Psychiatric comorbidity of migraine

Clinic-Based Characterization of Adolescents and Young Adults With Migraine: Psychological Functioning, Headache Days, and Disability

Background and Objectives

This cross-sectional observational study retrospectively examined clinical data collected from adolescents and young adults (AYAs) seeking care in a specialty headache clinic. We characterized participants' headache characteristics and psychological functioning and examined the association between self-reported anxiety and depressive symptoms and headache frequency, severity, and disability.

Methods

During their clinic visit, AYAs (M age = 18.36; range = 14-32, 79.5% female) completed an intake questionnaire and reported about their headache characteristics (i.e., frequency, severity, and duration of symptoms in months), mental health history (i.e., previous diagnosis of an anxiety or depressive disorder), and utilization of emergency department (ED) services for migraine. AYAs also completed psychometrically validated screening tools for anxiety and depressive symptoms (i.e., the GAD-7 and PHQ-9). We computed descriptive statistics and examined associations among scores on psychological measures and headache characteristics, including migraine-related disability. We also tested whether individuals with clinically elevated GAD-7 and PHQ-9 scores had higher levels of disability relative to those with fewer/subclinical levels of anxiety and depressive symptoms.

Results

Participants (N = 283) reported more than 19 headache days per month on average, with more than 90% describing their average headache intensity as moderate or severe. Nearly half of AYAs reported severe headache-related disability. Approximately one-quarter of AYAs reported a previous diagnosis anxiety or depressive disorder diagnosis, and more than one-third scored above clinical cutoffs on the PHQ-9 and GAD-7. Higher scores on both psychological screening instruments were associated with greater headache frequency. More than 10% of patients endorsed current suicidal ideation; this was not related to headache-related disability. Participants reported a high degree of ED utilization for headache; these rates were unrelated to endorsement of psychological comorbidities.

Discussion

In this sample of AYAs, headache characteristics were generally unrelated to scores on measures on psychological functioning. However, the observed rates of clinically elevated anxiety/depressive symptoms and suicidality in this sample of AYAs underscore the importance of screening for psychological comorbidities in neurology clinics that serve this age group, irrespective of self-reported disability. Results also emphasize the need to expand access to behavioral health services for AYAs with headache disorders and the importance of incorporating a biopsychosocial perspective to the transition of health care from pediatrics to adult neurology practice.

The effect of greater occipital nerve block on amplification of somatic symptoms and anxiety and depression levels in chronic migraine

OBJECTIVES

It is known that chronic migraine (CM) is often accompanied by anxiety, depression, and psychosomatic complaints. We designed this study with the assumption that greater occipital nerve (GON) block treatment could potentially improve not only pain symptoms but also psychosomatic complaints. This study aimed to evaluate the changes in the visual analog scale (VAS), somatosensory amplification scale (SSAS), beck depression ınventory (BDI), and beck anxiety ınventory (BAI) with GON block treatment in patients with CM.

METHODS

This study was conducted retrospectively on 164 patients with CM between December 2018 and January 2023. Patients underwent six sessions of GON block treatment at weeks 0, 1, 2, 3, 5, and 7. VAS, SSAS, BAI, and BDI scores; number of attacks per month (NAM); attack pain duration (APD); and monthly use of analgesics (UA) were compared before the start and at week 8 of GON block treatment.

RESULTS

The mean age of the subjects was 38 ± 9 years. Statistical analysis revealed that VAS, SSAS, BAI, and BDI scores; NAM; APD; and monthly UA were statistically significantly lower following GON block treatment than before GON block treatment (p < 0.001 each).

CONCLUSION

GON block treatment was effective for pain and somatic complaints (amplification of physical symptoms), anxiety, and depressive symptoms accompanying CM in patients with CM.

The effect of selenium supplementation on oxidative stress, clinical symptoms and mental health status in patients with migraine: a study protocol for a double-blinded randomized clinical trial

BACKGROUND

Despite a number of recommended strategies, effective treatment of migraine remains elusive. Given the role of oxidative stress in the pathogenesis of migraine, selenium, as an antioxidant nutrient, may have a beneficial effect on migraine outcomes. However, no study has explored the effects of selenium supplementation on migraine symptoms, oxidative stress biomarkers, and mental health. Therefore, this randomized, double-blinded, placebo-controlled clinical trial aims to examine the effects of selenium supplementation among migraine patients.

METHODS

Seventy-two migraine patients will receive either 200 µg/day selenium supplement (n = 36) or placebo (n = 36) for 12 weeks in a randomized, double-blinded, placebo-controlled study. The severity, frequency, and duration of headaches, mental health indices including depression, anxiety, and distress, and quality of life, as well as biomarkers of oxidative stress such as nitric oxide (NO), malondialdehyde (MDA), total antioxidant capacity (TAC), and total oxidant status (TOS), will be measured at the baseline and end of the study. The intention-to-treat (ITT) approach will be used to estimate missing values. One-way analysis of covariance (ANCOVA) will be performed to detect the effect of selenium supplementation on outcome variables.

DISCUSSION

Oxidative stress is recognized as a key contributor to migraine pathogenesis. Selenium is an essential trace element with antioxidant properties, capable of crossing the blood-brain barrier (BBB), holding promise to alleviate the oxidative stress and neurotoxicity. Thus, selenium may beneficially affect clinical symptoms and oxidative stress as well as the quality of life in migraine patients.

TRIAL REGISTRATION

This trial was registered in the Iranian Registry of Clinical Trials ( https://www.irct.ir/ ) on 27 May 2023 with the code number IRCT20121216011763N60.

Adverse Childhood Experiences and Primary Headache Disorders: A Systematic Review, Meta-analysis, and Application of a Biological Theory

BACKGROUND AND OBJECTIVES

Headache disorders are among the leading causes of disability worldwide. While an association between adverse childhood experiences and primary headaches has been reported, the pooled magnitude across studies and pathways of the association are unknown. Our objectives were (1) to estimate the pooled effect of ≥1 adverse childhood experience (ACE) on primary headache disorders in adulthood and (2) to test the hypothesis that ACEs categorized as "threat" traumas or "deprivation" traumas have distinct effects on primary headaches based on a selected theory from our narrative review of how ACEs affect human development along the life course.

METHODS

PubMed, EMBASE, MEDLINE, Web of Science, Google Scholar, Biological Psychiatry, and gray literature were searched up to March 16, 2023 (PROSPERO, CRD42020223403). Selected articles included (1) observational studies with a comparator group, (2) ACEs that occurred before 18 years of age, and (3) primary headaches occurring at or after 21 years of age. Pooled odds ratios (ORs) were calculated using multilevel linear random-effects modeling. The narrative review included theories that describe how ACEs affect human development and disease across the life course. We selected a theory from our narrative review and tested ACEs categorized according to this theory for any modification of point estimates.

RESULTS

Our search identified 32 studies, of which 28 were eligible for meta-analysis (n = 154,739 participants, 19 countries). The occurrence of ≥1 adverse childhood experience(s) was associated with primary headaches (pooled OR = 1.48 [95% CI 1.36-1.61]; high-quality evidence, 134,696 participants). As the number of ACEs increased, the odds of primary headaches increased (range: 1 ACE OR = 1.24 [95% CI 1.14-1.35] to ≥4 ACEs OR = 2.09 [95% CI 1.83-2.38], p for trend <0.0001). From the narrative review, a neurodevelopmental theory that categorizes ACEs into threat or deprivation was tested, and both were independently associated with primary headaches (threat OR = 1.46 [95% CI 1.32-1.60] and deprivation OR = 1.35 [95% CI 1.23-1.49], respectively), accounting for heterogeneity (p = 0.021).

DISCUSSION

This systematic review and meta-analysis confirm that ACEs are important risk factors of primary headache disorders in adulthood. Our findings provide epidemiologic support that ACEs categorized as threat and deprivation may manifest as distinct pathways of early adversity.

Anxiety and depression and health-related quality of life among adults with migraine: a National Population-Based Study

Background

Adults who suffer from migraines are highly susceptible to mental illnesses that may have significant association with their HRQoL. Therefore, this study aimed to investigate how anxiety and depression related to HRQoL in adults with Migraine.

Methods

Data from the Medical Expenditure Panel Survey for 2017 to 2020 were used to identify adult patients 18 years of age and older with a migraine diagnosis. The Physical and Mental Component Summary (PCS & MCS) scores from the SF-12 were used to calculate HRQoL. To adjust for a wide range of variables, multivariate linear regressions were used to evaluate the association between depression and anxiety and HRQoL among adults with migraine.

