Migraine and sleep disorders: a systematic review

Headache in long COVID as disabling condition: A clinical approach

Background and purpose

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection can exacerbate previous headache disorders or change the type of pain experienced from headaches. This study aimed to investigate the clinical features of Long COVID headaches.

Method

This was a cross-sectional, descriptive, and analytical observational study that included 102 patients (with previous headache, n = 50; without previous headache, n = 52) with long COVID and headache complaints. The Migraine Disability Assessment Test and Visual Analog Pain Scale were used to collect participants' headache data according to a standardized protocol.

Results

The patients in this study who reported experiencing headaches before COVID-19 had longer headache duration in the long COVID phase than that in the pre-long COVID phase (p = 0.031), exhibited partial improvement in headache symptoms with analgesics (p = 0.045), and had a duration of long COVID of <1 year (p = 0.030). Patients with moderate or severe disability and those classified as having severe headaches in the long COVID phase were highly likely to develop chronic headaches. Hospital admission [odds ratio (OR) = 3.0082; 95% confidence interval (95% CI): 1.10-8.26], back pain (OR = 4.0017; 95% CI: 1.13-14.17), insomnia (OR = 3.1339; 95% CI: 1.39-7.06), and paraesthesia (OR = 2.7600; 95% CI: 1.20-6.33) were associated with headache in these patients.

Conclusion

Headache is a disabling condition in patients with long COVID-19, exacerbating the conditions of those with headaches prior to contracting COVID-19.

Effect of Disease Severity on Comorbid Conditions in Atopic Dermatitis: Nationwide Registry-Based Investigation in Finnish Adults

The majority of registry studies on atopic dermatitis include only patients and diagnoses from specialized healthcare. The aim of this retrospective, real-world cohort study was to evaluate the effect of atopic dermatitis severity on comorbidities and total morbidity, with comprehensive data from both primary and specialty healthcare registries covering the entire Finnish adult population. In total, 124,038 patients were identified (median age 46 years; 68% female) and stratified by disease severity. All regression analyses (median follow-up 7.0 years) were adjusted at a minimum for age, sex, obesity, and educational level. Compared with mild atopic dermatitis, severe atopic dermatitis was significantly associated with multiple morbidities, including neurotic, stress-related and somatoform disorders, abscesses, erysipelas/cellulitis, impetigo, herpes zoster, extragenital herpes, bacterial conjunctivitis, septicaemia, lymphomas, alopecia areata, urticaria, other dermatitis, contact allergy, osteoporosis, and intervertebral disc disorders (p < 0.001). In addition, there were significant associations with alcohol dependence, depression, condylomas, rosacea, migraine, sleep apnoea, hypertension, enthesopathies, atherosclerosis, and drug-induced cataract (p < 0.05). Odds ratios were modest and mostly were between 1.10 and 2.75. Furthermore, patients with severe atopic dermatitis had lower incidences of prostate cancer, cystitis, and anogenital herpes than patients with mild atopic dermatitis (p < 0.05). These results suggest that severe atopic dermatitis results in significant overall morbidity.

Insufficient sleep may alter cortical excitability near the migraine attack: A blinded TMS crossover study

BACKGROUND

Migraine is a brain disorder with a multifaceted and unexplained association to sleep. Brain excitability likely changes periodically throughout the migraine cycle. In this study we examine the effect of insufficient sleep on neuronal excitability during the course of the migraine cycle.

METHODS

We examined 54 migraine patients after two nights of eight-hour habitual sleep and two nights of four-hour restricted sleep in a randomised, blinded crossover study. We performed transcranial magnetic stimulation and measured cortical silent period, short- and long-interval intracortical inhibition, intracortical facilitation and short-latency afferent inhibition. We analysed how responses changed before and after attacks with linear mixed models.

RESULTS

Short- interval intracortical inhibition was more reduced after sleep restriction compared to habitual sleep the shorter the time that had elapsed since the attack (p = 0.041), and specifically in the postictal phase (p = 0.013). Long-interval intracortical inhibition was more increased after sleep restriction with time closer before the attack (p = 0.006), and specifically in the preictal phase (p = 0.034). Short-latency afferent inhibition was more decreased after sleep restriction with time closer to the start of the attack (p = 0.026).

CONCLUSION

Insufficient sleep in the period leading up to a migraine attack may cause dysfunction in cortical GABAergic inhibition. The results also suggest that migraine patients may have increased need for sufficient sleep during a migraine attack to maintain normal neurological function after the attack.

Interrelationships of Sleep Quality, Obesity Severity, and Clinical Headache Features among Women with Comorbid Migraine and Obesity

Obesity and migraine are often comorbid. Poor sleep quality is also common among individuals with migraine and may be influenced by comorbidities such as obesity. However, understanding of migraine's relationship with sleep and the potential exacerbating effect of obesity remains limited. This study evaluated the associations of migraine characteristics and clinical features with sleep quality among women with comorbid migraine and overweight/obesity and assessed the interplay between obesity severity and migraine characteristics/clinical features in relation to sleep quality. Women seeking treatment for migraine and obesity (n = 127; NCT01197196) completed a validated questionnaire assessing sleep quality (Pittsburgh Sleep Quality Index-PSQI). Migraine headache characteristics and clinical features were assessed using smartphone-based daily diaries. Weight was measured in-clinic, and several potential confounders were assessed using rigorous methods. Nearly 70% of participants endorsed poor sleep quality. Greater monthly migraine days and the presence of phonophobia related to poorer sleep quality, and specifically poorer sleep efficiency, controlling for confounders. Obesity severity was neither independently associated nor interacted with migraine characteristics/features to predict sleep quality. Poor sleep quality is common among women with comorbid migraine and overweight/obesity, although obesity severity does not appear to uniquely relate to or exacerbate the association between migraine and sleep in this population. Results can guide research on mechanisms of the migraine-sleep link and inform clinical care.

Parasomnias in Pregnancy

OBJECTIVES

Pregnancy is often associated with reduced sleep quality and an increase in sleep disorders, such as restless leg syndrome, obstructive sleep apnea, and insomnia. There are few studies investigating the prevalence of parasomnias in pregnancy, although they may be expected to be a significant problem, as disturbed sleep in this time period in addition to these sleep disorders may trigger parasomnia episodes.

METHODS

We conducted a survey using an online questionnaire focusing on a comparison of the prevalence of parasomnias in three time periods: 3 months before pregnancy, during pregnancy, and 3 months after delivery. We also inquired about psychiatric and neurological comorbidities, current anxiety and depression symptoms, and pregnancy complications.

RESULTS

A total of 325 women (mean age 30.3 ± 5.3 years) participated in the online survey. The overall number of reported parasomnias increased during pregnancy compared to the 3 months before pregnancy (p < 0.001) and decreased after childbirth (p < 0.001). Specifically, we found a significant increase in sleepwalking (p = 0.02) and night terrors (p < 0.001), as well as in vivid dreams (p < 0.001) and nightmares (p < 0.001) during pregnancy. A similar significant increase during pregnancy was reported for head explosion (p < 0.011). In contrast, the number of episodes of sleep paralysis increased after delivery (p = 0.008). At the individual level, an increase in the severity/frequency of individual parasomnia episodes was also observed during pregnancy. Participants whose vivid dreams/nightmares persisted after delivery had higher BDI-II and STAI-T scores. Our data also suggest a significant impact of migraines and other chronic pain, as well as complications during pregnancy, on the presence of parasomnia episodes in our cohort.

CONCLUSIONS

We have shown that the prevalence of parasomnias increases during pregnancy and needs to be targeted, especially by non-pharmacological approaches. At the same time, it is necessary to inquire about psychiatric and neurological comorbidities and keep in mind that more sleep disorders may be experienced by mothers who have medical complications during pregnancy.

Association of Pain Disorder and Psychiatric Disease With Surgical Management of Obstructive Sleep Apnea

OBJECTIVE

Patients undergoing surgical management for obstructive sleep apnea (OSA) are likely medically distinct from their counterparts not treated surgically. This study examined the associations between psychiatric and pain comorbidities and the likelihood of undergoing sleep surgery.

STUDY DESIGN

A retrospective cohort study of adults with OSA.

SETTING

Large integrated healthcare system.

METHODS

The primary outcome was nonnasal, nonbariatric sleep surgery. The associations of baseline demographic and comorbid conditions with surgery to treat underlying OSA were examined using bivariable and multivariable analyses.

