Neurometabolic correlates of depression and disability in episodic cluster headache

Therapy for Psychiatric Comorbidities in Patients with Episodic Cluster Headache: A Prospective Multicenter Study

PURPOSE

To explore changes of depression, anxiety and sleep disturbance in patients with episodic cluster headache inside and outside the attack period and assess the therapy to improve the treatment.

PATIENTS AND METHODS

We prospectively recruited 396 patients from 11 specialized headache outpatients and analyzed their headache characteristics, Hospital Anxiety Depression Scale scores, Pittsburgh sleep quality index scores, and the usage of psychiatric medications during as well as 1 month after the attack period.

RESULTS

A total of 220 patients completed the follow-up, 52.73% of whom had anxiety, 47.27% had depression and 49.09% had sleep disturbance inside the attack period. At follow-up, the percentage of these patients significantly decreased to 16.36%, 21.82% and 14.55% in the remission period, respectively (p < 0.05). Antidepressants and mood stabilizers were prescribed to 58.18% of the patients. However, both of the changes of Hospital Anxiety Depression Scale scores after the end of the attack period for anxiety (3.52±2.91 vs 3.32±3.09, p =0.61) and depression (3.41±3.33 vs 2.90±3.58, P =0.28) were comparable in patients with and without taking these medications. Nocturnal onset of headache was positively correlated with Pittsburgh score (OR=8.71), anxiety (OR=2.33) and depression scores (OR=3.56) (p < 0.05).

CONCLUSION

Depression, anxiety and sleep disturbance were significantly alleviated after the attack period. However, psychiatric medications showed limited effect on depression and anxiety. Additionally, the nocturnal attack may cause anxiety and depression in episodic cluster headache.

Neural correlates of co-occurring pain and depression: an activation-likelihood estimation (ALE) meta-analysis and systematic review

The relationship between pain and depression is thought to be bidirectional and the underlying neurobiology 'shared' between the two conditions. However, these claims are often based on qualitative comparisons of brain regions implicated in pain or depression, while focused quantitative studies of the neurobiology of pain-depression comorbidity are lacking. Particularly, the direction of comorbidity, i.e., pain with depression vs. depression with pain, is rarely addressed. In this systematic review (PROSPERO registration CRD42020219876), we aimed to delineate brain correlates associated with primary pain with concomitant depression, primary depression with concurrent pain, and equal pain and depression comorbidity, using activation likelihood estimation (ALE) meta-analysis. Neuroimaging studies published in English until the 28th of September 2021 were evaluated using PRISMA guidelines. A total of 70 studies were included, of which 26 reported stereotactic coordinates and were analysed with ALE. All studies were assessed for quality by two authors, using the National Institute of Health Quality Assessment Tool. Our results revealed paucity of studies that directly investigated the neurobiology of pain-depression comorbidity. The ALE analysis indicated that pain with concomitant depression was associated with the right amygdala, while depression with concomitant pain was related primarily to the left dorsolateral prefrontal cortex (DLPFC). We provide evidence that pain and depression have a cumulative negative effect on a specific set of brain regions, distinct for primary diagnosis of depression vs. pain.

Clinical factors influencing the impact of cluster headache from a prospective multicenter study

Although many patients with cluster headaches (CH) are disabled by their condition, few studies have examined this in detail. This cross-sectional, multicenter observational study prospectively collected demographic and clinical questionnaire data from 224 consecutive patients with CH. We assessed headache impact using the six-item Headache Impact Test (HIT-6) and evaluated the factors associated with the impact of CH. Participants with a HIT-6 score ≥ 60 were classified into a severe impact group. The majority (190, 84.8%) of the participants were classified into the severe impact group. These patients were characterized by younger age, earlier onset of CH, longer duration of each headache attack, higher pain intensity, more cranial autonomic symptoms, a higher proportion of depression or anxiety, higher score of stress, and lower score of quality of life. The anxiety (OR = 1.19, 95% CI: 1.08–1.31, p = 0.006), greater pain intensity (OR = 1.06, 95% CI: 1.02–1.10, p = 0.002), and age (OR = 0.99, 95% CI: 0.99–1.00, p = 0.008) were significant predictors for a severe impact of CH patients. According to the HIT-6 results, most of the CH patients were significantly affected by CH. As well as pain intensity, anxiety and age modulated CH’s impact on their lives.