Results

Among the 1,713 identified adults with migraines, 11.2% experienced depression, 14.6% experienced anxiety, and 13.7% had both conditions. Compared to migraineurs who had only migraine, adults with comorbid depression and anxiety had the lowest mean scores on the PCS and MCS. Additionally, migraineurs who had depression had significantly lower HRQoL MCS scores (depression: β = -7.552, p < 0.001), and those with anxiety had significantly lower HRQoL MCS scores (anxiety: β = -4.844, p < 0.001) compared to those without these comorbidities. Notably, individuals with migraines who exercise had higher scores on both PCS and MCS than those who did not exercise.

Conclusion

This nationally representative sample provides insights into the associations between depression and anxiety with poor HRQoL among individuals with migraines. Additionally, it revealed the negative impact of concurrent chronic diseases, and poor socioeconomic status on HRQoL, while emphasizing the beneficial effects of regular exercise. This study highlights the clinical, policy, and public health implications for improving healthcare planning, resource allocation, and promoting lifestyle changes to reduce depression and anxiety in migraine sufferers.

Investigating the relationship between sleep and migraine in a global sample: a Bayesian cross-sectional approach

BACKGROUND

There is a bidirectional link between sleep and migraine, however causality is difficult to determine. This study aimed to investigate this relationship using data collected from a smartphone application.

METHODS

Self-reported data from 11,166 global users (aged 18-81 years, mean: 41.21, standard deviation: 11.49) were collected from the Migraine Buddy application (Healint Pte. Ltd.). Measures included: start and end times of sleep and migraine attacks, and pain intensity. Bayesian regression models were used to predict occurrence of a migraine attack the next day based on users' deviations from average sleep, number of sleep interruptions, and hours slept the night before in those reporting ≥ 8 and < 25 migraine attacks on average per month. Conversely, we modelled whether attack occurrence and pain intensity predicted hours slept that night.

RESULTS

There were 724 users (129 males, 412 females, 183 unknown, mean age = 41.88 years, SD = 11.63), with a mean monthly attack frequency of 9.94. More sleep interruptions (95% Highest Density Interval (95%HDI [0.11 - 0.21]) and deviation from a user's mean sleep (95%HDI [0.04 - 0.08]) were significant predictors of a next day attack. Total hours slept was not a significant predictor (95%HDI [-0.04 - 0.04]). Pain intensity, but not attack occurrence was a positive predictor of hours slept.

CONCLUSIONS

Sleep fragmentation and deviation from typical sleep are the main drivers of the relationship between sleep and migraine. Having a migraine attack does not predict sleep duration, yet the pain associated with it does. This study highlights sleep as crucial in migraine management.

Sex and stress hormone dysregulation as clinical manifestations of hypothalamic function in migraine disorder: A meta-analysis

Migraine is a leading cause of disability in young adults. It occurs more frequently in females, often comorbidly with stress disorders, suggesting an association with hypothalamic sex and stress hormonal function and a likely interaction with autonomic nervous system activation. Thus, this study aimed to meta-analyse current literature pertaining to female and male sex hormones (estrogen, progesterone and testosterone concentration), hypothalamic-pituitary-adrenal axis (HPA axis) cortisol responses and heart rate variability (HRV) in migraineurs and controls aged 13-65 years. A systematic search of MEDLINE, Embase, PsycINFO, PubMed, CINAHL and Web of Science databases on 29/08/2022 identified 29 studies for meta-analysis (encompassing 719 migraineur and 592 control participants) that met inclusion and NHLBI risk of bias criteria. Results demonstrated that estrogen concentrations of female migraineurs were reduced (g = -.60, 95% CI [-.91, -.29], p < .001) in the luteal phase of the menstrual cycle, compared to controls. No differences were found in progesterone levels overall in female migraineurs, nor in testosterone levels in male migraineurs compared to controls. Further, early diurnal cortisol concentrations were elevated (g = .32, 95% CI [.00, .63], p = .036) in female and male migraineurs compared to controls, though no differences were found in HRV of female or male migraineurs compared to controls. These findings of dysregulation of estrogen in females and cortisol dysregulation in female and male migraineurs indicate perturbed hypothalamic function and highlight the association of migraine with stress and the need for further rigorous investigation of hypothalamic neuroendocrine functions in migraineurs of both sexes.

Hazard of substance abuse onset among adults diagnosed with epilepsy or migraine

OBJECTIVE

We investigated adult-onset epilepsy as a risk factor for the development of substance use disorder (SUD) by comparing the rate of SUD diagnosis among adults diagnosed with epilepsy with presumably healthy controls with lower extremity fractures (LEF). For additional comparison, we investigated the risk for adults with migraine only. Epilepsy and migraine are both episodic neurological disorders and migraine is frequently comorbid with epilepsy.

METHODS

We conducted a time-to-event analysis using a subset of surveillance data of hospital admissions, emergency department visits, and outpatient visits in South Carolina, USA from January 1, 2000, through December 31, 2011. Individuals aged 18 years or older were identified using the International Classification of Disease, 9thRevision Clinical Modification (ICD-9) with a diagnosis of epilepsy (n = 78,547; 52.7% female, mean age 51.3 years), migraine (n = 121,155; 81.5% female, mean age 40.0 years), or LEF (n = 73,911; 55.4% female, mean age 48.7 years). Individuals with SUD diagnosis following epilepsy, migraine, or LEF were identified with ICD-9 codes. We used Cox proportional hazards regression to model the time to SUD diagnosis comparing adults diagnosed with epilepsy, migraine, and LEF, adjusting for insurance payer, age, sex, race/ethnicity, and prior mental health comorbidities.

RESULTS

Compared to LEF controls, adults with epilepsy were diagnosed with SUD at 2.5 times the rate [HR 2.48 (2.37, 2.60)] and adults with migraine only were diagnosed with SUD at 1.12 times the rate [HR 1.12 (1.06, 1.18)]. We found an interaction between disease diagnosis and insurance payer, with hazard ratios comparing epilepsy to LEF of 4.59, 3.48, 1.97, and 1.44 within the commercial payer, uninsured, Medicaid, and Medicare strata, respectively.

SIGNIFICANCE

Compared to presumably healthy controls, adults with epilepsy had a substantially higher hazard of SUD, while adults with migraine only showed a small, but significant, increased hazard of SUD.

Associations between Anxiety, Depression, Chronic Pain and Oral Health-Related Quality of Life, Happiness, and Polymorphisms in Adolescents' Genes

Adolescence is marked by changes and vulnerability to the emergence of psychological problems. This study aimed to investigate associations between anxiety/depression/chronic pain and oral health-related quality of life (OHRQoL)/happiness/polymorphisms in the COMT, HTR2A and FKBP5 genes in Brazilian adolescents. A cross-sectional study was conducted with ninety adolescents 13 to 18 years. Anxiety, depression and chronic pain were evaluated using the RDC/TMD. The Oral Health Impact Profile was used to assess oral OHRQoL. The Subjective Happiness Scale was used to assess happiness. Single-nucleotide polymorphisms in COMT (rs165656, rs174675), HTR2A (rs6313, rs4941573) and FKBP5 (rs1360780, rs3800373) were genotyped using the Taqman® method. Bivariate and multivariate logistic regression analyses were performed (p < 0.05). Chronic pain and depression were associated with feelings of happiness (p < 0.05). A significant inverse association was found between anxiety and OHRQoL (p = 0.004). The presence of minor allele C of COMT rs174675 was significantly associated with depression (p = 0.040). Brazilian adolescents with depression and chronic pain considers themselves to be less happy than others and those with anxiety are more likely to have a negative impact on OHRQoL. Moreover, the rs174675 variant allele in the COMT gene was associated with depressive symptoms in Brazilian adolescents.

Migraine and obesity: what is the real direction of their association?

INTRODUCTION

In recent decades, studies have addressed the issue of how migraine and obesity are related and have suggested obesity as a risk factor for migraine headache. However, the exact direction of this relationship remains under debate. In this review, the authors summarize the evidence that have suggested migraine as a risk factor for obesity and overweightness.

AREAS COVERED

This article reviews the results of the previous research published on PubMed and Scopus databases (from 2000 to 2020) concerning the association between migraine and obesity to determine the actual direction of their association. Special attention has been given to the common mechanistic pathways involved in the pathophysiology of migraine and obesity.

EXPERT OPINION

The majority of research conducted thus far has considered obesity as a risk factor for migraine. However, because of the cross-sectional design of available research, we cannot be certain of the proposed direction of this association. There is evidence supporting the hypothesis that obesity can serve as a consequence of migraine through the effects of neuropeptides, inflammatory mediators, adipokines, gut microbiota and modifications in eating behavior and lifestyle. However, the real direction of the relationship between migraine and obesity should be further investigated in large prospective studies.