RESULTS

Among 172,854 adults with OSA, 2456 received sleep surgery. Comorbid pain disorder and/or pain medication treatment was associated with 41% higher odds of surgery (95% confidence interval: 1.29-1.54). In bivariable analyses, those with a history of headache (p = .004), particularly migraine (p = .003), disorders of adult personality or behavior (p = .025), or behavioral/emotional disorder (p < .001) were more likely to undergo surgery. Younger adults were also more likely to undergo surgery (mean age at diagnosis 39.8 ± 12.6 vs 54.7 ± 14 years), as were men, Asian/Pacific Islander or Hispanic adults, those with lower body mass index (32 ± 7 vs 34.3 ± 8.1 kg/m² ), or those with Charlson Comorbidity Index of zero (p < .001).

CONCLUSION

Our study suggests a history of pain disorder (including receipt of pain medication), migraine, or certain behavioral and personality disorders are associated with an increased likelihood of undergoing sleep surgery. The findings may better characterize comorbid predictors of sleep surgery and potentially help clinicians tailor expectations, postoperative pain management, and overall sleep outcomes.

Additional effects of pain neuroscience education combined with physiotherapy on the headache frequency of adult patients with migraine: A randomized controlled trial

Aim To assess the efficacy of pain neuroscience education combined with physiotherapy for the management of migraine.Background Physiotherapy can significantly reduce the frequency of migraine, but the evidence is based only on a few studies. Pain neuroscience education might pose a promising treatment, as it addresses migraine as a chronic pain disease.Methods In this non-blinded randomized controlled trial, migraine patients received physiotherapy + pain neuroscience education or physiotherapy alone, preceded by a three-month waiting period. Primary outcomes were frequency of headache (with and without migraine features), frequency of migraine and associated disability.Results Eighty-two participants were randomized and analyzed. Both groups showed a decrease of headache frequency (p = 0.02, d = 0.46) at post-treatment (physiotherapy: 0.77 days, 95%CI: -0.75 to 2.29 and physiotherapy + pain neuroscience education: 1.25 days, 95%CI: -0.05 to 2.55) and at follow-up (physiotherapy: 1.93, 95%CI: 0.07 to 3.78 and physiotherapy + pain neuroscience education: 3.48 days, 95%CI: 1.89 to 5.06), with no difference between groups (p = 0.26, d = 0.26). Migraine frequency was reduced significantly in the physiotherapy + pain neuroscience education group, and not in the physiotherapy group, at post-treatment (1.28 days, 95%CI: 0.34 to 2.22, p = 0.004) and follow-up (3.05 days, 95%CI: 1.98 to 5.06, p < 0.0001), with a difference between groups at follow-up (2.06 days, p = 0.003). Migraine-related disability decreased significantly in both groups (physiotherapy: 19.8, physiotherapy + pain neuroscience education: 24.0 points, p < 0.001, d = 1.15) at follow-up, with no difference between groups (p = 0.583). Secondary outcomes demonstrated a significant effect of time with no interaction between time and group. No harm or adverse events were observed during the study.Conclusion In comparison to physiotherapy alone, pain neuroscience education combined with physiotherapy can further reduce the frequency of migraine, but had no additional effect on general headache frequency or migraine-related disability.Trial Registration The study was pre-registered at the German Clinical Trials Register (DRKS00020804).

The effect of bright light therapy in migraine patients with sleep disturbance: A prospective, observational cohort study protocol

Background

Migraine is a common disabling disorder, and its substantial burden is associated with a considerable negative impact on the patients' quality of life. Moreover, aging patients with migraine have more cognitive complaints. Additionally, the elderly are more likely to have sleep disturbances, which may also predict the risk of incident dementia. Migraines are reported to be closely associated with sleep and circadian rhythms. Sleep disturbance is a well-known trigger for migraine episodes; moreover, shift work or jet lag reportedly triggers some migraines. The hypothalamus is thought to be the migraine generator; sleep and circadian activity rhythm are also controlled by the hypothalamus. Evidence suggests an influence of both sleep and circadian system on migraine. Previously, light therapy has been show to stabilize sleep architecture and further improve insomnia related to circadian rhythm disorders. However, the beneficial effect of light therapy on migraine with sleep disturbance has not yet been determined. We aim to explore the effects of light therapy for migraine combined with sleep disturbance.

Methods and analysis

This project is a 2-year, randomized, double-blind, placebo-controlled clinical trial. The study design includes a 4-week monitoring period (baseline and pretest), a 4-week treatment period, and a posttest. The study participants will undergo assessments on headache frequency and severity and subjective and objective (wrist actigraphy and polysomnography) sleep disturbances, and quality of life and a series of blood tests for serum biomarkers.

Discussion

This study will establish evidence-based alternative medicine for the preventive effect of bright light therapy in migraine patients with sleep disturbances. Moreover, our data will be useful to comprehend the biochemical mechanism of light therapy in migraine prevention.Clinical Trial Registration: ClinicalTrials.gov, identifier NCT04890691.

Approach to a sleepy child: Diagnosis and treatment of excessive daytime sleepiness in children and adolescents

The aim of this review is to give updated information to pediatric neurologists on the correct diagnostic approach and treatment of excessive daytime sleepiness (EDS) in children and adolescents. Due to the change in the society habits, EDS is becoming an emerging problem for the health system. At the present there are few articles specifically devoted to the evaluation of EDS. EDS is often reported in several manuscripts as a side effect of other sleep disorders (obstructive sleep apnea, circadian disorders, etc.) or of the use of drugs or of the substance abuse or as a consequence of bad sleep habits and poor sleep hygiene. EDS, especially in children, may manifest with paradoxical symptoms like hyperactivity, inattention, and impulsiveness. However, common sign of EDS in children are the propensity to sleep longer than usual, the difficulty waking up in the morning, and falling asleep frequently during the day in monotonous situation. The diagnosis should include subjective (sleep diaries, questionnaires) and objective (polysomnography, multiple sleep latency test, etc.) instruments to avoid misdiagnosis. Narcolepsy is the most studied central disorder of hypersomnolence, and it is a predominantly pediatric disease with a peak age of onset in prepuberty but the diagnosis is often delayed especially in mild forms. The early and correct treatment of narcolepsy and of other form of EDS is extremely important since late and inappropriate treatments can affect the psychosocial development of the children and adolescents.

Targeting Orexin Receptors for the Treatment of Insomnia: From Physiological Mechanisms to Current Clinical Evidence and Recommendations

After a detailed description of orexins and their roles in sleep and other medical disorders, we discuss here the current clinical evidence on the effects of dual (DORAs) or selective (SORAs) orexin receptor antagonists on insomnia with the aim to provide recommendations for their further assessment in a context of personalized and precision medicine. In the last decade, many trials have been conducted with orexin receptor antagonists, which represent an innovative and valid therapeutic option based on the multiple mechanisms of action of orexins on different biological circuits, both centrally and peripherally, and their role in a wide range of medical conditions which are often associated with insomnia. A very interesting aspect of this new category of drugs is that they have limited abuse liability and their discontinuation does not seem associated with significant rebound effects. Further studies on the efficacy of DORAs are required, especially on children and adolescents and in particular conditions, such as menopause. Which DORA is most suitable for each patient, based on comorbidities and/or concomitant treatments, should be the focus of further careful research. On the contrary, studies on SORAs, some of which seem to be appropriate also in insomnia in patients with psychiatric diseases, are still at an early stage and, therefore, do not allow to draw definite conclusions.

Sleep quality evaluation, correlation with headache frequency, and propensity to conversion from episodic to chronic daily headache in migraine patients: A cross-sectional study

Objective

The aim of the study was to determine the association between sleep quality with headache frequency in migraine patients and also to evaluate migraine trigger and non-headache symptoms in episodic and chronic migraine groups and evaluation of the same in poor and good sleepers (GSs) in migraine population.

Materials and Methods

In a cross-sectional and observational study in a tertiary care hospital of East India between January 2018 and September 2020, migraine patients were evaluated. Migraine patients were divided into two groups: Episodic migraine (EM) and chronic migraine (CM) group according to ICHD 3 b classification and into poor sleepers (PSs, Global Pittsburgh Sleep Quality Index [PSQI] >5) and GSs (Global PSQI ≤5). Sleep was evaluated using PQSI - a self-rated questionnaire and disease pattern, associated non-headache symptoms, and triggers were evaluated in between groups. Demographic, headache character, and sleep parameters including seven "component" scores: Subjective sleep quality, sleep latency, sleeps duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication, and daytime dysfunction and global PQSI were compared between groups (EM and CM). Similar parameters were also compared between PSs and GSs group. Statistical analysis was performed using the χ2 test for categorical variables and the t-test and Wilcoxon rank-sum test for continuous variables. Correlation between two normally distributed numerical was tested by Pearson correlation coefficient assessment.