Personality disorders in cluster headache: a study using the Millon Clinical Multiaxial Inventory-III

A great deal of studies suggests that cluster headache (CH) patients are usually comorbid to anxiety-mood spectrum disorders and psychopathological symptoms; however, the personality profiles reported in the literature strictly depend on type of assessment used. Psychiatric comorbidities have been extensively studied in migraine and they are recognized to represent a major risk factor associated with poorer outcome, playing a role in the headache chronification process at once as cause and consequence of it. By contrast the incidence and role of psychopathological aspects in CH is still not clarified, insufficiently explored as the striking severity of such a physical pain apparently leaves no room to psychological explanations. The aim of the present study is to describe psychopathological aspects of CH patients by means of the Millon Clinical Multiaxial Inventory-III (MCMI-III), a psychological assessment tool compatible to Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) that correlates personality disorders (PDs) and clinical syndromes. We included all consecutive inward patients with CH between January 2014 and December 2016. Patients were evaluated using the MCMI-III a validated inventory assessing 14 PDs Scales (coordinate with DSM-IV Axis II disorders) and ten Clinical Syndrome Scales (coordinate with DSM-IV Axis I disorders). Twenty-six CH patients (24 chronic CH) were tested. Personality disorders were present in 92% of the patients. The most frequent PDs were: obsessive-compulsive (30.8%), histrionic (26.9%), narcissistic (11.5%), paranoid (11.5%) and avoidant (11.5%). According to the MCMI-III, patients with CH showed a high prevalence of personality disorders (Axis II-DSM-IV). PDs in CH patients can play an important role in determining CH course toward chronification. These preliminary results suggest that behavioral treatments can find room to support more conventional drug and neurostimulation therapies in these patients. In addition, the very high prevalence of PDs in our patients suggests that CH could in some cases be considered among the spectrum of somatoform and pain syndromes in patients with PDs.

Advances in the understanding of cluster headache

INTRODUCTION

Cluster headache is the worst primary headache form; it occurs in paroxysmal excruciatingly severe unilateral head pain attacks usually grouped in cluster periods. The familial occurrence of the disease indicates a genetic component but a gene abnormality is yet to be disclosed. Activation of trigeminal afferents and cranial parasympathetic efferents, the so-called trigemino-parasympathetic reflex, can explain pain and accompanying oculo-facial autonomic phenomena. In particular, pain in cluster headache is attributed, at least in part, to the increased CGRP plasma levels released by activated trigeminal system. Posterior hypothalamus was hypothesized to be the cluster generator activating the trigemino-parasympathetic reflex. Efficacy of monoclonal antibodies against CRGP is under investigation in randomized clinical trials. Areas covered: This paper will focus on main findings contributing to consider cluster headache as a neurovascular disorder with an origin from within the brain. Expert commentary: Accumulated evidence with hypothalamic stimulation in cluster headache patients indicate that posterior hypothalamus terminates rather than triggers the attacks. More extensive studies on the genetics of cluster headache are necessary to disclose anomalies behind the increased familial risk of the disease. Results from ongoing clinical trials in cluster headache sufferers using monoclonal antibodies against CGRP will open soon a new era.

Personality traits in patients with cluster headache: a comparison with migraine patients

Background

Cluster headache (CH) has been associated with certain personality traits and lifestyle features, but there are few studies assessing personality profiles in CH. We aimed to analyze personality traits in patients with CH, and to compare them with those found in migraine.

Methods

We included all consecutive patients with CH attending 5 outpatient offices between January and December 2013. Personality traits were evaluated using the Salamanca screening test, a validated inventory assessing 11 personality traits grouped in 3 clusters. We analyzed the test results in this population, and compared them with those of a migraine population previously assessed with the same test.

Results

Eighty patients with CH (75 men, 5 women; mean age, 43.2 ± 9.9 years) were recruited. The reference population consisted of 164 migraine patients (30 men, 134 women; mean age 36.4 ± 12.7 years). In CH patients, the most frequent personality traits were anancastic (52.5 %), anxious (47.5 %), histrionic (45 %), schizoid (42.5 %), impulsive (32.5 %) and paranoid (30 %). When compared to migraine patients, paranoid (p < 0.001; χ2 test), and schizoid traits (p = 0.007; χ2 test) were significantly more prevalent in CH patients. In logistic regression analysis the paranoid trait was significantly associated with CH (p = 0.001; OR: 3.27, 95 % CI [1.66–6.43]).