Alterations in metabolic flux in migraine and the translational relevance

BACKGROUND

Migraine is a highly prevalent disorder with significant economical and personal burden. Despite the development of effective therapeutics, the causes which precipitate migraine attacks remain elusive. Clinical studies have highlighted altered metabolic flux and mitochondrial function in patients. In vivo animal experiments can allude to the metabolic mechanisms which may underlie migraine susceptibility. Understanding the translational relevance of these studies are important to identifying triggers, biomarkers and therapeutic targets in migraine.

MAIN BODY

Functional imaging studies have suggested that migraineurs feature metabolic syndrome, exhibiting hallmark features including upregulated oxidative phosphorylation yet depleted available free energy. Glucose hypometabolism is also evident in migraine patients and can lead to altered neuronal hyperexcitability such as the incidence of cortical spreading depression (CSD). The association between obesity and increased risk, frequency and worse prognosis of migraine also highlights lipid dysregulation in migraine pathology. Calcitonin gene related peptide (CGRP) has demonstrated an important role in sensitisation and nociception in headache, however its role in metabolic regulation in connection with migraine has not been thoroughly explored. Whether impaired metabolic function leads to increased release of peptides such as CGRP or excessive nociception leads to altered flux is yet unknown.

CONCLUSION

Migraine susceptibility may be underpinned by impaired metabolism resulting in depleted energy stores and altered neuronal function. This review discusses both clinical and in vivo studies which provide evidence of altered metabolic flux which contribute toward pathophysiology. It also reviews the translational relevance of animal studies in identifying targets of biomarker or therapeutic development.

Psychological Disorders, Adverse Childhood Experiences and Parental Psychiatric Disorders in Children Affected by Headache: A Systematic Review

BACKGROUND

Pediatric headaches have been linked to adverse life events or psychological factors in children and their families, with a complex and bidirectional association. Moreover, it is well-known that psychological stress can trigger headaches.

METHODS

We searched three databases for studies focusing on headaches and adverse events or psychological factors in children up to 12 years old or in their caregivers.

RESULTS

We included 28 studies. Child psychological factors, including internal and external symptoms, were commonly associated with all types of headaches. Sleep disturbances showed a positive association with headaches in 3 out of 5 studies. Family conflict and unhappiness were frequently found in children suffering with headaches, while single-parent families and divorce were not associated. Stressful environments and adverse life events, particularly bullying, were also found to be linked with headaches.

CONCLUSIONS

Childhood headaches represent an alarm bell for clinicians to investigate and treat psychological or psychiatric disorders in children and their family. Further studies are needed to elucidate the role of early-life adverse events in children and their families.

Persistence, use of resources and costs in patients under migraine preventive treatment: the PERSEC study

Background

Migraine represents a serious burden for national health systems. However, preventive treatment is not optimally applied to reduce the severity and frequency of headache attacks and the related expenses. Our aim was to assess the persistence to traditional migraine prophylaxis available in Spain and its relationship with the healthcare resource use (HRU) and costs.

Methods

Retrospective observational study with retrospective cohort design of individuals with migraine treated with oral preventive medication for the first time from 01/01/2016 to 30/06/2018. One-year follow-up information was retrieved from the Big-Pac™ database. According to their one-year persistence to oral prophylaxis, two study groups were created and describe regarding HRU and healthcare direct and indirect costs using 95% confidence intervals (CI). The analysis of covariance (ANCOVA) was performed as a sensitivity analysis. Patients were considered persistent if they continued on preventive treatment until the end of the study or switched medications within 60 days or less since the last prescription. Non-persistent were those who permanently discontinued or re-initiated a treatment after 60 days.

Results

Seven thousand eight hundred sixty-six patients started preventive treatment (mean age (SD) 48.2 (14.8) and 80.4% women), of whom 2,545 (32.4%) were persistent for 6 months and 2,390 (30.4%) for 12 months. Most used first-line preventive treatments were antidepressants (3,642; 46.3%) followed by antiepileptics (1,738; 22.1%) and beta-blockers (1,399; 17.8%). The acute treatments prescribed concomitantly with preventives were NSAIDs (4,530; 57.6%), followed by triptans (2,217; 28.2%). First-time preventive treatment prescribers were mostly primary care physicians (6,044; 76.8%) followed by neurologists (1,221; 15.5%). Non-persistent patients required a higher number of primary care visits (mean difference (95%CI): 3.0 (2.6;3.4)) and days of sick leave (2.7 (0.8;4.5)) than the persistent ones. The mean annual expenditure was €622 (415; 829) higher in patients who not persisted on migraine prophylactic treatment.

Conclusions

In this study, we observed a high discontinuation rate for migraine prophylaxis which is related to an increase in HRU and costs for non-persistent patients. These results suggest that the treatment adherence implies not only a clinical benefit but also a reduction in HRU and costs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s10194-022-01448-2.

Chronic headache patients' health behavior and health service use 12 months after interdisciplinary treatment - what do they keep in their daily routines?

Background

We do not yet know whether or the extent to which multimodal therapy changes the health behaviors and health service use of chronic headache patients in the long term. Associations are expected between pain symptoms and pain management abilities for patients who are categorized as successfully treated and those who remain unchanged.

Methods

Routine longitudinal data of an enrolment period of five years from 101 headache patients treated with a two-week, full-day, semi-inpatient multimodal pain therapy at the Interdisciplinary Pain Center of the University Clinic Erlangen were available when therapy began and 12 months after treatment. To investigate long-term changes in health behavior and health service use as well as their associations with the outcome “reduction in pain days,” we used descriptive and inferential statistics (i.e., binary logistic regression).

Results

Patients who underwent interdisciplinary treatment showed statistically significant changes in their health behavior in five areas. Twelve months after treatment, we found a significantly higher frequency of engagement in athletic sports (p < .001) as well as increases in the use of relaxation techniques (p < .001), TENS devices for relaxation purposes (p = .008), psychological coping strategies (p < .001), and mindfulness-based techniques for dealing with pain (p < .001). 52.8% of the sample reported a reduction in the number of pain days 12 months after treatment. Binary logistic regression (χ² (12) = 21.419; p = .045; R² = .255) revealed that a reduction in pain days 12 months after treatment was positively associated with regular physical activity in the form of muscle strengthening and stretching (athletic sports) (p = .012).

Conclusion

Chronic headache patients acquired long-term skills from an interdisciplinary treatment concerning the use of relaxation techniques, the use of psychological coping strategies, and physical activity in the form of athletic exercise. Of those, regular athletic exercise was positively associated with a smaller number of pain days in the long term. Thus, a physical activity module should be an element of interdisciplinary treatment for chronic headache patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-022-02646-w.

High-School Football and Midlife Brain Health Problems

OBJECTIVE

To examine whether middle-aged men who played high-school football experience worse mental health or cognitive functioning than men who did not play high-school football.

DESIGN

Cross-sectional cohort study.

SETTING

Online survey completed remotely.

PARTICIPANTS

A total of 435 men between the ages of 35 and 55 completed the study, of whom 407 were included in the analyses after excluding participants who answered embedded validity items incorrectly (n = 16), played semiprofessional football (n = 2), or experienced a recent concussion (n = 10).

ASSESSMENT OF RISK FACTORS

Self-reported high school football participation, compared with those who played contact sports, noncontact sports, and no sports.

MAIN OUTCOME MEASURES

A lifetime history of depression or anxiety; mental health or cognitive problems in the past year; current depression symptoms, and post-concussion-like symptoms.

RESULTS

Middle-aged men who played high-school football did not have a higher prevalence of being prescribed medication for anxiety or depression or receiving treatment from a mental health professional. Similarly, there were no significant differences between groups on the rates in which they endorsed depression, anxiety, anger, concentration problems, memory problems, headaches, migraines, neck or back pain, or chronic pain over the past year. A greater proportion of those who played football reported sleep problems over the past year and reported being prescribed medication for chronic pain and for headaches.

CONCLUSIONS

Men who played high-school football did not report worse brain health compared with those who played other contact sports, noncontact sports, or did not participate in sports during high school.

Migraine: A Review on Its History, Global Epidemiology, Risk Factors, and Comorbidities

Migraine affects more than one billion individuals each year across the world, and is one of the most common neurologic disorders, with a high prevalence and morbidity, especially among young adults and females. Migraine is associated with a wide range of comorbidities, which range from stress and sleep disturbances to suicide. The complex and largely unclear mechanisms of migraine development have resulted in the proposal of various social and biological risk factors, such as hormonal imbalances, genetic and epigenetic influences, as well as cardiovascular, neurological, and autoimmune diseases. This review presents a comprehensive review of the most up-to-date literature on the epidemiology, and risk factors, as well as highlighting the gaps in our knowledge.