Results

One hundred migraine patients were analyzed, among which 57 were PSs and 43 were GSs and 51 patients had EM and 49 patients had CM. Moderately significant "r" value noted in between headache frequency and global PQSI score (r = 0.45, P < 0.01). In non-headache symptoms, blurring of vision (EM 8 [16%] and CM 16 [33%] P = 0.05), nasal congestion (EM - 3 [6%] and CM - 12 [24%], P = 0.01), and cervical muscle tenderness (EM- 23 [45%] and CM - 34 [69%], P = 0.01) were more prevalent in chronic headache group along with allodynia (EM - 11 [22%] and CM - 25 [51%], P < 0.01).

Conclusion

Chronic headache group had poor subjective sleep quality, increased sleep latency, decreased sleep duration, decreased sleep efficiency, and increased sleep disturbance in comparison to episodic group which has therapeutic implication. The non-headache symptoms which are more prevalent in CM patients increase the overall disability.

Caffeine consumption as a risk factor for childhood and adolescence migraine

BACKGROUND

Caffeine consumption is a risk factor for chronic daily headache but few studies have addressed relationships between pediatric patient caffeine levels and headache severity. We examined associations between serum and urine caffeine levels and headache severity in childhood and adolescent migraine cases.

METHODS

Levels of caffeine and caffeine metabolites in serum and urine samples were determined by liquid chromatography-tandem mass spectrometry (LC-MS/MS). The Wilcoxon rank-sum test was used for comparisons of age, sleep time, headache severity, caffeine consumption, and caffeine detection. Spearman's rank correlation coefficient (ρ) was calculated for associations. Correlations where ρ ≥ 0.3 and differences where p < 0.05 were considered statistically significant.

RESULTS

Of the 40 patients studied, 34 declared caffeine consumption and six declared no caffeine consumption. These two groups did not differ significantly in any of the above clinical parameters. Liquid chromatography-tandem mass spectrometry analysis of both serum and urine samples revealed nine caffeine-negative (level <0.0625 μM) and 31 caffeine-positive cases. The Headache Impact Test-6 (HIT-6) score was higher (p = 0.033) for the caffeine-positive group versus the caffeine-negative group. Caffeine was detected by LC-MS/MS in the serum and/or urine of three of the six patients who declared no caffeine consumption. No significant correlations were observed among age, sleep times, headache severity score, or levels of caffeine and caffeine metabolites.

CONCLUSION

Thirty one of 40 (77.5%) cases of childhood/ adolescence migraine showed serum and urine caffeine positivity based on LC-MS/MS. The HIT-6 score, a measure of headache severity, was significantly higher for caffeine-positive versus caffeine-negative cases. Symptoms of childhood/adolescence migraine were exacerbated by caffeine consumption.

Changes in gamma-aminobutyric acid and glutamate/glutamine levels in the right thalamus of patients with episodic and chronic migraine: A proton magnetic resonance spectroscopy study

OBJECTIVE

To explore gamma-aminobutyric acid (GABA) and glutamate/glutamine (Glx) levels in the right thalamus of patients with episodic migraine (EM) and chronic migraine (CM) and their effects on the chronification of migraine.

BACKGROUND

Migraine affects approximately 1 billion people worldwide, with 2.5%-3% of people with EM progressing to CM each year. Magnetic resonance spectroscopy studies have revealed altered GABA and Glx levels in the thalamus of patients with migraine without aura, but these neurometabolic concentrations are underexplored in the thalamus of patients with CM.

METHODS

In this cross-sectional study, patients with EM and CM were recruited. Mescher-Garwood point resolved spectroscopy sequence was used to acquire neurotransmitter concentrations in the right thalamus of patients with EM and CM and matched healthy controls (HCs).

RESULTS

A total of 26 patients (EM, n = 11; CM, n = 15) and 16 age- and sex-matched HCs were included in the analysis. There were significantly lower GABA+/Water levels in the right thalamus of the CM group (mean ± standard deviation: 2.27 ± 0.4 [institutional units]) than that of the HC group (2.74 ± 0.4) (p = 0.026; mean difference [MD] = -0.5 [i.u.]), and lower Glx/Cr levels in the EM group (mean ± SD: 0.11 ± < 0.1) than in the HCs (0.13 ± < 0.1) and CM group (0.13 ± < 0.1) (p = 0.023, MD < -0.1, and p = 0.034, MD < -0.1, respectively). The GABA+/Glx ratio was lower in the CM group (mean ± SD: 0.38 ± 0.1) compared to the EM group (0.47 ± 0.1) (p = 0.024; MD = -0.1). The area under the curve for GABA+/Water levels in differentiating patients with CM from HCs was 0.83 (95% confidence interval 0.68, 0.98; p = 0.004). Correlation analyses within the migraine group revealed no significant correlation between metabolite concentration levels and headache characteristics after Bonferroni correction.

CONCLUSION

Reduced GABA+/Water levels and imbalance of excitation/inhibition in the right thalamus may contribute to migraine chronification.

Can calcitonin gene-related peptide monoclonal antibody improve migraine and restless legs syndrome?

BACKGROUND

A significant association between migraine and restless legs syndrome (RLS) has been reported, and their coexistence is not uncommon. We report a patient with concomitant migraine and RLS who showed improvement of both migraine and RLS symptoms after treatment with galcanezumab, a calcitonin gene-related peptide (CGRP) monoclonal antibody.

CASE PRESENTATION

A 47-year-old woman had been treated in our outpatient headache clinic for migraine without aura. She had RLS since childhood and had been treated with dopamine agonists and α2δ ligands. Over the past 2 months, the patient suffered from frequent migraine headaches and worsening RLS symptoms, despite ongoing treatment. Therefore, galcanezumab was started. After 1 month, the number of headache days decreased from 20 to 4, and her score on the International RLS Study Group Rating Scale improved from 38 to 10. Her photo/phono/osmo-phobia were also markedly improved. The efficacy of galcanezumab for both headache and RLS was sustained over 5 months.

CONCLUSION

We report a case of improvement of both migraine and RLS after treatment with CGRP monoclonal antibody. Additional studies are needed to clarify how CGRP antagonism affects RLS symptoms in patients with migraine and RLS comorbidity.

Headache in Workers: A Matched Case-Control Study

A case−control study including 446 workers reporting headaches (cases; 136 males and 310 females, mean age 46.71 ± 10.84 years) and 446 age- and sex-matched colleagues without headaches (controls; mean age 45.44 ± 10.13) was conducted in the second half of 2020 in a sample drawn from socio health and commercial services companies to investigate the association of headache with lifestyle, metabolic, and work-related factors. Workers suffering from headache reported higher body weight (OR: 1.92, 95% CI: 1.46−2.53, p < 0.001), higher blood cholesterol (OR: 2.01, 95% CI: 1.46−2.77, p < 0.001), triglyceride (OR: 2.01, 95% CI: 1.20−3.35, p < 0.01), blood glucose (OR: 1.91, 95% CI: 1.16−3.24, p < 0.01), and blood pressure levels (OR: 1.76, 95% CI: 1.23−2.52, p < 0.01). In the year preceding the survey, cases had experienced a higher frequency of workplace violence (OR: 2.29, 95% CI: 1.25−4.20, p < 0.01 for physical aggression, OR: 2.22, 95% CI: 1.45−3.41, p < 0.001 for threat, OR: 2.74, 95% CI: 1.72−4.38, p < 0.001 for harassment) and were more frequently distressed (effort/reward ratio > 1) (OR: 1.82, 95% CI: 1.39−2.40, p < 0.001) than the controls. Compared to the controls, cases also had higher scores on anxiety and depression scales, lower scores on happiness, and lower levels of sleep quality (p < 0.001). The association of headaches with metabolic and mental health problems suggests that monitoring headaches in the workplace could help to identify workers at risk of impairment.

Prediction and associated factors of non-steroidal anti-inflammatory drugs efficacy in migraine treatment

Background: The selection strategy of non-steroidal anti-inflammatory drugs (NSAIDs) for migraine is hard to judge whether it is effective, leading to unnecessary exposure to insufficient or lengthy treatment trials. The goal of the study was to investigate potential predictors of NSAIDs efficacy in migraine therapy and to explore their influence on efficacy. Methods: 610 migraine patients were recruited and assigned into responders and non-responders. Potential predictors among demographic and clinical characteristics for NSAIDs efficacy were extracted using multivariable logistic regression (LR) analysis, and were applied to construct prediction models via machine learning (ML) algorithms. Finally, Cochran-Mantel-Haenszel tests were used to examine the impact of each predictor on drug efficacy. Results: Multivariate LR analysis revealed migraine-related (disease duration, headache intensity and frequency) and psychiatric (anxiety, depression and sleep disorder) characteristics were predictive of NSAIDs efficacy. The accuracies of ML models using support vector machine, decision tree and multilayer perceptron were 0.712, 0.741, and 0.715, respectively. Cochran-Mantel-Haenszel test showed that, for variables with homogeneity of odds ratio, disease duration, frequency, anxiety, and depression and sleep disorder were associated with decreased likelihood of response to all NSAIDs. However, the variabilities in the efficacy of acetaminophen and celecoxib between patients with mild and severe headache intensity were not confirmed. Conclusion: Migraine-related and psychiatric parameters play a critical role in predicting the outcomes of acute migraine treatment. These models based on predictors could optimize drug selection and improve benefits from the start of treatment.

