Allergic Rhinitis and Chronic Daily Headaches: Is There a Link?

No causal association between allergic rhinitis and migraine: a Mendelian randomization study

PURPOSE

Allergic rhinitis (AR) and migraine are among the most common public health problems worldwide. Observational studies on the correlation between AR and migraine have reported inconsistent results. This study aimed to investigate the causal relationship of AR with migraine and its subtypes, including migraine with aura (MA) and migraine without aura (MO).

METHODS

Bidirectional two-sample Mendelian randomization (MR) analysis was performed with publicly available summary-level statistics of large genome-wide association studies to estimate the possible causal effects. The inverse variance-weighted method was selected for primary analysis and was supplemented with the weighted median, weighted mode, and MR-Egger methods. The causal analysis using summary effect estimates (CAUSE) were further performed to verify the causality. Several sensitivity tests, including the leave-one-out, Cochran's Q, MR-Egger intercept, and MR-PRESSO tests, were performed to assess the robustness of the results.

RESULTS

AR did not exhibit a significant causal correlation with the elevated risk of any migraine (odd ratio (OR), 0.816; 95% confidence interval (CI), 0.511-1.302; P = 0.394), MA (OR, 0.690; 95% CI 0.298-1.593; P = 0.384), or MO (OR, 1.022; 95% CI 0.490-2.131; P = 0.954). Consistently, reverse MR analysis did not reveal causal effects of any migraine or its subtypes on AR. Almost all sensitivity analyses supported the robustness of the results.

CONCLUSIONS

This MR study did not reveal a clear causal association between AR and migraine risk. More research is warranted to reveal the complex association between AR and migraine.

Bioequivalence of 2 Pediatric Formulations of Fexofenadine Hydrochloride Oral Suspension

Fexofenadine hydrochloride (HCl) is a second-generation, nonsedating, histamine H1-receptor antagonist used to manage seasonal allergic rhinitis and chronic idiopathic urticaria. A new oral pediatric suspension of fexofenadine HCl has been developed, with the preservative potassium sorbate replacing parabens. The objective of this phase 1 single-center, open-label, randomized, 2-treatment, full-replicated, 4-period, 2-sequence crossover study in healthy adult volunteers was to assess the bioequivalence of 30 mg of the new oral suspension of fexofenadine HCl (test) versus 30 mg of the marketed pediatric oral suspension of fexofenadine HCl (reference). The replicate design was based on the high intra-individual variability of fexofenadine (>30% on Cmax ). The study comprised 68 randomized and treated volunteers. Plasma concentrations of fexofenadine were similar following the administration of a single dose of each formulation. Cmax , AUClast , AUC, median tmax , and mean t1/2z were similar between administrations of the same fexofenadine formulation and between formulations. A high intra-individual variability was confirmed with both formulations. Bioequivalence of the test and reference fexofenadine HCl formulations was demonstrated as the 90% confidence intervals of the geometric least squares mean ratio for Cmax , AUClast , and AUC of fexofenadine were all within the bioequivalence range of 0.80-1.25. There were no serious adverse events (AEs) or study discontinuations due to treatment-emergent AEs with either fexofenadine HCl formulation. The new paraben-free fexofenadine HCl 30-mg oral suspension and marketed fexofenadine HCl 30-mg pediatric oral suspension are bioequivalent under fasting conditions, with no safety concerns and a safety profile consistent with the known profile of fexofenadine.

A longitudinal prospective study of septoplasty impact on headache and allergic rhinitis in patients with septal deviation

OBJECTIVE

To measure the severity of allergic rhinitis (AR) and different types of headaches in patients with septal deviation before and after septoplasty.

METHODS

This multicentre, prospective, longitudinal, observational study enrolled patients with deviated nasal septum, nasal symptoms and headaches associated with persistent AR lasting at least 2 months without resolution. The nasal obstruction evaluation (NOSE) scale, immunoglobulin-E (Ig-E) levels and visual analogue scale (VAS) for headache pain severity were evaluated before and after septoplasty using Wilcoxon signed-rank test.

