebos in recent times, little is known about the nocebo effect, a phenomenon that is opposite to the placebo effect and whereby expectations of symptom worsening play a crucial role. By studying experimental ischemic arm pain in healthy volunteers and by using a neuropharmacological approach, we found that verbally induced nocebo hyperalgesia was associated to hyperactivity of the hypothalamic-pituitary-adrenal (HPA) axis, as assessed by means of adrenocorticotropic hormone and cortisol plasma concentrations. Both nocebo hyperalgesia and HPA hyperactivity were antagonized by the benzodiazepine diazepam, suggesting that anxiety played a major role in these effects. The administration of the mixed cholecystokinin (CCK) type-A/B receptor antagonist proglumide blocked nocebo hyperalgesia completely but had no effect on HPA hyperactivity, which suggests a specific involvement of CCK in the hyperalgesic but not in the anxiety component of the nocebo effect. Importantly, both diazepam and proglumide did not show analgesic properties on basal pain, because they acted only on the nocebo-induced pain increase. These data indicate a close relationship between anxiety and nocebo hyperalgesia, in which the CCKergic systems play a key role in anxiety-induced hyperalgesia. These results, together with previous findings showing that placebo analgesia is mediated by endogenous opioids, suggest that the analgesic placebo/hyperalgesic nocebo phenomenon may involve the opposite activation of endogenous opioidergic and CCKergic systems.

[Non-alimentary trigger factors of migraine and tension-type headache]

Based on an overview of the literature, this contribution critically discusses the importance of non-alimentary trigger factors of migraine and tension-type headache. Menstruation, environmental factors, psychological effects as well as sleep disorders and fatigue are mentioned most frequently. According to controlled studies, menstruation is indubitably associated with an increased risk of headache. Although a correlation between specific meteorological parameters and the appearance of headaches was established in some patients, the subjective observations of the patients did not however correlate with the objective weather data. Sensory stimuli function as triggers particularly for migraine with aura. Psychological factors, especially stress and everyday pressures, have been confirmed as trigger factors, but further prospective trials addressing this issue would be advantageous. Additional studies are also needed to elucidate the significance of sleep (disorders) and fatigue since their importance as triggers or symptoms of a headache attack has not been conclusively determined.

Day of the week of intensive care admission and patient outcomes: a multisite regional evaluation

BACKGROUND

Relationships between day of the week of admission to hospitals and hospital outcomes have been poorly studied. Intensive care units (ICUs) appear to be uniquely suited to examine such a question given the unpredictability of ICU admissions and the clinical instability of their patient populations.

METHODS

This retrospective cohort study included 156,136 patients admitted to 38 ICUs in 28 hospitals in a large Midwestern metropolitan area during 1991 to 1997. Demographic and clinical data were collected from patients' medical records and used in multivariable risk-adjustment models that examined the risk for in-hospital death and ICU length of stay.

RESULTS

The adjusted odds of in-hospital death were 9% higher (OR 1.09; 95% CI, 1.04-1.15; P <0.001) for weekend admissions (Saturday or Sunday) than in patients admitted midweek (Tuesday through Thursday). However, the adjusted odds of death were also higher (P <0.001) for patients admitted on Monday (OR 1.09) or Friday (OR 1.08). Findings were generally similar in analyses stratified by admission type (medical vs. surgical), hospital teaching status, and illness severity. Adjusted ICU length of stay was 4% longer (P <0.001) for weekend or Friday admissions, compared with midweek admissions.

CONCLUSIONS

Patients admitted to an ICU on the weekend have a modestly higher risk for death and ICU length of stay. However, the similar risk for death in patients admitted on Friday and Monday suggests that "weekend effects" may be more related to unmeasured severity of illness and/or selection bias than to differences in quality of care.

Gender differences in treatment-seeking chronic headache sufferers

OBJECTIVE

To identify gender differences within a group of patients seeking treatment for chronic headache. Previous studies of the general population have reported differences in headache symptoms, frequency, disability, and psychological distress, with women affected with more severe and disabling symptoms than men. This study evaluated these features in a population seeking treatment.

METHODS

Two hundred fifty-eight consecutive patients with headache attending a university headache clinic were evaluated with questionnaires about headache symptoms and psychological distress. Comparisons between men and women were made for headache symptoms, severity, frequency, trigger factors, comorbid depression and anxiety, and response to treatment.

RESULTS

There were no gender differences in headache symptoms, frequency, severity, and duration. Headache triggers were gender-specific, with men more likely to endorse exercise and women more likely to endorse stress and exposure to odors. Psychological comorbidity was similar among men and women seeking treatment, with a mean Beck Depression Inventory score of 10 and a mean Spielberger trait anxiety score of 39 for both men and women. Disability was greater in men, with 46% reporting restrictions in activities more than 3 days per week because of headache compared with 29% of women. In addition, men were more likely to contribute headache control to external figures than women.

CONCLUSIONS

Patients seeking treatment for chronic headache do not have the same gender-specific differences that have been reported in general population surveys. Men who seek treatment for headache are more likely to have significant disability, and are equally likely to have symptoms of depression and anxiety as women who seek treatment. Clinical and research investigations of headache triggers need to be gender-specific.

Weekend attacks in migraine patients: caused by caffeine withdrawal?

The principal reasons for a predominantly weekend incidence of migraine attacks are likely to be social or psychological in origin. There may be another factor. This study examines the use, and more importantly the way of use, of caffeine containing substances. We collected data by questionnaire from 151 consecutive Migraine Clinic patients with the diagnosis of migraine or tension type headache. Of the whole group, 21.9% claimed to have weekend attacks, with relatively more males than females. The males amongst these were all migraine patients, but 23% of the women suffered from tension-type headache. Patients with both a high daily caffeine intake and excessively delayed wakening at weekends (each defined as greater than the mean for the whole group) had a 69% risk of weekend headache. This compared with 4% in patients exceeding the mean in one only, and zero in those with moderate habits in both. These results support the idea that weekend attacks are linked to caffeine withdrawal. Sleeping in is not on its own a significant cause. We suggest that this possibility should be considered in clinical management of affected patients.

Psychiatric aspects of headache

Psychological factors, such as psychological stressors, personality style, conditioning, and psychodynamic issues, play a role in the etiology of chronic migraine and muscle contraction headaches. Psychiatric disorders, such as depression, anxiety, personality disorders, conversion, and hypochondriasis, may accompany and complicate headache. Psychiatric diagnosis and treatment add a useful and important dimension to the medical care of the patient. This article presented a useful conceptual model for discriminating between different kinds of psychological influencing factors and guidelines for selecting the appropriate form of psychiatric treatment.