A Preliminary Analysis on the Feasibility and Short-Term Efficacy of a Phase-III RCT on Mindfulness Added to Treatment as Usual for Patients with Chronic Migraine and Medication Overuse Headache

This preliminary analysis of a single-blind phase-III RCT aims to compare the feasibility and short-term efficacy of mindfulness as an add-on to treatment as usual (TaU) in the management of patients with chronic migraine (CM) and medication overuse headache (MOH). Patients were randomized to either TaU (structured withdrawal of overused drugs, patient education and pharmacological prophylaxis) or TaU + MIND, wherein patients additionally received six 90 min weekly group sessions of mindfulness-based therapy. Repeated measures analyses were used to test whether patients in the two arms showed different course with regard to headache frequency and medication intake over a three-month period. Drop-out rates were not different between the two groups: 6/89 (6.7%) and 9/88 (10.2%) among those in TaU and TaU + MIND, respectively. A significant effect of time for all variables was shown, together with a significant effect of time by group, favoring TaU + MIND condition for headache frequency (p = 0.025) and NSAID intake (p = 0.007), controlling for age and CM duration. In total, 45/83 (54.2%) and 69/79 (75.9%) of the patients allocated to TaU and TaU + MIND, respectively, achieved 50% or more headache-day reduction (chi-squared 8.38, p = 0.004). Our preliminary analysis indicates that adding six mindfulness-based sessions to TaU was feasible and showed short-term efficacy in the treatment of patients with CM and MOH.

The Impact of Workplace Violence on Headache and Sleep Problems in Nurses

Workplace violence (WV) is a significant occupational hazard for nurses. Previous studies have shown that WV has a reciprocal relationship with occupational stress. Headaches and sleep problems are early neuropsychological signs of distress. This cross-sectional study aims to ascertain the frequency of physical or verbal assaults on nurses and to study the association of WV with headaches and sleep problems. During their regular medical examination in the workplace, 550 nurses and nursing assistants (105 males, 19.1%; mean age 48.02 ± 9.98 years) were asked to fill in a standardized questionnaire containing the Violent Incident Form (VIF) concerning the episodes of violence experienced, the Headache Impact Test (HIT-6) regarding headaches, and the Pittsburgh Sleep Quality Inventory (PSQI) on sleep quality. Occupational stress was measured using the Effort/Reward Imbalance questionnaire (ERI). Physical and non-physical violence experienced in the previous year was reported by 7.5% and 17.5% of workers, respectively. In the univariate logistic regression models, the workers who experienced violence had an increased risk of headaches and sleep problems. After adjusting for sex, age, job type, and ERI, the relationship between physical violence and headaches remained significant (adjusted odds ratio aOR = 2.25; confidence interval CI95% = 1.11; 4.57). All forms of WV were significantly associated with poor sleep in a multivariate logistic regression model adjusted for sex, age, job type, and ERI (aOR = 2.35 CI95% = 1.44; 3.85). WV was also associated with the impact of headaches and with sleep quality. WV prevention may reduce the frequency of lasting psychoneurological symptoms, such as headaches and poor sleep quality, that interfere with the ability to work.

Management of chronic migraine

Chronic migraine is a neurologic disorder associated with considerable disability, lost productivity, and a profound economic burden worldwide. The past five years have seen a dramatic expansion in new treatments for this often challenging condition, among them calcitonin gene related peptide antagonists and neuromodulatory devices. This review outlines the epidemiology of and diagnostic criteria and risk factors for chronic migraine. It discusses evidence based drug and non-drug treatments, their advantages and disadvantages, and the principles of patient centered care for adults with chronic migraine, with attention to differential diagnosis and comorbidities, clinical reasoning, initiation and monitoring, cost, and availability. It discusses the international guidelines on drug treatment for chronic migraine and evaluates non-drug treatments including behavioral and complementary therapies and lifestyle modifications. Finally, it discusses the management of chronic migraine in special populations, including pediatrics, pregnancy, and older people, and considers future questions and emerging research in the field.

Frequency of migraine according to the ICHD-3 criteria and its association with sociodemographic and triggering factors in Pakistan: A cross-sectional study

Background

Migraine is a primary headache disorder marked by episodes of moderate to severe headache that is unilateral, throbbing in character, having a duration of 4 h to three days, and associated with nausea, vomiting, photophobia, and phonophobia.

Aims

Our study aims to determine the frequency of migraine in Pakistan, its association with sociodemographic variables and triggering factors, and the coping mechanisms used.

Methods

A cross-sectional study was conducted through an online survey from March 19, 2022, to June 15, 2022. The snowball sampling technique was used for data collection. The questions asked included those on sociodemographic information, screening questions, and questions on triggering factors and coping mechanisms. The screening was done using the ICHD-3 criteria and percentages were calculated using SPSS.

Results

Of the 986 respondents, 393 suffered from migraine. The majority of them were female (78.1%), belonged to the age group 20–29 years (69.2%), and were students (76.1%). 32.8% of the migraineurs had a family history of migraine. Most frequent triggers included sleep disturbance (70.5%), stress (66.7%) and fatigue (64.4%). Of the female migraineurs, 31.8% had menstruation as a trigger. The coping mechanisms used included taking rest, medication, staying in a quiet and dark place, and doing massage.

Conclusion

The findings suggest that young adults, especially females, with a stressful and sleep-deprived lifestyle are more vulnerable to migraine. However, further studies must focus on trigger synergy and interrelation of triggers that precipitate migraine so a better understanding can be developed for the prevention, diagnosis, and treatment of migraine.

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Females, majorly students, of the age group 20–29 years were the most affected by migraine.

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The migraine attacks were mostly triggered by sleep disturbance, stress, excess screen time, loud noise, and missed meals.

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The most frequently used coping mechanism by the migraineurs to relieve pain was taking rest.

Sleep Disturbances in Neurological Disease: A Target for Intervention

Sleep is a biological function required for neurological and general health, but a significant and under-recognized proportion of the population has disturbed sleep. Here, we briefly overview the biology of sleep, sleep requirements over the lifespan, and common sleep disorders. We then turn our attention to five neurological diseases that significantly contribute to global disease burden and neurology practice makeup: epilepsy, headache, ischemic stroke, Parkinson's disease, and Alzheimer's disease. For each disease, we review evidence that sleep disturbances contribute to disease risk and severity and discuss existing data that addressing sleep disturbances may have disease-modifying effects. We provide recommendations derived from the literature and existing clinical guidelines to facilitate the evaluation and management of sleep disturbances within the context of each neurological disease. Finally, we synthesize identified needs and commonalities into future directions for the field and practical sleep-related recommendations for physicians caring for patients at risk for or currently suffering from neurological disease.

Association between sleep quality, migraine and migraine burden

Background

The relationship between sleep and migraine is well known to be bidirectional. However, few studies have systematically assessed the association between sleep quality and the risk of developing migraine, and its gender and age differences are unclear. And there is currently limited evidence on the associations between sleep quality and migraine-related burdens.

Objective

The objectives of this study were to: (1) explore the association between sleep quality and the risk of developing migraine, and its gender and age differences; (2) investigate the associations between sleep quality and the total pain burden, severity, disability, headache impact, quality of life, anxiety, and depression of migraine patients.

Methods

This study consecutively enrolled 134 migraine patients and 70 sex- and age-matched healthy control subjects. Sleep quality was assessed through the Pittsburgh Sleep Quality Index (PSQI). Logistic regression and linear regression analyses were used to explore the associations between sleep quality with the risk of developing migraine and the migraine-related burdens.

Results

The prevalence of poor sleep quality in migraine patients was significantly higher than that in subjects without migraine (P &lt; 0.001). After adjusting for various confounding factors, the risk of migraine with poor sleep quality remained 3.981 times that of those with good sleep quality. The subgroup analysis showed that there were significant additive interactions between poor sleep quality and the risk of migraine in gender, age, and education level (P for interaction &lt; 0.05), and the stronger correlations were found in females, populations with ages more than 35 years old, and with lower education levels. In addition, multivariate linear regression analysis showed that poor sleep quality was significantly and independently associated with the total pain burden, severity, headache impact, quality of life, anxiety, and depression in migraine patients (P trend &lt; 0.05).