RESULTS

A total of 196 patients were enrolled in the study (102 males; 94 females). A total of 134 patients (68%) were diagnosed with severe AR and 166 (85%) experienced headaches with AR. The majority (100 of 166 patients; 60%) had sinusoidal headaches, while 25% (42 of 166 patients) reported a combination of sinusoidal headache and migraine and 14% (24 of 166 patients) experienced migraines. A comparison of preoperative and postoperative Ig-E levels, NOSE and VAS scores demonstrated that septoplasty significantly improved AR symptoms and headaches. Although there were significant improvements in headaches overall post-septoplasty, only the sinusoidal components improved, while migraine remained unaffected.

CONCLUSION

Septoplasty improved AR and sinusoidal headaches in patients with septal deviation, but migraines remained unaffected.

Applying fuzzy qualitative comparative analysis to identify typical symptoms of COVID-19 infection in a primary care unit, Rio de Janeiro, Brazil

This study aims to identify a set of symptoms that could be predictive of SARS-CoV-2 cases in the triage of Primary Care services with the contribution of Qualitative Comparative Analysis (QCA) using Fuzzy Sets (fsQCA). A cross-sectional study was carried out in a Primary Health Care Unit/FIOCRUZ from 09/17/2020 to 05/05/2021. The study population was suspect cases that performed diagnostic tests for COVID-19. We collected information about the symptoms to identify which configurations are associated with positive and negative cases. For analysis, we used fsQCA to explain the outcomes "being a positive case" and "not being a positive case". The solution term "loss of taste or smell and no headache" showed the highest degree of association with the positive result (consistency = 0.81). The solution term "absence of loss of taste or smell combined with the absence of fever" showed the highest degree of association (consistency = 0,79) and is the one that proportionally best explains the negative result. Our results may be useful to the presumptive clinical diagnosis of COVID-19 in scenarios where access to diagnostic tests is not available. We used an innovative method used in complex problems in Public Health, the fsQCA.

A Comparison of Clinical Features of Youth with and without Rhinitis Signs and Symptoms Who Are Hospitalized for Headache

Headache and allergic rhinitis (AR) are common in children and often co-occur. We investigated the clinical characteristics of pediatric headaches and the association of AR and chronic headaches. We retrospectively reviewed the medical records of patients admitted to our pediatric inpatient and outpatient clinics with complaints of headache between January 2017 and June 2020 for headache-specific history, AR signs and symptoms, allergy skin prick test, inhalant multiple allergen simultaneous test results, laboratory and imaging findings, and medication history. The patients were divided into three subgroups: AR, non-AR, and headache groups, reporting 45.7% patients with headache alone, 13.7% with additional AR, and 31.6% with abnormal imaging findings, suggesting that headache was combined with sinusitis (24.3%) or mastoiditis (7.3%). Furthermore, 6% of the patients had both AR and sinusitis. Body mass index (BMI) differed significantly between the AR and the non-AR and headache groups (p = 0.03). The BMI differed significantly according to headache severity (p ˂ 0.001). The most common allergen was “dust or mites” (41.1%). Acetaminophen (35.9%) was the most commonly used painkiller. The coexistence of AR and headache may indicate that these conditions share a similar pathophysiology. Better management of allergies may facilitate diagnosis, treatment, and prophylaxis of headaches.

Headache and rhinitis: pattern search on Google Trends for 17 years

OBJECTIVE

Headache and rhinitis are highly prevalent and comorbid. The objective of the present study is to analyze the correlation of headache and rhinitis, in addition to the temporal pattern of these diseases in 17 years, using the Google Trends platform.

METHODS

Google Trends was searched from January 2004 to June 2021, using the entry: ["rinite" (rhinitis) + "dor de cabeça" (headache)" + "Alzheimer" + "enxaqueca" (migraine)]. Migraine, primary headache, and Alzheimer's, with no clear relation with headache, were used as controls. After the descriptive analysis by dispersion diagrams, Pearson's test and a simple regression model were performed. Subsequently, this study analyzed the seasonality of the volume of research on rhinitis and headache.