Pattern-Induced Visual Discomfort and Anxiety in Migraineurs: Their Relationship and the Effect of Colour

In migraineurs, coloured lenses were found to reduce the visual stress caused by an aversive pattern known to trigger migraines by 70%, but do such patterns also produce a low-level anxiety/fear response? Is this response lessened by colour? We sought to investigate this in a study comprising a broad screening component followed by a dot-probe experiment to elicit attentional biases (AB) to aversive patterns. Undergraduate psychology students completed headache and visual discomfort (VD) questionnaires (N = 358), thereby forming a subject pool from which 13 migraineurs with high visual discomfort and 13 no-headache controls with low visual discomfort, matched on age and sex, completed a dot-probe experiment. Paired stimuli were presented for 500 ms: aversive achromatic 3 cpd square wave gratings vs control, scrambled patterns. These conditions were repeated using the colour that was most comfortable for each participant. VD was greater in the more severe headache groups. On all measures, the migraineurs were more anxious than the controls, and a positive relationship was found between VD and trait anxiety. The 3 cpd gratings elicited an aversive AB in the migraine group which was somewhat reduced by the use of colour, and this was not seen in the controls. The results suggest a new role for colour in reducing visual stress via anxiety/fear reduction.

Quality of Life and Disability Among Migraine Patients: A Single-Center Study in AlAhsa, Saudi Arabia

Background Migraine is a major public health issue that leads to frequent visits to medical care. It is generally considered a disabling disease among individuals below the age of 50 years old predominantly seen in females. Migraine headache has a strong influence on disability, functional impairments, and psychological effects. The majority of the physicians fail to address the degree and extent of impediment caused by a migraine, which contributes to low quality of life and disability. Thus, this study aims to assess the health-related quality of life (QOL) and disability among migraine sufferers in AlAhsa, Saudi Arabia. Material and methods This descriptive cross-sectional study was carried out in the neurology clinics at King Fahad Hospital-Hofuf, AlAhsa, Saudi Arabia, from May to August 2021. The data were collected through a self-administered questionnaire. The migraine-specific quality of life questionnaire (MSQ), version 2.1, was used. MSQ is measured in three domains, including role function restrictive (RR), preventive (RP), and emotional function (EF). Disability related to migraine was assessed by the Migraine Disability Assessment Test (MIDAS). MIDAS classifies disability from no disability to severe disability. Two-tailed with an alpha level of 0.05 considering the significance of a p-value less than or equal to 0.05. The mean scores of QOL domains were compared by one-way analysis of variance (ANOVA) and independent t-tests. Results A total of 101 out of 359 participants were identified to have a migraine. Eighty-two participants met the inclusion criteria, 75.6% were females. The age of the participants ranged from 18 to more than 45 years with a mean age of 36.4 ± 11.9 years old. The mean score of QOL in the restrictive, preventive, and emotional domains were 46.3% ± 21.5%, 52.1% ± 24.3%, and 61.5% ± 30.8%, respectively. More than half of the participants (57.3%) suffered from a severe disability caused by migraines as compared to 20.7% with a moderate disability. Low QOL scores were associated with females and a significant relationship was found between migraine-associated disability and patients' emotional function in QOL. Conclusion Clinicians should routinely evaluate disability related to migraine and QOL as a complementary approach to migraine patients to ensure that patients are receiving proper treatment and whether additional strategies are needed or not.

Brazilian version of headache management self-efficacy scale

Background Headache-management self-efficacy has been associated with pain severity and headache-related disability. Objective The aim of this study was to test the cross-cultural adaptation and psychometric properties of a Brazilian version of the Headache Management Self-Efficacy Scale (HMSE) in a sample of patients coming from three tertiary headache centers in Brazil. Methods 137 migraine outpatients completed the Headache Management Self-Efficacy Scale (HMSE) and measures of psychopathological symptoms, pain catastrophizing, depression, anxiety, quality of life and headache-related disability. Results HMSE-10 showed good reliability (α = 0.84) and adequate corrected item-total correlation, ranging from 0.46 to 0.64. HMSE-10 was positively correlated with 6 of 8 domains of overall health status and negatively correlated with psychopathological symptoms, depression, anxiety, pain catastrophizing, headache-related disability, headache frequency and headache intensity. The difference between the means of the episodic and chronic headache patients had a magnitude of moderate effect in all the study measures, being headache-related disability the largest one found (d = 0.68). Along with headache intensity and depression, Efficacy Scale beliefs were predictors of headache-related disability. Conclusions The Brazilian short version of Headache Management Self-Efficacy Scale (HMSE-10) was revealed as a valid and reliable measure of headache-specific Efficacy Scale beliefs.

A Case of Intranasal Ketamine Misuse: Considerations for Clinical Practice

Despite the growing off-label use of ketamine for depression and other psychiatric indications, its long-term safety profile and abuse potential remain unclear. We present a case of a patient who presented with paranoia and personality changes attributed to ketamine misuse, which illustrates the need for more robust screening and systematic monitoring with this medication. Continued evaluation of the abuse potential of ketamine in long-term treatment as well as restricted access and in-office administration are important, to develop a better understanding of the risk-benefit profile of this drug.

The Relationship of Psychiatric Comorbidities and Their Impact on Trigger Site Deactivation Surgery for Headaches

BACKGROUND

Patients seeking trigger site deactivation surgery for headaches often have debilitating symptoms that can affect their functional and mental health. Although prior studies have shown a strong correlation between psychiatric variables and chronic headaches, their associations in patients undergoing surgery have not been fully elucidated. This study aims to analyze psychiatric comorbidities and their impact on patients undergoing trigger site deactivation surgery for headaches.

METHODS

One hundred forty-two patients were prospectively enrolled. Patients were asked to complete the Patient Health Questionnaire-2 and Migraine Headache Index surveys preoperatively and at 12 months postoperatively. Data on psychiatric comorbidities were collected by means of both survey and retrospective chart review.

RESULTS

Preoperatively, 38 percent of patients self-reported a diagnosis of depression, and 45 percent of patients met Patient Health Questionnaire-2 criteria for likely major depressive disorder (Patient Health Questionnaire-2 score of ≥3). Twenty-seven percent of patients reported a diagnosis of generalized anxiety disorder. Patients with depression and anxiety reported more severe headache symptoms at baseline. At 1 year postoperatively, patients with these conditions had successful surgical outcomes comparable to those of patients without these conditions. Patients also reported a significant decrease in their Patient Health Questionnaire-2 score, with 22 percent of patients meeting criteria suggestive of depression, compared to 45 percent preoperatively.

CONCLUSIONS

There is a high prevalence of depression and anxiety in patients undergoing trigger site deactivation surgery. Patients with these comorbid conditions achieve successful surgical outcomes comparable to those of the general surgical headache population. Furthermore, trigger site deactivation surgery is associated with a significant decrease in depressive symptoms.

Increased migraine-free intervals with multifocal repetitive transcranial magnetic stimulation

INTRODUCTION

Episodic migraine is a debilitating condition associated with vast impairments of health, daily living, and life quality. Several prophylactic treatments exist, having a moderate ratio of action related to side effects and therapy costs. Repetitive transcranial magnetic stimulation (rTMS) is an evidence based therapy in several neuropsychiatric conditions, showing robust efficacy in alleviating specific symptoms. However, its efficacy in migraine disorders is unequivocal and might be tightly linked to the applied rTMS protocol. We hypothesized that multifocal rTMS paradigm could improve clinical outcomes in patients with episodic migraine by reducing the number of migraine days, frequency and intensity of migraine attacks, and improve the quality of life.

METHODS

We conducted an experimental, double-blind, randomized controlled study by applying a multifocal rTMS paradigm. Patients with episodic migraine with or without aura were enrolled in two centers from August 2018, to December 2019, and randomized to receive either real (n = 37) or sham (sham coil stimulation, n = 28) multifocal rTMS for six sessions over two weeks. Patients, physicians, and raters were blinded to the applied protocol. The experimental multifocal rTMS protocol included two components; first, swipe stimulation of 13 trains of 140 pulses/train, 67 Hz, 60% of RMT, and 2s intertrain interval and second, spot burst stimulation of 33 trains of 15 pulses/train, 67 Hz, 85% of RMT, and 8s intertrain interval. Reduction >50% from the baseline in migraine days (as primary outcome) and frequency and intensity of migraine attacks (as key secondary outcomes) over a 12-week period were assessed. To balance the baseline variables between the treatment arms, we applied the propensity score matching through the logistic regression.