Conclusion

According to the Salamanca screening test, personality traits included in cluster A (odd or eccentric disorders) are more prevalent in CH patients than in a population of migraineurs. Larger studies are needed to determine whether certain personality traits are related to CH.

Principal Component Analysis and Risk Factors for Acute Mountain Sickness upon Acute Exposure at 3700 m

OBJECTIVE

We aimed to describe the heterogeneity in the clinical presentation of acute mountain sickness (AMS) and to identify its primary risk factors.

METHODS

The participants (n = 163) received case report form questionnaires, and their heart rate (HR), oxygen saturation (SpO2), echocardiographic and transcranial Doppler variables, ability to perform mental and physical work, mood and psychological factors were assessed within 18 to 22 hours after arriving at 3700 m from sea level (500 m) by plane. First, we examined the differences in all variables between the AMS-positive and the AMS-negative groups. Second, an adjusted regression analysis was performed after correlation and principal component analyses.

RESULTS

The AMS patients had a higher diastolic vertebral artery velocity (Vd; p = 0.018), a higher HR (p = 0.006) and a lower SpO2. The AMS subjects also experienced poorer sleep quality, as quantified using the Athens Insomnia Scale (AIS). Moreover, the AMS population exhibited more negative mood states, including anxiety, depression, hostility, fatigue and confusion. Five principal components focused on diverse aspects were also found to be significant. Additionally, more advanced age (p = 0.007), a higher HR (p = 0.034), a higher Vd (p = 0.014), a higher AIS score (p = 0.030), a decreased pursuit aiming capacity (p = 0.035) and decreased vigor (p = 0.015) were risk factors for AMS.

CONCLUSIONS

Mood states play critical roles in the development of AMS. Furthermore, an elevated HR and Vd, advanced age, elevated AIS sores, insufficient vigor and decreased mental work capacity are independent risk factors for AMS.

Short-term effect of acute and repeated urinary bladder inflammation on thigmotactic behaviour in the laboratory rat

Understanding the non-sensory components of the pain experience is crucial to developing effective treatments for pain conditions. Chronic pain is associated with increased incidence of anxio-depressive disorders, and patients often report feelings of vulnerability which can decrease quality of life. In animal models of pain, observation of behaviours such as thigmotaxis can be used to detect such affective disturbances by exploiting the influence of nociceptive stimuli on the innate behavioural conflict between exploration of a novel space and predator avoidance behaviour. This study investigates whether acute and repeated bladder inflammation in adult female Wistar rats increases thigmotactic behaviour in the open field paradigm, and aims to determine whether this correlates with activation in the central amygdala, as measured by c-Fos immunoreactivity. Additionally, up-regulation of inflammatory mediators in the urinary bladder was measured using RT-qPCR array featuring 92 transcripts to examine how local mediators change under experimental conditions. We found acute but not repeated turpentine inflammation of the bladder increased thigmotactic behaviour (decreased frequency of entry to the inner zone) in the open field paradigm, a result that was also observed in the catheter-only instrumentation group. Decreases in locomotor activity were also observed in both models in turpentine and instrumentation groups. No differences were observed in c-Fos activation, although a general increased in activation along the rostro-caudal axis was seen. Inflammatory mediator up-regulation was greatest following acute inflammation, with CCL12, CCL7, and IL-1β significantly up-regulated in both conditions when compared to naïve tissue. These results suggest that acute catheterisation, with or without turpentine inflammation, induces affective alterations detectable in the open field paradigm accompanied by up-regulation of multiple inflammatory mediators.

Major depressive disorder is associated with abnormal interoceptive activity and functional connectivity in the insula

BACKGROUND

Somatic complaints and altered interoceptive awareness are common features in the clinical presentation of major depressive disorder (MDD). Recently, neurobiological evidence has accumulated demonstrating that the insula is one of the primary cortical structures underlying interoceptive awareness. Abnormal interoceptive representation within the insula may thus contribute to the pathophysiology and symptomatology of MDD.

METHODS

We compared functional magnetic resonance imaging blood oxygenation level-dependent responses between 20 unmedicated adults with MDD and 20 healthy control participants during a task requiring attention to visceral interoceptive sensations and also assessed the relationship of this blood oxygenation level-dependent response to depression severity, as rated using the Hamilton Depression Rating Scale. Additionally, we examined between-group differences in insula resting-state functional connectivity and its relationship to Hamilton Depression Rating Scale ratings of depression severity.