Conclusion

Poor sleep quality was significantly independently associated with an increased risk of developing migraine and the migraine-related burdens. Strengthening PSQI assessment is valuable for the early prevention and treatment of migraine patients.

Behavioral and psychological factors in individuals with migraine without psychiatric comorbidities

BACKGROUND

It is well known that the course of migraine is influenced by comorbidities and that individual psychological characteristics may impact on the disease. Proper identification of psychological factors that are relevant to migraine is important to improve non-pharmacological management. This study aimed at investigating the relationship between psychological factors and migraine in subjects free of psychiatric comorbidities.

METHODS

A sample of women with episodic (EM) and chronic migraine (CM) without history of psychiatric comorbidities were included in this cross-sectional study. The study also included female healthy controls (HC) without migraine or other primary headaches. We evaluated sleep, anxiety, depression, intolerance of uncertainty, decision making style and tendence to pain catastrophizing by validated self-report questionnaires or scales. Comparisons among groups were performed using ANOVA and Bonferroni post-hoc tests. Statistical significance was set at p < 0.05.

RESULTS

A total of 65 women with EM (mean age ± SD, 43.9 ± 7.2), 65 women with CM (47.7 ± 8.5), and 65 HC (43.5 ± 9.0) were evaluated. In sleep domains, CM patients reported poorer overall sleep quality, more severe sleep disturbances, greater sleep medication use, higher daytime dysfunction, and more severe insomnia symptoms than HC. EM group showed better sleep quality, lower sleep disturbances and sleep medication use than CM. On the other hand, the analysis highlighted more severe daytime dysfunction and insomnia symptoms in EM patients compared to HC. In anxiety and mood domains, CM showed greater trait anxiety and a higher level of general anxiety sensitivity than HC. Specifically, CM participants were more afraid of somatic and cognitive anxiety symptoms than HC. No difference in depression severity emerged. Finally, CM reported a higher pain catastrophizing tendency, more severe feeling of helplessness, and more substantial ruminative thinking than EM and HC, whilst EM participants reported higher scores in the three above-mentioned dimensions than HC. The three groups showed similar decision-making styles, intolerance of uncertainty, and strategies for coping with uncertainty.

CONCLUSIONS

Even in individuals without psychiatric comorbidities, specific behavioral and psychological factors are associated with migraine, especially in its chronic form. Proper identification of those factors is important to improve management of migraine through non-pharmacological strategies.

Applying a biopsychosocial model to migraine: rationale and clinical implications

Migraine is a complex condition in which genetic predisposition interacts with other biological and environmental factors determining its course. A hyperresponsive brain cortex, peripheral and central alterations in pain processing, and comorbidities play a role from an individual biological standpoint. Besides, dysfunctional psychological mechanisms, social and lifestyle factors may intervene and impact on the clinical phenotype of the disease, promote its transformation from episodic into chronic migraine and may increase migraine-related disability.Thus, given the multifactorial origin of the condition, the application of a biopsychosocial approach in the management of migraine could favor therapeutic success. While in chronic pain conditions the biopsychosocial approach is already a mainstay of treatment, in migraine the biomedical approach is still dominant. It is instead advisable to carefully consider the individual with migraine as a whole, in order to plan a tailored treatment. In this review, we first reported an analytical and critical discussion of the biological, psychological, and social factors involved in migraine. Then, we addressed the management implications of the application of a biopsychosocial model discussing how the integration between non-pharmacological management and conventional biomedical treatment may provide advantages to migraine care.

Efficacy of contralateral acupuncture in women with migraine without aura: protocol for a randomised controlled trial

INTRODUCTION

Migraine is a common neurological disorder with a higher prevalence occurring in women. Migraine without aura (MwoA) is the most common type of migraine. In recent years, the safety and effectiveness of acupuncture for migraines have been internationally recognised. Contralateral acupuncture (CAT) (Jùcì) is an ancient classic acupuncture technique from Huang Di Nei Jing that refers to the acupoints on the right side (healthy side) selected for diseases on the left (affected side) and vice versa. Some studies have shown that efficacy of CAT on the painful disorder is even better than ipsilateral acupuncture (IAT), but there remains a lack of high-quality evidence to support it.

METHODS AND ANALYSIS

This is a single-centre, randomised and sham-controlled clinical trial in China with three parallel groups that aim to evaluate the efficacy of CAT in women with unilateral MwoA. 243 participants will be randomly divided into the experimental group (CAT group), control group 1 (IAT group) and control group 2 (sham acupuncture group) (1:1:1 allocation ratio). Each group will be given 30-minute treatment sessions, once every other day, approximately three times per week, for a total of 24 treatments and follow-up visits two times. The primary outcome is the changes in days of migraine attacks. The secondary outcomes are frequency of migraine attacks, intensity of migraine, migraine duration, the dose of intake of acute medication, the Migraine-Specific Quality of Life Questionnaire, the Migraine Disability Assessment Score, the Headache Impact Test-6 and the Pittsburgh Sleep Quality Index. The data will be collected at the baseline time (week 0), end of treatment (week 4-8) and the follow-up time (week 12-16). Adverse events will be collected and recorded during each treatment.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Ethics Committee of the Sports Trauma Specialist Hospital of Yunnan Province (2021-01). All participants will provide written informed consent before randomisation. The results of this study will be published in a peer-reviewed journal and presented at conferences.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Registration Center (ChiCTR2100051479).

Erenumab Impact on Sleep Assessed With Questionnaires and Home-Polysomnography in Patients With Migraine: The ERESON Study

Introduction

Migraine and sleep share a complex and unclear relationship. Poor sleep may trigger migraine attacks; migraine, in turn, is frequently associated with sleep disorders. Few previous studies used questionnaires to assess sleep changes in patients who were treated with migraine-preventive medications (MPMs). More extensive polysomnography (PSG)-based studies for this purpose were not available.

Objective

To investigate possible sleep changes in patients with migraine treated with erenumab, using validated sleep questionnaires and home-PSG.

Methods

This observational, prospective, open-label pilot study was conducted at the Clinical Neurology Unit Headache Center of Udine University Hospital from 2020 to 2021. Patients were treated with erenumab as monotherapy or add-on treatment for migraine prevention. Sleep changes were evaluated with questionnaires and polysomnographic recordings at baseline, after 3 and 12 months of treatment. Erenumab efficacy and safety in migraine prophylaxis were also investigated.

Results

Twenty-nine patients completed 3 months of follow-up, whereas 15 patients completed 12 months. We found a weak trend of improvement in daytime somnolence after 3 months of treatment, with stronger results after 12 months (median Epworth Sleepiness Scale (ESS) score from 6.0 to 4.0, p = 0.015); a significant improvement in subjective sleep quality (median Pittsburgh Sleep Quality Index (PSQI) total score from 7 to 5; p = 0.001) was also observed. Home-PSG showed a significant increase in objective sleep efficiency (SE), both after 3 (from 88.1 to 91.0, p = 0.006) and 12 months (from 87.1 to 91.0, p = 0.006) of treatment. In addition, our data confirmed erenumab effectiveness and safety in migraine prevention.

Conclusion

Our study demonstrated an improvement in both subjective and objective sleep quality in patients treated with a migraine-preventive therapy. Erenumab, in particular, does not cross the blood-brain barrier (BBB), thus a direct effect on sleep is unlikely. Future studies are needed to better understand the mutual influence between migraine and sleep disorders.

The effectiveness of non-pharmacological sleep interventions for people with chronic pain: a systematic review and meta-analysis

Objective

About two thirds of people with chronic pain report problems sleeping. We aimed to evaluate the effectiveness of non-pharmacological sleep interventions for improving sleep in people with chronic pain.

Design

We conducted a systematic review of non-pharmacological and non-invasive interventions to improve sleep quality or duration for adults with chronic non-cancer pain evaluated in a randomised controlled trial. Our primary outcome of interest was sleep; secondary outcomes included pain, health-related quality of life, and psychological wellbeing. We searched the Cochrane Library, MEDLINE, Embase, PsycINFO and CINAHL from inception to April 2020. After screening, two reviewers evaluated articles and extracted data. Meta-analysis was conducted using a random effects model. Risk of bias was assessed with the Cochrane tool.

Results

We included 42 trials involving 3346 people randomised to 94 groups, of which 56 received an intervention targeting sleep. 10 studies were of fair and 32 of good methodological quality. Overall risk of bias was judged to be low in 11, high in 10 and unclear in 21 studies. In 9 studies with 385 people randomised, cognitive behavioural therapy for insomnia showed benefit post-treatment compared with controls for improved sleep quality, standardised mean difference − 1.23 (95%CI -1.76, − 0.70; p < 0.00001). The effect size was only slightly reduced in meta-analysis of 3 studies at low risk of bias. The difference between groups was lower at 3 and 6 months after treatment but still favoured cognitive behavioural therapy for insomnia. Pain, anxiety and depression were reduced post-treatment, but evidence of longer term benefit was lacking. There was no evidence that sleep hygiene interventions were effective in improving sleep and there was some evidence in comparative studies to suggest that cognitive behavioural therapy for insomnia was more effective than sleep hygiene.