RESULTS

Among 65 randomized patients, sixty (age 39.7 ± 11.6; 52 females; real rTMS n = 33 and sham rTMS n = 27) completed the trial and five patients dropped out. Over 12 weeks, the responder's rate in the number of migraine days was significantly higher in the real rTMS compared to the sham group (42% vs. 26%, p < 0.05). The mean migraine days per month decreased from 7.6 to 4.3 days in the real rTMS group and from 6.2 to 4.3 days in the sham rTMS group, resulting in a difference with real vs. sham rTMS of -3.2 days (p < 0.05). Similarly, over the 12-week period, the responder's rate in the reduction of migraine attacks frequency was higher in the real rTMS compared to the sham group (42% vs 33%, p < 0.05). No serious adverse events were observed.

CONCLUSION

Our pilot study shows compelling evidence in a double placebo-controlled trial that multifocal rTMS is an effective and well-tolerated preventive treatment in patients with episodic migraine.

Psychological predictors of negative treatment outcome with Erenumab in chronic migraine: data from an open label long-term prospective study

Background

Monoclonal antibodies (mABs) targeting the calcitonin gene-related peptide (CGRP) pathway represent the first disease-specific preventive migraine therapy. Growing evidence suggests that they are effective in the preventive treatment of difficult-to-treat patients. In this study, we evaluated the psychological predictors of the outcome of treatment with the anti-CGRP monoclonal antibody erenumab in patients with chronic migraine (CM).

Methods

Seventy-five patients with CM who had already failed at least 3 preventive therapies received erenumab every 28 days for a period of 12 months. Before the first administration, patients received a full psychological evaluation using The Structured Clinical Interview for DSM-5 Clinician Version (SCID-5-CV) to assess personality disturbances (primary outcome), mood and anxiety disorders, and as well specific questionnaires to evaluate alexithymia traits, childhood traumas, and current stressors (secondary outcomes).

Results

After 12 months of treatment, 53 patients reported a reduction of at least 50% in headache days/per month (Responders), whereas 22 did not (Non Responders). When compared to Responders, Non Responders were characterized by a higher prevalence of personality disorders belonging to Cluster C (avoidant, dependent, and obsessive-compulsive) (77% vs 37%, p = .001). Non Responders were also characterized by a higher prevalence of anxiety disorders (90% vs 60%, p = 0.007), showed more alexithymic traits (51.7 ± 13.7 vs 42.9 ± 14.3, p = 0.017), and reported a higher number of 'at least serious' current stressors (3.2 ± 4.0 vs 0.8 ± 1.4, p < .0001) than Responders. At the multivariate analysis, higher prevalence of Cluster C personality disorders (OR 3.697; p = 0.05) and higher number of ‘at least serious’ life events (OR 1.382; p = 0.017) arose as prognostic factors of erenumab failure.

Conclusions

Erenumab confirmed its effectiveness in a population of difficult-to-treat migraine. The presence of “anxious-fearful” personality together with current stressors and anxiety represent negative predictors of treatment outcome.

Trial registration

The study protocol was registered at clinicaltrials.gov (NCT04361721).

Primary headaches among gender dysphoric female-to-male individuals: A cross-sectional survey on gender transition experience

OBJECTIVE

To investigate the frequency, attack characteristics, and treatment experiences of migraine and tension-type headache (TTH) among gender dysphoric female-to-male (FtM) participants as well as in relation to psychiatric comorbidities and real-life experience that relates to being transgender in Turkey.

BACKGROUND

There are only a few publications to date on transgender individuals with headache. Further studies to understand the distinctive needs might provide better management.

METHODS

A total of 88 gender dysphoric FtM individuals (mean (SD) age: 24.8 (5.7) years) were included on a voluntary basis in this cross-sectional survey. Each participant filled out the questionnaire form that elicited items on sociodemographic characteristics, Gender Identity Transition Inventory, Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), and Headache Questionnaire.

RESULTS

Overall, 32/88 (36.4%; 95% confidence interval [CI]: 27.0%-47.0%) participants were diagnosed with migraine, and 36/88 (40.9%; 95% CI: 31.5%-52.3%) participants were diagnosed with TTH. High rates of unemployment, smoking, and social drinking were observed in our sample compared with the general population in Turkey. The three-item ID migraine screener was positive in 20.5% (18/88 patients) of our population. Patients with migraine in comparison with patients with TTH had statistically significantly higher BDI [12.0 (1-50) vs. 7.0 (0-33); p = 0.013] and BAI [13 (1-48) vs. 5 (0-22); p = 0.016] scores, longer headaches in the past month [median 3 vs. 1 day; p < 0.001], higher Numerical Rating Scale scores for headache severity [7 (2-10) vs. 5 (1-9), p < 0.001], and higher likelihood of menstruation acting as a triggering factor [8/32 patients (25.0%) vs. 0/36 patients (0.0%); p = 0.001] as well as increased rates of previously given diagnosis by a physician [15/32 patients (46.9%) vs. 4/36 patients (11.1%); p < 0.001], a greater number of neuroimaging tests being performed [12/32 patients (37.5%) vs. 3/36 patients (9.1%); p = 0.012], and a higher rate of emergency room utilization [7/32 patients (21.9%) vs. 1/36 patients (2.8%); p = 0.039] for headache.

CONCLUSIONS

In the FtM transgender population we investigated, migraine and TTH were quite common. The screening and early recognition of comorbid migraine, as well as the comorbid depression and anxiety, seem to be important in gender dysphoric FtM individuals. Further studies are needed to better understand the potential interaction of migraine with comorbid psychiatric disorders and the prevalence of headache types and gender-affirmative hormone treatment outcomes in the transgender population.

Headache attributed to idiopathic intracranial hypertension and persistent post-idiopathic intracranial hypertension headache: A narrative review

OBJECTIVE

Headache is a near-universal sequela of idiopathic intracranial hypertension (IIH). The aim of this paper is to report current knowledge of headache in IIH and to identify therapeutic options.

BACKGROUND

Disability in IIH is predominantly driven by headache; thus, headache management is an urgent and unmet clinical need. At present, there is currently no scientific evidence for the directed use of abortive or preventative headache therapy.

METHODS

A detailed search of the scientific literature and narrative review was performed.

RESULTS

Headache in IIH is driven by raised intracranial pressure (ICP) and reduction of ICP has been reported in some studies to reduce headache. Despite resolution of papilledema and normalization of raised ICP, a majority suffer persistent post-IIH headache. The lack of evidence-based management approaches leaves many untreated. Where clinicians attempt to manage IIH headache, they use off-label therapies to target the prevailing headache phenotype. A recent prospective open-label study demonstrated the effective use of a calcitonin gene-related peptide monoclonal antibody therapy in IIH for persistent post-IIH headache.

CONCLUSIONS

There is overwhelming evidence of the headache burden in IIH. Studies are required to investigate the biological foundations of headache related to ICP and to develop treatments specifically directed to manage headache in IIH.

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.

Clinical Profile of Migraine in a Rural Population Presenting to Tertiary Care Hospital in North India

Background and Objective:

Migraine is one of the most common types of headache leading to significant disability; still people do not seek early help in developing countries. Therefore, we planned to conduct a study to assess the clinical profile of migraine, its triggers, comorbidities, and related disability in rural India.

Design:

An observational study in which 1,245 men and women suffering from migraine were recruited at a tertiary care hospital and were asked to complete a questionnaire related to migraine, its triggers, comorbidities, and disability.

Results:

Out of 1245 patients, females constituted 75% (937) of the patient pool and rest 25% were males (308). Fatigability (52.7%), nausea/vomiting (42.7%), phonophobia (33.57%), numbness (28.2%), and vertiginous sensation (20.8%) were accompanying features. Stress was the most common trigger impacting 44.9% of the patient population, followed by noise in 44.3% of cases. Exertion and sleep disturbance acted as triggers in 36.1%, smells in 20.5%, hormonal factors in 11.5%, and visual stimuli in 5.1% of patients. Anxiety was identified as the most common comorbidity affecting 542 patients (43.5%), followed by depression in 25.7%of patients. Around 103 patients (8.2%) had other psychiatric illnesses such as panic disorder and bipolar mood disorder.

Conclusion:

The migraine-related disability is high; therefore we conducted a study to understand its triggers and clinical profile. This was the first observational study conducted in a tertiary care hospital on migraine in north India catering to a sizeable rural population however, larger population studies are required to understand migraine more exhaustively.

Introduction of a smartphone based behavioral intervention for migraine in the emergency department

OBJECTIVE

To determine whether a smartphone application (app) with an electronic headache diary and a progressive muscle relaxation (PMR) intervention is feasible and acceptable to people presenting to the Emergency Department (ED) with migraine.

METHODS

This single arm prospective study assessed feasibility by actual use of the app and acceptability by satisfaction with the app. We report preliminary data on change in migraine disability and headache days.