RESULTS

Relative to the healthy control subjects, unmedicated MDD subjects exhibited decreased activity bilaterally in the dorsal mid-insula cortex (dmIC) during interoception. Activity within the insula during the interoceptive attention task was negatively correlated with both depression severity and somatic symptom severity in depressed subjects. Major depressive disorder also was associated with greater resting-state functional connectivity between the dmIC and limbic brain regions implicated previously in MDD, including the amygdala, subgenual prefrontal cortex, and orbitofrontal cortex. Moreover, functional connectivity between these regions and the dmIC was positively correlated with depression severity.

CONCLUSIONS

Major depressive disorder and the somatic symptoms of depression are associated with abnormal interoceptive representation within the insula.

Cluster headache is associated with an increased risk of depression: A nationwide population-based cohort study

Objective

To investigate whether cluster headache (CH) was a risk factor for depression in a nationwide population-based follow-up study.

Background

There are few studies about the relationship between CH and depression, and prior research has been limited by cross-sectional studies or small sample sizes.

Methods

We identified 673 CH patients from the Taiwan National Health Insurance database between 2005 and 2009. The two comparison cohorts included age-, sex- and Charlson’s score-matched migraine patients ( n = 2692) and controls (patients free from migraine or CH, n = 2692). The cumulative incidence of depression was compared among these three cohorts until the end of 2009. We also calculated predictors of depression in the CH cohort.

Results

After the median 2.5-year follow-up duration, the CH cohort had a greater risk for developing depression compared to the control cohort (adjusted hazard ratio; aHR = 5.6, 95% CI 3.0–10.6, p < 0.001) but not the migraine cohort (aHR = 1.1, 95% CI 0.7–1.7, p = 0.77). Of the CH patients, the number of cluster bout periods per year was a risk factor for depression (aHR = 3.8, 95% CI 2.6–5.4, p < 0.001).

Conclusion

Our results showed that CH is associated with an increased risk for depression. The strength of this association is similar to that of migraine.

Cluster headache and neuropsychological functioning

BACKGROUND

Despite significant advances in unravelling the pathophysiology of cluster headache (CH), little is known about neuropsychological functioning. Apart from neuroimaging studies indicating involvement of posterior hypothalamic and other areas frequently involved in nociception, some studies suggest involvement of prefrontal areas. Among others, these mediate executive functioning (EF).

METHODS

Therefore, three neuropsychological tests (Trail Making Test (TMT), Go/Nogo Task and Stroop Task) were completed by four headache patient samples (chronic CH, episodic CH in the active or inactive period, and migraine patients) and compared to healthy controls.

RESULTS

Analyses revealed that patients especially with chronic and active episodic CH were particularly impaired in tests relying more on intact EF (i.e. TMT-B, Stroop interference) than on basal cognitive processes (i.e. TMT-A, Stroop naming). Within the CH groups performance decreased linearly with increasing severity.

DISCUSSION

These findings are in line with a recently proposed involvement of prefrontal structures in CH pathophysiology as patients performed worse on neuropsychological tasks relying on these structures. Impaired EF could also result from medication and sleep disturbances due to active CH. Because the decreased performance was also present outside the attacks it may hint at generally altered brain functions, but do not necessarily reflect clinically relevant behaviour.

Aggressiveness in different presentations of cluster headache: Results from a controlled multicentric study

Background: The hypothalamus has been discussed as a pivotal structure for both cluster headache (CH) and aggressiveness, but little is known about the extent of self-reported aggressiveness in patients with CH.

Patients and methods: Twenty-six patients with chronic, 25 with active episodic and 22 with episodic CH outside the active period were examined interictally with a validated questionnaire quantifying factors of aggression and compared with 24 migraine patients and 31 headache-free volunteers.

Results: The ANOVA was significant for the subscale ‘self-aggression/depression’ ( F4, 123 = 5.771, p < 0.001) with significant differences between chronic and episodic CH and healthy volunteers. No significant changes were found for other subscales and the sum scale ( F4, 123 < 1.421, p > 0.230). Especially in the clinically most affected group of patients (chronic CH and active episodic CH), high levels of “self-aggression/depression” correlate with higher prevalence of depressive symptoms and higher impairment measured on an emotional and functional level.

Discussion: Self-aggressive and depressive cognitions with highest scores in chronic CH seem to be reactive as they correlate with depressive symptoms and impairment. They should be considered as an important therapeutic target since they impair the patient’s life significantly.