RESULTS

A strong correlation between rhinitis and headache (0.86) was found in the time interval analyzed. In addition, a seasonality was identified in the volume of searches for the term rhinitis with increased volume in the fall and peaks in the month of May, with a decrease in the spring and early summer. Moreover, an increase of searches on headache was observed, suggesting worse burden of this pathology.

CONCLUSION

Headaches and rhinitis were correlated in 17 years of research on the Google Trends platform. Circannual variation of both conditions was observed. Additional studies with digital research may be useful to better understand the epidemiology and comorbidities of headache.

[Comorbidity in migraine]

Migraine is a common and often disabling disease with a prominent genetic basis. There are many comorbidities associated with migraine which have been identified as risk factors for progression to chronic migraine. Each of these has its own genetic load and shares some common characteristics with migraine. The identification of migraine comorbidities may help clarify common underlying genetic and biological mechanisms of diseases. The treatment of migraine should involve a multifaceted approach, aimed at identifying and reducing possible risk and comorbidity factors. This may prevent the evolution toward a chronic form and then toward pharmacological resistance.

Headache and immunological/autoimmune disorders: a comprehensive review of available epidemiological evidence with insights on potential underlying mechanisms

Several lines of evidence support a role of the immune system in headache pathogenesis, with particular regard to migraine. Firstly, alterations in cytokine profile and in lymphocyte subsets have been reported in headache patients. Secondly, several genetic and environmental pathogenic factors seem to be frequently shared by headache and immunological/autoimmune diseases. Accordingly, immunological alterations in primary headaches, in particular in migraine, have been suggested to predispose some patients to the development of immunological and autoimmune diseases. On the other hand, pathogenic mechanisms underlying autoimmune disorders, in some cases, seem to favour the onset of headache. Therefore, an association between headache and immunological/autoimmune disorders has been thoroughly investigated in the last years. The knowledge of this possible association may have relevant implications in the clinical practice when deciding diagnostic and therapeutic approaches. The present review summarizes findings to date regarding the plausible relationship between headache and immunological/autoimmune disorders, starting from a description of immunological alteration of primary headaches, and moving onward to the evidence supporting a potential link between headache and each specific autoimmune/immunological disease.

Pathophysiological Bases of Comorbidity in Migraine

Despite that it is commonly accepted that migraine is a disorder of the nervous system with a prominent genetic basis, it is comorbid with a plethora of medical conditions. Several studies have found bidirectional comorbidity between migraine and different disorders including neurological, psychiatric, cardio- and cerebrovascular, gastrointestinal, metaboloendocrine, and immunological conditions. Each of these has its own genetic load and shares some common characteristics with migraine. The bidirectional mechanisms that are likely to underlie this extensive comorbidity between migraine and other diseases are manifold. Comorbid pathologies can induce and promote thalamocortical network dysexcitability, multi-organ transient or persistent pro-inflammatory state, and disproportionate energetic needs in a variable combination, which in turn may be causative mechanisms of the activation of an ample defensive system with includes the trigeminovascular system in conjunction with the neuroendocrine hypothalamic system. This strategy is designed to maintain brain homeostasis by regulating homeostatic needs, such as normal subcortico-cortical excitability, energy balance, osmoregulation, and emotional response. In this light, the treatment of migraine should always involves a multidisciplinary approach, aimed at identifying and, if necessary, eliminating possible risk and comorbidity factors.

Turbinate Submucosal Reduction Operation Reduced Migraine Admission among Patients with Chronic Hypertrophic Rhinitis