RESULTS

The 51 participants completed PMR sessions on a mean of 13 ± 19 (0,82) days for the 90-day study period, lasting a median of 11 min (IQR 6.5, 17) each. Median number of days of diary use was 34 (IQR 10, 77). Diaries were completed at least twice a week in half of study weeks (337/663). Participants were likely (≥4/5 on a 5-point Likert scale) to recommend both the app (85%) and PMR (91%). MIDAS scores significantly decreased by a mean of 38 points/participant (p < 0.0001). More frequent PMR use was associated with a higher odds of headache free days (p = 0.0148).

CONCLUSION

Smartphone-based PMR introduced to patients who present to the ED for migraine is feasible and acceptable. More frequent users have more headache free days. Future work should focus on intervention engagement.

An underrepresented majority: A systematic review utilizing allodynic criteria to examine the present scarcity of discrete animal models for episodic migraine

BACKGROUND

Despite increasing evidence differentiating episodic and chronic migraine, little work has determined how currently utilized animal models of migraine best represent each distinct disease state.

AIM

In this review, we seek to characterize accepted preclinical models of migraine-like headache by their ability to recapitulate the clinical allodynic features of either episodic or chronic migraine.

METHODS

From a search of the Pu bMed database for "animal models of migraine", "headache models" and "preclinical migraine", we identified approximately 80 recent (within the past 20 years) publications that utilized one of 10 different models for migraine research. Models reviewed fit into one of the following categories: Dural KCl application, direct electrical stimulation, nitroglycerin administration, inflammatory soup injection, CGRP injection, medication overuse, monogenic animals, post-traumatic headache, specific channel activation, and hormone manipulation. Recapitulation of clinical features including cephalic and extracephalic hypersensitivity were evaluated for each and compared.

DISCUSSION

Episodic migraineurs comprise over half of the migraine population, yet the vast majority of current animal models of migraine appear to best represent chronic migraine states. While some of these models can be modified to reflect episodic migraine, there remains a need for non-invasive, validated models of episodic migraine to enhance the clinical translation of migraine research.

Onabotulinumtoxin A Improves Psychological Aspects in Chronic Migraine Patients

Background: Chronic migraine (CM) affects 5.4% of the Kuwaiti population. It is associated with significant headache-related disability, psychiatric comorbidity and reduced quality of life. The aim of this study is to assess the efficacy of Onabotulinumtoxin A on psychological aspects of chronic migraine patients. Methods: This prospective study over 36 months included chronic migraine patients in a tertiary headache center. Eligible patients met International Classification of Headache Disorders disorders-third edition, beta version (ICHD-III) revision criteria for chronic migraine. Patients with history of psychiatric or medical problems other than migraine disorders were excluded. Patients who received less than 4 injections cycles of Onabotulinumtoxin A were excluded. Identified patients received 155 units of Onabotulinumtoxin A quarterly according to the Phase III Research Evaluating Migraine Prophylaxis Therapy Trail (PREEMPT) protocol. Quality of life, the seven-item Generalized Anxiety Disorder (GAD-7) scores, the nine-item Patient Health Questionnaire (PHQ9), and the Pittsburgh Sleep Quality Index (PSQI) were collected before injection and at the end of the study. Mean comparison tests were performed using the independent sample t-test to assess the effects of Onabotulinumtoxin A on quality of life and comorbid symptoms of anxiety, depression, and quality of sleep. Results: The study identified 131 chronic migraine patients with a mean age of 44.92 years, mean disease duration of 12.20 years and a mean treatment sessions of 7.58. In their last visit, most of our sample showed improvement in quality of life (81%), GAD-7 (81%), PHQ9 (79%), and PSQ1 (76%). The mean score of patient satisfaction was 7.21. Onabotulinumtoxin A treatment for CM improved quality of life significantly (72.92 vs. 103.62; P < 0.0001). It was also associated with significant reduction in anxiety [GAD-7 (12.00 vs. 6.61; P < 0.0001)] and depression [PHQ-9 (17.91 vs. 12.52; P < 0.0001)] scores, as well as reduced difficulty in sleeping [PSQI (12.60 vs. 6.66; P < 0.0001)] at the last visit. Conclusion: Prophylactic Onabotulinumtoxin A treatment for CM was associated with significant improvement of quality of life, reduction in symptoms of anxiety and depression, as well as improved symptoms of poor sleep.

The Migraine-Anxiety Comorbidity Among Migraineurs: A Systematic Review

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

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

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

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

Prescribing practices of migraine-specific pharmacotherapy associated with emergency department use for migraine

OBJECTIVE

This study compared migraine medication prescribing between patients with a migraine diagnosis who used versus did not use the emergency department (ED) for migraine.

BACKGROUND

Headache is the fifth most common chief complaint for ED visits nationwide and the third most common potentially avoidable ED diagnosis in the University of Colorado Health system. The reasons some patients use the ED for migraine management while others do not and whether some ED admissions might be preventable remain unclear.

METHODS

This retrospective cohort study identified adults with migraine-related diagnoses within 1 year before the index date of July 1, 2018 and compared patient characteristics and migraine medication prescribing patterns between those who did or did not have a subsequent migraine-related ED encounter the following year. ED admission notes were manually reviewed to identify potentially preventable circumstances that led to the ED visit. The primary outcome was the proportion of patients with an active triptan prescription at the index date.

RESULTS

Of the 3843 patients identified, 35 patients (0.9%) had a migraine-related ED encounter. Of these, 17/35 (49%) had an active triptan prescription compared to 1360/3808 (36%) of non-ED utilizers (p = 0.114), OR 1.22 (95% CI 0.61-2.45). More ED utilizers had an active prescription for opioids (11/35 [31%] vs. 663/3808 [17%], p = 0.030) and migraine preventive therapy (19/35 [54%] vs. 1149/3808 [30%], p = 0.002), and neurology referrals (20/35 [57%] vs. 654/3808 [17%], p < 0.001) compared to non-ED utilizers. The most common circumstance for migraine-related ED visits was nonresponse to migraine abortive medications administered at home.

CONCLUSIONS

Triptan prescribing did not differ between ED utilizers and non-ED utilizers for migraine. Overall, less than half of the total patient population had a triptan prescribed. More ED utilizers had neurology referrals, prescriptions for opioids and preventive therapies, and a history of previous ED visit for any reason, which may be markers for higher disease severity or behavior patterns. Future research and interventions to reduce migraine-related ED use could target high-risk patients such as those with previous ED visits for any indication and neurology referrals.

Exploratory study to understand association of emotional comorbidities and sleep with migraine

BACKGROUND

Migraine is often associated with psychiatric and emotional co-morbidities. Several studies have shown association of sleep problems and/or emotional co-morbidities among migraineurs. However, less is known about the association of migraine disability with sleep and emotional co-morbidities.

OBJECTIVE

To explore the association of emotional co-morbidities and sleep quality with migraine disability among migraineurs in the central part of India.

METHODS AND MATERIAL

A cross-sectional study enrolling 132 patients of migraine was conducted at a tertiary care centre. They were evaluated for migraine disability by Migraine Disability Assessment Test (MIDAS), emotional co-morbidities by depression, anxiety, stress scale (DASS-21) and sleep quality by Pittsburgh Sleep Quality Index (PSQI).

RESULT

Mean age of participants was 32.9 ± 9.8 and 83.3% (n = 110) were females. Fourty seven percentage(n = 62) patients reported moderate to severe disability on MIDAS. Anxiety was most frequent (n = 87; 65.9%) emotional co-morbidity followed by depression (n = 70;53%) and stress (n = 52;39.4%). Severity of emotional co-morbidities increased while sleep quality deteriorated with increasing migraine disability. However, migraine frequency had positive correlation only with sleep quality. Stress showed a linear relationship with migraine disability at highest second-third decile of MIDAS.

CONCLUSION

Migraineurs in central India have higher emotional co-morbidities. These co-morbidities increased and sleep quality deteriorated with increasing migraine disability. Frequency of migraine has no association with emotional co-morbidities. Linear association of stress at higher migraine disability prompts possible role of stress management to break the complex relationship between stress and migraine.

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.

Clinical Correlates and Outcome of Major Depressive Disorder and Comorbid Migraine: A Report of the European Group for the Study of Resistant Depression

BACKGROUND

The present multicenter study aimed at defining the clinical profile of patients with major depressive disorder (MDD) and comorbid migraine.

METHODS

Demographic and clinical information for 1410 MDD patients with vs without concurrent migraine were compared by descriptive statistics, analyses of covariance, and binary logistic regression analyses.