Numerous other interventions were evaluated in small numbers of studies, but evidence was insufficient to draw conclusions about effectiveness.

Conclusions

Cognitive behavioural therapy for insomnia is an effective treatment to improve sleep for people with chronic pain, but further high-quality primary research is required to explore combined CBT content that will ensure additional improvements to pain, quality of life and psychological health and longer-term maintenance of benefits. Primary research is also needed to evaluate the effectiveness of interventions for which insufficient evidence exists.

Trial registration

PROSPERO registration number: CRD42019093799.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05318-5.

Enhanced mindfulness-based stress reduction in episodic migraine-effects on sleep quality, anxiety, stress, and depression: a secondary analysis of a randomized clinical trial

ABSTRACT

Patients with migraine suffer from high morbidity related to the repeated headache attacks, characteristic of the disorder, poor sleep, and a high prevalence of comorbid psychosocial disorders. Current pharmacological therapies do not address these aspects of migraine, but nonpharmacological treatments such as mindfulness-based stress reduction (MBSR) have been shown to improve both pain and psychological well-being. In this secondary analysis, we examined the change over time in sleep quality and psychosocial outcomes from the magnetic resonance imaging outcomes for mindfulness meditation clinical trial and assessed how these mediated treatment response (50% reduction in headache frequency postintervention). We also examined the relationship between baseline values and treatment response. The trial (primary outcomes previously reported) included 98 patients with episodic migraine randomized to either enhanced MBSR (MBSR+) or stress management for headache. They completed psychosocial questionnaires and headache diaries at baseline (preintervention), midintervention (10 weeks after baseline), and postintervention (20 weeks after baseline). There was a significant improvement in sleep quality from baseline to postintervention (P = 0.0025) in both groups. There were no significant changes from baseline or between groups in anxiety, depression, and stress. There was also no significant association between baseline scores and treatment response. Mediation analysis showed a significant indirect effect of 6% for sleep: In other words, small improvements in sleep may have contributed to the efficacy of MBSR+.Trial registration: NCT02133209.

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.

Healthy Dwelling: Design of Biophilic Interior Environments Fostering Self-Care Practices for People Living with Migraines, Chronic Pain, and Depression

The benefits of biophilic interior design have been recognized by healthcare facilities, but residential environments receive relatively less attention with respect to improving the health of people living with chronic diseases. Recent “stay-at-home” restrictions due to the COVID-19 pandemic further emphasized the importance of creating interior spaces that directly and indirectly support physical and mental health. In this viewpoint article, we discuss opportunities for combining biophilic interventions with interior design, fostering disease-specific self-care. We provide examples of designing residential spaces integrating biophilic interventions, light therapy, relaxation opportunities, mindfulness meditation, listening to music, physical activities, aromatherapy, and quality sleep. These modalities can provide the clinical benefits of reducing migraine headaches and chronic pain, as well as improving depressive symptoms. The disease-specific interior environment can be incorporated into residential homes, workplaces, assisted-living residences, hospitals and hospital at home programs. This work aims to promote a cross-disciplinary dialogue towards combining biophilic design and advances in lifestyle medicine to create therapeutic interior environments and to improve healthcare outcomes.

[Research progress on the mechanism of comorbidities of vestibular migraine and sleep disorders]

Vestibular migraine （VM） is one of the common vestibular diseases characterized by recurrent vertigo and migraine. Studies have shown that the sleep structure of VM patients is similar to that of migraine patients, and they have a common pathophysiological pathogenesis. There is a strong correlation between VM and the clinical symptoms of sleep disorders. Sleep disorders can trigger VM. On the contrary, VM can affect sleep regulatory centers and lead to structural sleep disorders. In addition, there is a common relationship between VM and sleep disorders in neuroanatomy, neurotransmitters and neural pathways. A correct understanding of the relationship between vestibular migraine and sleep disorders can provide some help for clinical diagnosis and treatment. This article reviews the relationship between vestibular migraine and the pathogenesis of sleep disorders.

Chronic migraine treatment: multidisciplinary approach. Case report

We described clinical case of chronic migraine and such comorbid disorders as insomnia and panic disorder. The influence of anxiety, insomnia, painkillers overuse on the chronicity of migraine has been shown. Multidisciplinary program was made for treatment of patient with chronic migraine, insomnia and panic disorder. Multidisciplinary program included education, detoxification therapy, cognitive-behavioral therapy and pharmacotherapy. Patient's mistaken ideas about disorders was changed by using of cognitive-behavioral therapy. Also techniques of cognitive-behavioral therapy were needed for education of patient about effective skills to overcome pain, insomnia and anxiety. The transformation of migraine from chronic to episodic, improved sleep, improved emotional state and functional activity were noted after 3 months of treatment. Follow-up of the patient for 12 months showed long lasting positive effect of treatment for chronic migraine, insomnia and panic disorder.

Periodic limb movements during sleep: a narrative review

Objective

Using narrative review techniques, this paper evaluates the evidence for separable underlying patho-mechanisms of periodic limb movements (PLMs) to separable PLM motor patterns and phenotypes, in order to elucidate potential new treatment modalities.

Background

Periodic limb movement disorder (PLMD) is estimated to occur in 5–8% of the paediatric population and 4–11% of the general adult population. Due to significant sleep fragmentation, PLMD can lead to functional impairment, including hyperactivity and delayed language development in children, and poor concentration and work performance in adults. Longitudinal data demonstrate that those with PLMD are at greater risk of depression and anxiety, and a 4-fold greater risk of developing dementia. PLMD has been extensively studied over the past two decades, and several key insights into the genetic, pathophysiological, and neural correlates have been proposed. Amongst these proposals is the concept of separable PLM phenotypes, proposed on the basis of nocturnal features such as the ratio of limb movements and distribution throughout the night. PLM phenotype and presentation, however, varies significantly depending on the scoring utilized and the nocturnal features examined, across age, and co-morbid clinical conditions. Furthermore, associations between these phenotypes with major neurologic and psychiatric disorders remain controversial.

Methods

In order to elucidate potential divergent biological pathways that may help clarify important new treatment modalities, this paper utilizes narrative review and evaluates the evidence linking PLM motor patterns and phenotypes with hypothesised underlying patho-mechanisms. Distinctive, underlying patho-mechanisms include: a pure motor mechanism originating in the spinal cord, iron deficiency, dopamine system dysfunction, thalamic glutamatergic hyperactivity, and a more cortical-subcortical interplay. In support of the latter hypothesis, PLM rhythmicity appears tightly linked to the microarchitecture of sleep, not dissimilarly to the apnoeic/hypopneic events seen in obstructive sleep apnea (OSA).

Conclusions

This review closes with a proposal for greater investigation into the identification of potential, divergent biological pathways. To do so would require prospective, multimodal imaging clinical studies which may delineate differential responses to treatment in restless legs syndrome (RLS) without PLMS and PLMS without RLS. This could pave the way toward important new treatment modalities.

Current Perspectives on the Impact of Chronic Migraine on Sleep Quality: A Literature Review

OBJECTIVE

Recent studies have shown that sleep problems occur in migraineurs and poor sleep causes chronification, but the mechanisms by which chronic migraine affects sleep quality are still unknown. This review aims to analyze commonly reported sleep disturbances in chronic migraine (CM) and determine the effect of CM on sleep quality.

MATERIALS AND METHODS

We conducted a comprehensive review of all published articles on CM and sleep quality from inception to March 2022 in the literature. Clinical trials, observational studies, and case series (≥20 cases) were included. Two reviewers and a supervisor reviewed the titles and abstracts of all search results with predefined inclusion and exclusion criteria. PubMed search for randomized controlled trials and open studies on CM and sleep quality reported in English between 1983 and 2022 was conducted using the keywords including chronic migraine, sleep, insomnia, sleep quality, polysomnography, and Pittsburgh Sleep Quality Index.

RESULTS

A total of 535 potentially relevant articles were found. A total of 455 articles and reviews, meta-analyses published in any language other than English, with other exclusion criteria, were excluded from the review. In the remaining articles, 36 clinical studies, reviewing sleep quality and its association with migraine, were identified and reviewed. Evidence from this review shows that poor sleep and migraine chronicity are intertwined with other accompanying comorbidities and dysregulation of circadian rhythm that innovative treatments promise to bring relief to both poor sleep as well as migraine.