Rhinitis increases migraine risk. Chronic hypertrophic rhinitis can be treated with turbinate submucosal reduction operation. The relationship between migraine and chronic hypertrophic rhinitis after turbinate submucosal reduction operation is still unclear. The goal of this study was to evaluate the correlation between turbinate submucosal reduction operation and subsequent migraine admission in Asian chronic hypertrophic rhinitis patients. We identified patients suffering from chronic hypertrophic rhinitis and receiving turbinate submucosal reduction operation. The control group was selected from patients with chronic hypertrophic rhinitis without operation. The event was migraine admission. The risk factors of migraine admission were established using multivariate Cox proportional hazard regression. The risk of migraine admission after turbinate submucosal reduction operation is represented by a hazard ratio (HR) of 0.858 (95% confidence interval (CI): 0.633–0.962). The higher risk of migraine included depression with HR 4.348 (95% CI: 2.826–6.69), anxiety with HR 3.75 (95% CI: 2.267–6.203), fibromyalgia with HR of 7.326 (95% CI: 3.427–15.661), and asthma with HR 1.969 (95% CI: 1.11–3.491). Our study revealed that turbinate submucosal reduction operation led to a 14.2% reduction in migraine admission. Clinicians should understand the benefit of turbinate submucosal reduction operation and provide suitable treatments for comorbid conditions. Further prospective studies are required to confirm our findings.

Headache Caused by Sinus Disease

Headaches and sinus disease are common reasons to seek medical care, with marked worldwide prevalence and large socioeconomic burdens. Headaches caused by sinus diseases are rare; many "rhinogenic headaches" are actually migraines. The similar symptoms may result from autonomic dysfunction and trigeminovascular pathways. Using the mnemonic ACHE, this article presents key Anatomy, Clinical cases, How to image, Essential clinical and radiographic features that help the radiologist, otolaryngologist, and neurologist evaluate sinus disease and headaches.

The role of the otolaryngologist in the evaluation and management of headaches

BACKGROUND

Headaches are commonly evaluated in otolaryngology and often represent a diagnostic dilemma. This review addresses rhinogenic headache as well as trigeminal neuralgia and migraine, both of which can masquerade as sinus headache and whose management increasingly involves otolaryngology intervention. Discussion considers diagnostic criteria and novel therapies and derives an algorithm for clinical decision-making.

DATA SOURCES

OVID MEDLINE, Cochrane Library, and Google Scholar databases.

METHODS

A literature search was performed to identify relevant articles published in the past 10 years addressing the diagnosis and management of rhinogenic headache, trigeminal neuralgia and/or migraine.

FINDINGS

Rhinogenic headache: Identification of the specific cause must be achieved before treatment. No studies have mentioned the effect of certain therapies on the amelioration of headache. New techniques of balloon dilation for sinusitis are controversial, and their use remains contingent on surgeon preference. Removal of mucosal contact points has been shown to benefit quality of life in patients with contact point headache. Trigeminal neuralgia: Microvascular decompression is considered the gold standard for treatment, but percutaneous therapies can be effective for achieving pain control. Migraine: Patients who report amelioration of symptoms after targeted botulinum toxin injection may benefit from definitive decompression or nerve avulsion. Patients with mucosal contact points may have less favorable outcomes with migraine surgery if they are not simultaneously addressed.

CONCLUSIONS

A comprehensive understanding of the diagnostic workup and therapeutic options available for common headache etiologies is key to the management of a patient presenting with headache attributed to a rhinogenic cause.

Co-occurrence of migraine and atopy in children and adolescents: myth or a casual relationship?

PURPOSE OF REVIEW

To clarify the causal relationship between migraine and atopic disorders in children and adolescents.

RECENT FINDINGS

Migraine headache and atopic disorders including asthma are both common functional syndromes of childhood in which nature of the relationship is still debated. Attacks may induce in both disorders upon exposure to potential triggers in genetically susceptible individuals. Clinical phenotype manifests by temporary dysfunction of target tissue mediated by inflammation triggered by specific agents. Clinical features also change after puberty because of the partial effect of female sex hormones on the process. Appropriate definition of the syndrome and differentiating from other disorders are necessary not only for correct diagnosis, but also for planning of management strategies in children. Allergic rhinosinusitis needs to be differentiated from migraine even in experienced clinics. Questioning the presence of cranial autonomic symptoms is important clue in the differential diagnosis. Atopic disorder screening is particularly required in the diagnosis of migraine in childhood and adolescents. The link between both disorders of childhood seems to be far from a coincidence and some common inflammatory mechanisms are shared.

SUMMARY

On the basis of clinical features, laboratory findings and some practical clues in children, accurate diagnosis of migraine and atopic disorders are very critical for physicians, pediatricians and algologists.