RESULTS

The point prevalence rate for comorbid migraine was 13.5% for female and 6.2% for male patients. MDD + migraine patients were significantly younger, heavier, more likely female, of non-Caucasian origin, outpatient, and suffering from asthma. The presence of MDD + migraine resulted in a significantly higher functional disability. First-line antidepressant treatment strategy revealed a trend towards agomelatine. Second-generation antipsychotics were significantly less often administered for augmentation treatment in migraineurs. Overall, MDD + migraine patients tended to respond worse to their pharmacotherapy.

CONCLUSION

Treatment guidelines for comorbid depression and migraine are warranted to ensure optimal efficacy and avoid possible pitfalls in psychopharmacotherapy, including serotonin syndrome.

The Effect of Psychiatric Comorbidities on Headache-Related Disability in Migraine: Results From the Chronic Migraine Epidemiology and Outcomes (CaMEO) Study

OBJECTIVE

To examine the influences of depression and anxiety on headache-related disability in people with episodic migraine or chronic migraine.

BACKGROUND

Depression and anxiety are common comorbidities in people with migraine, especially among those with chronic migraine.

METHODS

This cross-sectional analysis of data from the longitudinal, internet-based Chronic Migraine Epidemiology and Outcomes Study assessed sociodemographic and headache features, and headache-related disability (Migraine Disability Assessment Scale). Four groups were defined based on scores from validated screeners for depression (9-item Patient Health Questionnaire) and anxiety (7-item Generalized Anxiety Disorder Scale): depression alone, anxiety alone, both, or neither.

RESULTS

Respondents (N = 16,788) were predominantly women (74.4% [12,494/16,788]) and white (84.0% [14,044/16,788]); mean age was 41 years. Depression was more likely in persons with chronic migraine vs episodic migraine (56.6% [836/1476] vs 30.0% [4589/15,312]; P < .001), as were anxiety (48.4% [715/1476] vs 28.1% 4307/15,312]; P < .001) and coexisting depression and anxiety (42.0% [620/1476] vs 20.8% [3192/15,312]; P < .001). After controlling for headache frequency and other covariates, depression alone, and anxiety alone were associated with 56.0% (rate ratio [RR], 1.56; 95% confidence interval [CI], 1.46-1.66) and 39.0% (RR, 1.39; 95% CI, 1.30-1.50) increased risks of moderate/severe migraine-related disability (both P < .001), respectively; the combination had an even greater effect on risk of moderate/severe disability (79.0% increase; RR, 1.79; 95% CI, 1.71-1.87; P < .001).

CONCLUSIONS

Depression alone and anxiety alone are associated with greater headache-related disability after controlling for sociodemographic and headache features. Coexisting depression and anxiety are more strongly associated with disability than either comorbidity in isolation. Interventions targeting depression and anxiety as well as migraine itself may improve headache-related disability in people with migraine.

Criterion-related validity in a sample of migraine outpatients: the diagnostic criteria for psychosomatic research

OBJECTIVE

The Diagnostic Criteria for Psychosomatic Research (DCPR) are those of psychosomatic syndromes that did not find room in the classical taxonomy. More recently, the DCPR were updated, called DCPR-revised (DCPR-R). The present study was conducted to test the criterion-related validity of the DCPR-R.

METHODS

Two hundred consecutive subjects were enrolled at the Headache Center of Careggi University Hospital (Italy): 100 subjects had a diagnosis of chronic migraine (CM) and 100 had a diagnosis of episodic migraine (EM). Participants received a clinical assessment, which included the DCPR-revised Semi-Structured Interview (DCPR-R SSI), the Structured Clinical Interview for DSM-5 (SCID-5), and the psychosocial index (PSI).

RESULTS

Forty-seven subjects (23.5%) had at least one DSM-5 diagnosis: major depressive disorder (8.5%; n = 17) and agoraphobia (7.5%; n = 15) were the most frequent. One hundred and ten subjects (55%) reported a DCPR-R diagnosis: allostatic overload (29%; n = 58) and type A behavior (10.5%; n = 21) were the most frequent. When the incremental validity of the DCPR system over the DSM system was tested using PSI subscales as the criterion variable, the DCPR-R increased up to 0.11-0.24 the amount of explained variance. Subjects with at least one DCPR-R diagnosis showed lower PSI well-being scores (p = .001), higher PSI stress scores (p < .001), and higher PSI psychological distress scores (p = .008) than subjects without a DCPR-R diagnosis.

CONCLUSION

The DCPR-R showed a good criterion-related validity in migraine outpatients. Thus, they might be implemented, together with the DSM-5, in the assessment of migraine subjects.

The impact of remission and coexisting migraine on anxiety and depression in cluster headache

Background

Our aim was to investigate the relationship between coexisting cluster headache (CH) and migraine with anxiety and depression during active cluster bouts, and how symptoms change during remission.

Methods

We analyzed data from 222 consecutive CH patients and 99 age- and sex-matched controls using a prospective multicenter registry. Anxiety or depression was evaluated using the Generalized Anxiety Disorder-7 (GAD-7) or Patient Health Questionnaire-9 (PHQ-9), respectively. Moderate-to-severe anxiety or depression was defined as a score of ≥10 at baseline (during a cluster bout). We assessed for changes in anxiety and depression during CH remission periods.

Results

Among the CH patients, the prevalence of moderate-to-severe anxiety and depression was seen in 38.2% and 34.6%, respectively. Compared with controls, CH patients were associated with moderate-to-severe anxiety and depression (multivariable-adjusted odds ratio [aOR] = 7.32, 95% confidence intervals [CI] = 3.35–15.99 and aOR = 4.95, 95% CI = 2.32–10.57, respectively). CH patients with migraine were significantly more likely to have moderate-to-severe anxiety and depression (aOR = 32.53, 95% CI = 6.63–159.64 and aOR = 16.88, 95% CI = 4.16–68.38, respectively), compared to controls without migraine. The GAD-7 and PHQ-9 scores were significantly reduced between cluster bout and remission periods (from 6.8 ± 5.6 to 1.6 ± 2.8; P < 0.001, and from 6.1 ± 5.0 to 1.8 ± 2.4; P < 0.001, respectively).

Conclusions

Our results indicate that CH patients are at increased risk of anxiety and depression, especially in the presence of coexisting migraine. However, the anxiety and depression can improve during remission periods.

One-Day Acceptance and Commitment Therapy Compared to Support for Depressed Migraine Patients: a Randomized Clinical Trial

In patients with migraine, depression is associated with poorer medical prognosis, decreased quality of life, and increased risk of suicidality and disability; yet, behavioral interventions have rarely been investigated. The current study compared the efficacy of two 1-day (5- to 6-h) interventions for co-occurring migraine and depression: (1) acceptance and commitment therapy plus migraine education (ACT-ED), and (2) support plus migraine education (S-ED). One hundred and thirty-six patients with comorbid depression and migraine were randomized to a treatment. One hundred and three (76%) completed the ACT-ED (N = 56) or S-ED (N = 47) workshop. Primary outcomes were depression diagnosis and symptoms. Secondary outcomes were anxiety symptoms, headache-related disability and general functioning, and quality of life. Assessments were completed at baseline and 3 and 6 months following the workshop. At the 6-month follow-up, on categorical outcomes, a significantly greater number of people in the ACT-ED condition no longer met criteria for a major depressive episode and exhibited a > 50% drop in symptoms on the Hamilton Rating Scale of Depression. Similarly, though, weaker results were found when examining depressive symptoms dimensionally. On secondary outcomes, people in the ACT-ED condition exhibited significantly greater improvements in anxiety, headache-related disability, and quality of social relationships, compared to S-ED, No differences between groups were observed in general functioning. A 1-day (5- to 6-h) ACT workshop can deliver substantial and lasting benefits to depressed migraineurs, over and above those provided by group support and education. This approach is an attractive alternative to weekly psychotherapy. Clinicaltrials.gov # NCT02108678.

Psychosocial repercussion of migraine: is it a stigmatized disease?

INTRODUCTION

Stigma manifests both in prejudices and rejection from society towards patients who suffer from a specific pathology, and by patient's internalization of this discrimination, with the consequent repercussions on their state of mind and quality of life. The aim of the study was to quantify the stigma associated with migraine and analyze whether it is related to the clinical-demographic characteristics of the patients, as well as the possible impact on their daily lives.

MATERIALS AND METHODS

The stigma scale for chronic illness (SSCI) and other questionnaires were administered to 56 patients with episodic migraine (EM), 18 with chronic migraine (CM), and 21 with epilepsy, as a control group.

RESULTS

The mean SSCI score was higher (51.6 ± 15.0) in the CM group than in the EM (45.0 ± 13.5) and epilepsy (47.6 ± 15.5) groups, without reaching statistical significance. In addition, the score was higher in patients who were unemployed, divorced, and in those who had migraine with aura. A statistically significant correlation was found between the SSCI score and the impact of migraine on daily life, the presence of stress, anxiety and depression, and low self-esteem.