CONCLUSION

Sleep disorders are common in CM and the association between migraine chronification and sleep quality is bidirectional. Comorbid conditions with accompanying frequent attacks in migraine may impair sleep quality. While the maladaptive pain process worsens sleep, poor sleep quality also negatively affects migraine pain. Sleep disturbance, which is affected by worsening migraine attacks, causes deterioration in the quality of life, loss of workforce, and economic burden.

Identification of Novel Genetic Variants Associated with Insomnia and Migraine Comorbidity

PURPOSE

Although insomnia and migraine are often comorbid, the genetic association between insomnia and migraine remains unclear. This study aimed to identify susceptibility loci associated with insomnia and migraine comorbidity.

PATIENTS AND METHODS

We performed a genome-wide association study (GWAS) involving 1063 clinical outpatients at a tertiary hospital in Taiwan. Migraineurs with and without insomnia were genotyped using the Affymetrix Axiom Genome-Wide TWB 2.0. We performed association analyses for the entire cohort and stratified patients into the following subgroups: episodic migraine (EM), chronic migraine (CM), migraine with aura (MA), and migraine without aura (MoA). Potential correlations between SNPs and clinical indices in migraine patients with insomnia were examined using multivariate regression analysis.

RESULTS

The SNP rs1178326 in the gene HDAC9 was significantly associated with insomnia. In the EM, CM, MA, and MoA subgroups, we identified 30 additional susceptibility loci. Multivariate regression analysis showed that SNP rs1178326 also correlated with higher migraine frequency and the Migraine Disability Assessment (MIDAS) questionnaire score. Finally, two SNPs that had been previously reported in a major insomnia GWAS were also significant in our migraineurs, showing a concordant effect.

CONCLUSION

In this GWAS, we identified several novel loci associated with insomnia in migraineurs in a Han Chinese population in Taiwan. These results provide insights into the possible genetic basis of insomnia and migraine comorbidity.

External Trigeminal Nerve Stimulation as a Non-pharmacological Option for the Prevention and Acute Treatment of Migraine

Migraine is a common condition affecting approximately 1.04 billion people worldwide. Despite the available pharmaceutical therapies, patients with migraine often prefer, or may require, non-medicinal treatments for their disease. External trigeminal nerve stimulation (e-TNS) is a non-invasive, non-drug device treatment approved by the US Food and Drug Administration for the prevention and acute treatment of migraine. The trigeminovascular system plays a key role in migraine pathophysiology; e-TNS percutaneously stimulates the supraorbital and supratrochlear branches of the ophthalmic division of the trigeminal nerve. This article reviews published studies of e-TNS in the prevention and acute treatment of migraine, highlights the versatility of e-TNS in individualizing migraine treatment and discusses future directions for research and clinical applications of e-TNS therapy.

Relation of hypertension with episodic primary headaches and chronic primary headaches in population of Rafsanjan cohort study

Headache has a variety of types, such as episodic primary headaches (EPH) and chronic primary headache (CPH) in its primary form. There is a positive correlation between these two types of headaches and hypertension (HTN), but in some works this correlation has been reported negatively. Therefore, we planned to study HTN-CPH as well as HTN-EPH correlation in our population. A sample of Rafsanjan population (10,000 individuals) entered the cohort study, as one of the Prospective Epidemiological Research Studies in Iran (PERSIAN). We compared the frequency of HTN categories in CPH and EPH cases with a normal population. Out of 9933 participants (46.6% males and 53.4% females) about 29% had EPH and 7.5% had CPH. HTN was found in 24.27% of EPH cases and 31.98% of CPH cases. HTN was also found to be associated with EPH and CPH in the crude model. Two Categories of HTN (Long controlled and uncontrolled) were not associated with EPH. On the other hand, CPH showed associations with all of the HTN categories. After included all variables and confounders, EPH and CPH had association with HTN without any considerable changes. There is strong HTN-EPH as well as HTN-CPH correlations in the studied population.

Association Between Migraine Complicated With Restless Legs Syndrome and Vitamin D

Background: This study aimed to evaluate the prevalence of restless legs syndrome (RLS) in patients with migraine and explore its association with vitamin D deficiency, aiming to provide biological support for the comorbidity of migraine with RLS, and shed new lights into clinical diagnosis and treatment.

Methods: A case-control study was performed on 175 migraine patients and 151 non-headache controls. The information of all subjects concerning headache severity [visual analog scale (VAS) score], RLS, RLS severity [International Restless Legs Scale (IRLS) score], sleep quality [Pittsburgh sleep quality index (PSQI)], anxiety and depression symptoms [hospital anxiety and depression scale (HADS)], and demographic data were collected. At the same time, serum 25-(OH) D levels were also measured (concentration <20 ng/ml was defined deficiency). Afterward, the logistic regression model was adopted to explore the risk factors for RLS in patients with migraines.

Results: Compared with control group, migraine group had lower vitamin D levels [(21.10 ± 6.58) vs. (16.42 ± 5.6) ng/ml, P < 0.001], a higher rate of vitamin D deficiency (45.03 vs. 72%, P <0001), higher prevalence of RLS (6.62 vs. 22.29%, P < 0.001). Compared with the pure RLS group, RLS with the migraine group had lower vitamin D levels and higher IRLS score (P < 0.05). Compared with pure migraine group, migraine with RLS group had lower vitamin D levels [(17.36 ± 5.56) vs. (13.15 ± 4.42) ng/ml, P < 0.001], higher incidence of vitamin D deficiency (66.18 vs. 92.31%, P = 0.001), higher frequency of headache attacks (P = 0.004). Thereafter, the multivariate logistic regression model was employed to adjust confounding factors such as age, gender, season, frequency of headache attacks, PSQI score, and HADS scores. According to the results vitamin D deficiency in patients with migraines was an independent risk factor for RLS (OR = 5.03, 95%CI: 1.2–21.16, P = 0.027).

Conclusions: The prevalence of RLS in migraine patients was significantly higher than that in the non-headache population. Besides, vitamin D levels decreased, while the incidence of vitamin D deficiency increased in the migraine patients complicated with RLS. Finally, the occurrence of RLS in migraine patients was significantly related to vitamin D deficiency.

Association Between Asthma and Migraine: A Systematic Review and Meta-Analysis of Observational Studies

Objectives: The purpose of this study was to determine the association between asthma and migraine and assess the risk for migraine in patients with asthma.

Methods: We systematically searched the Cochrane Library, PubMed, Medical Literature Analysis and Retrieval System Online (MEDLINE), and Excerpta Medica dataBASE (EMBASE) databases from inception to September 26, 2021, for indexed observational studies that examined either the odds or risk of migraine in subjects with asthma. The qualities of the included studies were evaluated using the Newcastle–Ottawa Scale. A random-effects meta-analysis was performed to calculate the odds ratio for case-control and cross-sectional studies and the risk ratio for cohort studies.

Results: Seven observational studies (four cross-sectional and three cohort studies) with a total of 549,534 study subjects were included in this systematic review and meta-analysis and selected for data extraction. Four articles were considered to be of moderate quality; other studies were considered to be of high quality. Asthma was associated with increased odds (OR, 1.85; 95%CI, 1.39–2.45) and risk of migraine (RR, 1.70; 95%CI, 1.52–1.90).

Conclusions: The available evidence that supports the existence of an association between asthma and migraine is limited. Clinicians should be aware that patients with asthma show both increased prevalence and incidence of migraine. Further studies are warranted to further clarify the relationship between asthma and migraine.

Systematic Review Registration:https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=185881, identifier: CRD42020185881.

Subjective Symptoms in Magnetic Resonance Imaging Personnel: A Multi-Center Study in Italy

Introduction: Magnetic Resonance Imaging (MRI) personnel have significant exposure to static and low-frequency time-varying magnetic fields. In these workers an increased prevalence of different subjective symptoms has been observed. The aim of our study was to investigate the prevalence of non-specific subjective symptoms and of "core symptoms" in a group of MRI personnel working in different centers in Italy, and of possible relationships with personal and occupational characteristics. Methods: The occurrence of 11 subjective symptoms was evaluated using a specific questionnaire with 240 subjects working in 6 different Italian hospitals and research centers, 177 MRI health care and research personnel and 63 unexposed subjects employed in the same departments. Exposure was subjectively investigated according to the type of MRI scanner (≤1.5 vs. ≥3 T) and to the number of MRI procedures attended and/or performed by the personnel, even if no information on how frequently the personnel entered the scanner room was collected. The possible associations among symptoms and estimated EMF exposure, the main characteristics of the population, and job stress perception were analyzed. Results: Eighty-six percent of the personnel reported at least one symptom; drowsiness, headache, and sleep disorders were the most frequent. The total number of symptoms did not differ between exposed persons and controls. Considering the total number of annual MRI procedures reported by the personnel, no significant associations were found nor with the total number of symptoms, nor with "core symptoms." Only subjects complaining of drowsiness also reported a significantly higher mean annual number of MRI procedures with ≤ 1.5 T scanners when compared with exposed subjects without drowsiness. In a multivariate model, subjects with a high level of perceived stress complained of more symptoms (p = 0.0002). Conclusions: Our study did not show any association between the occurrence of reversible subjective symptoms, including the more specific "core symptoms," and the occupational exposure of MRI personnel to static and low-frequency time-varying magnetic fields. On the other hand, the role played by occupational stress appears to be not negligible. In further research in this field, measurements of EMF exposure should be considered.