CONCLUSIONS

There is a stigma around migraine in our society, which seems to be more prevalent in patients with certain socio-demographic characteristics, and that is related to stress, mood alterations, and low self-esteem. Trying to reduce stigma could contribute to improve the control of migraine and reduce the impact of the disease at a socio-economic level.

Suicide Attempts among Those with Migraine: Findings from a Nationally Representative Canadian Study

The objectives of this study were to identify the gender-specific prevalence of suicide attempts among those with migraine and to examine what factors are associated with suicide attempts among migraineurs. This study was a nationally representative analysis of the 2012 Canadian Community Health Survey - Mental Health (CCHS-MH) with 21,744 respondents, of whom 2,223 had migraine. Bivariate and logistic regression analyses were conducted. Those with migraine had a much higher prevalence of ever attempting suicide than those without migraine (men: 7.5% vs 1.9%; women; 9.3% vs 2.7%, p < .001). Among migraineurs, the odds of suicide attempts were higher among poorer respondents, those in chronic pain and those with a history of childhood adversities, substance dependence and/or mental illness. Targeted outreach is needed to reduce suicidality in this vulnerable population.

Prevalence and comorbidity of migraine headache: results from the Singapore Mental Health Study 2016

BACKGROUND AND AIM

Migraine is a highly prevalent and disabling neurological disorder associated with a wide range of psychiatric comorbidities. Studies have revealed that those with migraine headache and coexisting psychiatric disorders have poorer treatment outcomes and increased disability. The study aims to establish the prevalence, correlates, and comorbidities of migraine headache among the multi-ethnic Asian population in Singapore.

METHOD

Data were extracted from the Singapore Mental Health Study 2016 (SMHS 2016), a cross-sectional epidemiological survey of a nationally representative sample. Face-to-face interviews were completed with 6126 participants between 2016 and 2017. The data relating to chronic medical conditions, psychiatric conditions, and 30-day functioning and disability were captured using the World Mental Health Composite International Diagnostic Interview (CIDI) version 3.0.

RESULTS

The lifetime prevalence for migraine headache in the Singapore general population was 8.2%. Malay ethnicity (versus Chinese), female gender (versus male), and diploma holders (versus university) were significantly more likely to experience migraine headache. Participants belonging to the older age group (65 years and above versus 18-34 years of age), and those who were economically inactive (versus employed) were less likely to experience migraine headache. The mean age of onset for migraine was 26.4 years (SD = 11.1). Poisson regression analyses showed that migraine headache was also significantly associated with psychiatric conditions such as major depressive disorder (MDD) (prevalence ratio (PR), 1.80; 95% CI, 1.25-2.58), bipolar disorder (BD) (PR, 3.55; 95% CI, 2.29-5.51), generalized anxiety disorder (GAD) (PR, 2.04; 95% CI, 1.12-3.69), obsessive compulsive disorder (OCD) (PR, 2.20; 95% CI, 1.49-3.26), and alcohol use disorder (AUD) (PR, 1.93; 95% CI, 1.20-3.08). Those with migraine headache were significantly associated with poor functioning and disability compared to those without migraine headache.

CONCLUSIONS AND DISCUSSION

Our study showed significant associations between migraine headache and psychiatric disorders, as well as with role functioning and disability. The findings of our study emphasise the need for screening for psychiatric comorbidity among those with migraine and the development of appropriate interventions for this group.

Genetic Screening of Plasticity Regulating Nogo-Type Signaling Genes in Migraine

Migraine is the sixth most prevalent disease in the world and a substantial number of experiments have been conducted to analyze potential differences between the migraine brain and the healthy brain. Results from these investigations point to the possibility that development and aggravation of migraine may include grey matter plasticity. Nogo-type signaling is a potent plasticity regulating system in the CNS and consists of ligands, receptors, co-receptors and modulators with a dynamic age- and activity-related expression in cortical and subcortical regions. Here we investigated a potential link between migraine and five key Nogo-type signaling genes: RTN4, OMGP, MAG, RTN4R and LINGO1, by screening 15 single nucleotide polymorphisms (SNPs) within these genes. In a large Swedish migraine cohort (749 migraine patients and 4032 controls), using a logistic regression with sex as covariate, we found that there was no such association. In addition, a haplotype analysis was performed which revealed three haplotype blocks. These blocks had no significant association with migraine. However, to robustly conclude that Nogo-type genotypes signaling do not influence the prevalence of migraine, further studies are encouraged.

Comparison of patients with migraine and tension-type headache in terms of somatosensory amplification and health anxiety

INTRODUCTION

Although it is known that anxiety and depressive disorders frequently accompany migraine and TTH, the role of somatic amplification (SSA) and health anxiety in these diseases is not adequately known.

OBJECTIVE

The aim of this study is to compare SSA and health anxiety in patients with migraine or TTH, and healthy controls and to investigate the relationships between SSA, health anxiety, headache characteristics, anxiety and depressive symptoms.

METHODS

Fifty-four migraine, 50 TTH patients from the outpatient unit of the neurology department and 53 healthy volunteers were recruited for the study. The somatosensory amplification scale (SSAS), health anxiety inventory, Beck depression (BDI) and anxiety inventory (BAI) were administered to all participants.

RESULTS

The SSAS scores were significantly higher in migraineurs compared with the healthy controls. The health anxiety scores were significantly higher in both migraine and TTH groups. The BDI and BAI scores were also significantly higher in migraine and TTH groups compared with the controls. A significant positive correlation was found between headache frequency and BAI scores, the visual analogue scale scores and SSAS and BDI scores in migraineurs. The SSAS scores were also significantly correlated with the BDI and BAI scores in both of the headache groups. A similar correlation was determined with the health anxiety scores.

CONCLUSIONS

While patients with migraine and TTH evalute, taking into account the SSA and health anxiety may contribute to the prognosis and treatment of these diseases.

Association Between Personality Traits and Onabotulinumtoxin A Response in Patients With Chronic Migraine

OBJECTIVE

The aim of this study was to analyze the potential association between personality traits and onabotulinumtoxin A (onabotA) response in patients with chronic migraine (CM).

BACKGROUND

Previous studies from a categorial perspective show that patients with CM have anxious or obsessive personality according to the Salamanca screening test. However, the influence of personality traits in onabotA response in patients with CM has not yet been studied. We hypothesize that cluster C personality traits may be associated with non-response to onabotA.

METHODS

This case-control observational study includes patients with CM who received at least 2 treatment cycles of onabotA in 2 headache units between January and May 2018. onabotA response was defined as a reduction of at least 50% in the number of monthly migraine days. Personality traits were evaluated using the Salamanca questionnaire, a validated categorial inventory assessing 11 personality traits.

RESULTS

One hundred and twelve patients, 100/112 (89.6%) females, mean age (standard deviation): 43 (11) years, were recruited. 96/112 (85.7%) achieved response to onabotA. Dependent trait was significantly associated with non-response to onabotA (P = .008; OR: 0.223 [95%CI: 0.074 to 0.675]). Significant association with other personality traits or confounders was not found.

CONCLUSIONS

To the best of our knowledge, this is the first study showing personality traits may predict onabotA response in patients with CM. The presence of dependent personality trait in patients with CM is associated with non-response to onabotA.

A Prospective Observational Cohort Study on Pharmacological Habitus, Headache-Related Disability and Psychological Profile in Patients with Chronic Migraine Undergoing OnabotulinumtoxinA Prophylactic Treatment

Chronic Migraine (CM) is a disabling neurologic condition with a severe impact on functioning and quality of life. Successful therapeutic management of patients with CM is complex, and differences in therapeutic response could be attributable to genetically determined factors, sensitivity to pharmacological treatment, psychosocial and relational factors affecting the patient’s compliance and approach on the therapeutic treatment. The aim of this prospective observational study was to explore self-efficacy, coping strategies, psychological distress and headache-related disability in a cohort of 40 patients with CM (mean age: 46.73; standard deviation 13.75) treated with OnabotulinumtoxinA and the relationship between these clinical and psychological aspects and acute medication consumption during OnabotulinumtoxinA prophylactic treatment. Patients presented an overall significant reduction in the Headache Index (HI) (p < 0.001), HI with severe intensity (p = 0.009), and total analgesic consumption (p = 0.003) after the prophylactic treatment. These results are in line with the literature. Despite this, higher nonsteroidal anti-inflammatory drugs consumption was associated with higher psychological distress, higher HI with severe and moderate intensity, and worse quality of life. Conversely, triptans consumption was correlated with HI of mild intensity, and problem-focused coping strategies. To conclude, the psychological profile, and in particular, the psychological distress and specific coping strategies might influence the self-management of acute medication.