Nightmares in Migraine: A Focused Review

Nightmares usually occur during the sleep phase of rapid eye movement (REM) and are associated with some physical symptoms, including sweating, shortness of breath, and lower limb movements. Emotions of fear, anger, shame, and sadness may also accompany nightmares. These symptoms can occur during dreaming, upon awakening, or later when the dream experience is recollected. Nightmares may sporadically occur for everyone, but nightmare disorders are associated with features of impaired mental and physical health and require professional medical treatment. The occurrence of nightmares with several disorders has been reported in the literature, but in migraines it has only been investigated in a small number of studies. Considering the existing relationship between sleep disorders and migraine, the occurrence of nightmares in migraine can negatively affect this association and elevate the risk of depression and anxiety. This, in turn, further reduces the quality of life of affected individuals. Hence, expanding the knowledge on the link between nightmares and migraine, promoting an acceptable quantity and quality of sleep through pharmacological and nonpharmacological interventions in the management of nightmares in migraine, and further scientific investigation of the biopsychosocial mechanisms underlying the link, will be highly valuable for optimal care. This focused review, therefore, gives a brief overview of the current understanding of nightmares in migraine to highlight the open questions and value of further research. The ultimate goal is to contribute to timely recognition and sufficient action to offer beneficial outcomes for affected patients.

Association Between Insomnia and Migraine Risk: A Case-Control and Bidirectional Mendelian Randomization Study

Background

The causal relationship between insomnia and migraine is contradictory and no study has been carried out among the Chinese population to date.

Methods

In this case, we conducted a case–control study and a bidirectional mendelian randomization (MR) analysis to determine whether insomnia is causally related to the development of migraine. The instrumental variables for insomnia were derived from the largest genome-wide association study of 1,331,010 participants, while the genetic instruments for migraine were available from the largest meta-analysis of migraine with 59,674 cases and 316,078 controls.

Results

In case–control study, subjects with insomnia have significantly higher risk of migraine (OR=4.29, 95% CI: 3.21–5.74, P<0.001), compared with those without insomnia. The bidirectional two-sample MR analysis revealed that insomnia was significantly associated with higher risk of migraine (OR=1.24, 95% CI: 1.11–1.38, P=1.01×10-4), and the results were validated in the UK Biobank data. The results showed no indication for directional pleiotropy effects as assessed by the MR-Egger intercept (P>0.05).

Conclusion

Conclusively, our study highlighted that increased migraine risk was confined to subjects with a genetic pre-disposition to insomnia, and these findings had potential implications for improving the sleep quality to reduce the burden of migraine.

Comorbidities of primary headache disorders: a literature review with meta-analysis

Background

Primary headache disorders are common and burdensome conditions. They are associated to several comorbidities, such as cardiovascular or psychiatric ones, which, in turn, contribute to the global burden of headache. The aim of this study is to provide a comprehensive description of the pooled prevalence of comorbidities of primary headache disorders using a meta-analytical approach based on studies published between 2000 and 2020.

Methods

Scopus was searched for primary research (clinical and population studies) in which medical comorbidities were described in adults with primary headache disorders. Comorbidities were extracted using a taxonomy derived from the Global Burden of Disease (GBD) study. We compared prevalence of comorbidities among headache sufferers against general population using GBD-2019 estimates, and compared comorbidities’ proportions in clinical vs. population studies, and by age and gender.

Results

A total of 139 studies reporting information on 4.19 million subjects with primary headaches were included: in total 2.75 million comorbidities were reported (median per subject 0.64, interquartile range 0.32–1.07). The most frequently addressed comorbidities were: depressive disorders, addressed in 51 studies (pooled proportion 23 %, 95 % CI 20–26 %); hypertension, addressed in 48 studies (pooled proportion 24 %, 95 % CI 22–26 %); anxiety disorders addressed in 40 studies (pooled proportion 25 %, 95 % CI 22–28 %). For conditions such as anxiety, depression and back pain, prevalence among headache sufferers was higher than in GBD-2109 estimates. Associations with average age and female prevalence within studies showed that hypertension was more frequent in studies with higher age and less females, whereas fibromyalgia, restless leg syndrome, and depressive disorders were more frequent in studies with younger age and more female.

Conclusions

Some of the most relevant comorbidities of primary headache disorders – back pain, anxiety and depression, diabetes, ischemic heart disease and stroke – are among the most burdensome conditions, together with headache themselves, according to the GBD study. A joint treatment of headaches and of these comorbidities may positively impact on headache sufferers’ health status and contribute to reduce the impact of a group of highly burdensome diseases.

Supplementary Information

The online version contains supplementary material available at 10.1186/s10194-021-01281-z.

Metabolic Aspects of Migraine: Association With Obesity and Diabetes Mellitus

Migraine is a disabling neurovascular disorder, characterized by moderate to severe unilateral headaches, nausea, photophobia, and/or phonophobia, with a higher prevalence in women than in men, which can drastically affect the quality of life of migraine patients. In addition, this chronic disorder is related with metabolic comorbidities associated with the patient's lifestyle, including obesity and diabetes mellitus (DM). Beyond the personal and socioeconomic impact caused by migraine, obesity and DM, it has been suggested that these metabolic disorders seem to be related to migraine since: (i) they are a risk factor for developing cardiovascular disorders or chronic diseases; (ii) they can be influenced by genetic and environmental risk factors; and (iii) while clinical and epidemiological studies suggest that obesity is a risk factor for migraine, DM (i.e., type 1 and type 2 DM) have been reported to be either a protective or a risk factor in migraine. On this basis, and given the high worldwide prevalence of migraine, obesity, and DM, this article provides a narrative review of the current literature related to the association between the etiology and pathophysiology of migraine and these metabolic disorders, considering lifestyle aspects, as well as the possible involvement of neurotransmitters, neuropeptides, and/or sex hormones. While a link between migraine and metabolic disorders has been suggested, many studies are contradictory and the mechanisms involved in this association are not yet sufficiently established. Therefore, further research should be focused on understanding the possible mechanisms involved.

Migraine and Sleep-An Unexplained Association?

Migraine and sleep disorders are common chronic diseases in the general population, with significant negative social and economic impacts. The association between both of these phenomena has been observed by clinicians for years and is confirmed by many epidemiological studies. Despite this, the nature of this relationship is still not fully understood. In recent years, there has been rapid progress in understanding the common anatomical structures of and pathogenetic mechanism between sleep and migraine. Based on a literature review, the authors present the current view on this topic as well as ongoing research in this field, with reference to the key points of the biochemical and neurophysiological processes responsible for both these disorders. In the future, a better understanding of these mechanisms will significantly expand the range of treatment options.

Allostatic Load in Perimenopausal Women With Migraine

Objective: There is very limited data on women with migraine disease as they age and transition to menopause. Despite evidence for the increased burden of the disease during this transition, there is no data on the association between migraine and allostatic load as a marker of cumulative biological risk. We aimed to determine whether women with migraine suffer from higher levels of allostatic load during perimenopausal transition. Methods: A total of 2,105 perimenopausal women from the first wave of the Study of Women's Health Across the Nation (SWAN) were included in this study. Allostatic Load (AL) score was estimated for each participant from the measurements of: systolic and diastolic blood pressure, C-reactive protein level, high-density lipoprotein cholesterol level, total cholesterol level, waist-to-hip ratio, fasting serum glucose, triglycerides, and dehydroepiandrosterone levels. Results: Of the 2,105 participants included in the study, there were 369 migraineurs and 1,730 controls. Migraineurs had 63% higher odds of increased load score (odds ratio 1.63; 95% confidence interval, 1.17-2.29). Compared to controls, migraineurs were more likely to experience sleep problems in the univariate analysis, however despite the high burden of sleep problems, there were no significant associations between allostatic load and sleep disturbances in perimenopausal women with migraine after controlling for other factors. Conclusion: This is the first study to systematically and quantitatively examine allostatic load in migraine patients. The findings establish that migraineurs are more likely to experience higher allostatic load than their non-migraine counterparts during perimenopausal transition. The findings encourage new lines of investigation for lowering the burden of the disease through interventions that modify the levels of allostatic load biomarkers examined in this study.