Laterality of pain in migraine with comorbid unipolar depressive and bipolar II disorders

Comparison of migraine with left- versus right-sided headache: A cross-sectional study

OBJECTIVE

The goal of this study was to clarify whether clinical differences exist between patients with migraine who experience headache that is typically left-sided ("left-migraine") versus right-sided ("right-migraine") during attacks.

BACKGROUND

Migraine has been associated with unilateral headache for millennia and remains a supportive trait for the clinical diagnosis of migraine of the International Classification of Headache Disorders. It is currently unknown why headache in migraine is commonly unilateral, and whether headache-sidedness is associated with other clinical features.

METHODS

This is a cross-sectional study comparing left- versus right-migraine using all available intake questionnaires of new patients evaluated at an academic tertiary headache center over a 20-year period. Eligibility was based on patient written responses indicating the typical location of headache during attacks. In our analyses, the side of headache (left or right) was the predictor variable. The outcomes included various migraine characteristics and psychiatric comorbidities.

RESULTS

We identified 6527 patients with migraine, of which 340 met study eligibility criteria. Of these, 48.8% (166/340) had left migraine, and 51.2% (174/340) had right migraine. When comparing patients with left- versus right-migraine, patients with left migraine experienced 3.6 fewer headache-free days (95% confidence interval [CI] 1.3-5.9; p = 0.002) and 2.4 more severe headache days (95% CI 0.8-4.1; p = 0.004) in the previous 4 weeks. No significant differences in age, sex, handedness, migraine characteristics, or psychiatric comorbidities were identified between the two groups.

CONCLUSIONS

Patients with migraine with typically left-sided headache during attacks reported a higher burden of headache frequency and severity than those with typically right-sided headache during attacks. These findings may have implications for our understanding of migraine pathophysiology, treatment, and clinical trial design.

Left- vs right-sided migraine: a scoping review

BACKGROUND

Migraine is a historically unilateral head pain condition, the cause of which is not currently known. A growing body of literature suggests individuals who experience migraine with left-sided headache ("left-sided migraine") may be distinguished from those who experience migraine with right-sided headache ("right-sided migraine").

OBJECTIVE

In this scoping review, we explore migraine unilaterality by summarizing what is currently known about left- and right-sided migraine.

METHODS

Two senior medical librarians worked with the lead authors to construct and refine a set of search terms to identify studies of subjects with left- or right-sided migraine published between 1988, which is the year of publication of the first edition of the International Classification of Headache Disorders (ICHD), and December 8, 2021 (the date the searches were conducted). The following databases were searched: Medline, Embase, PsycINFO, PubMed, Cochrane Library, and Web of Science. Abstracts were loaded into Covidence review software, deduplicated, then screened by two authors to determine study eligibility. Eligible studies were those involving subjects diagnosed with migraine (according to ICHD criteria) in which the authors either: a) compared left- to right-sided migraine; or b) described (with analysis) a characteristic that differentiated the two. Data were extracted by the lead author, including ICHD version, the definition of unilateral migraine used by the authors, sample size, whether the findings were collected during or between attacks, and their key findings. The key findings were grouped into the following themes: handedness, symptoms, psychiatric assessments, cognitive testing, autonomic function, and imaging.

RESULTS

After deduplication, the search yielded 5428 abstracts for screening. Of these, 179 met eligibility criteria and underwent full text review. 26 articles were included in the final analysis. All of the studies were observational. One study was performed during attack, nineteen between attacks, and six both during and between attacks. Left- and right-sided migraine were found to differ across multiple domains. In several cases, reciprocal findings were reported in left- and right-migraine. For example, both left- and right-sided migraine were associated with ipsilateral handedness, tinnitus, onset of first Parkinson's symptoms, changes in blood flow across the face, white matter hyperintensities on MRI, activation of the dorsal pons, hippocampal sclerosis, and thalamic NAA/Cho and NAA/Cr concentrations. In other cases, however, the findings were specific to one migraine laterality. For example, left-sided migraine was associated with worse quality of life, anxiety, bipolar disorder, PTSD, lower sympathetic activity, and higher parasympathetic activity. Whereas right-sided migraine was associated with poorer performance on multiple cognitive tests, a greater degree of anisocoria, changes in skin temperature, higher diastolic blood pressure, changes in blood flow through the middle cerebral and basilar arteries, and changes on EEG.

CONCLUSION

Left- and right-sided migraine differed across a wide range of domains, raising the possibility that the pathophysiology of left- and right-migraine may not be identical.

Cyclothymic temperament: Associations with ADHD, other psychopathology, and medical morbidity in the general population

BACKGROUND

Cyclothymic temperament (CT) is an affective disposition often preceding bipolar disorder (BD), and is the most common affective temperament in patients with BD. In depressed patients, CT is a predictor for developing a bipolar course. In a clinical sample of adults with BD and attention deficit hyperactivity disorder (ADHD), CT was associated with higher loads of psychiatric symptoms, somatic comorbidity, impairment, and higher morbidity among first-degree relatives. We aimed to investigate the morbidity and occupational functioning of persons with CT in the general population.

METHODS

Randomly recruited Norwegian adults (n = 721) were assessed with a 21-item cyclothymic subscale from the TEMPS Autoquestionnaire. Self-reported data were collected on psychiatric symptoms, comorbidity, educational and occupational level, and known family morbidity.

RESULTS

Thirteen percent had CT associated with an increased prevalence of ADHD, BD, high scores on the Mood Disorder Questionnaire (MDQ), and childhood and adulthood ADHD symptoms. CT was found in 75% (p < .001) of the bipolar participants, and in 68% (p < .001) of those with a positive MDQ score. CT was associated with more anxiety/depression, substance and alcohol problems, lower educational and occupational levels, and having a first-degree relative with anxiety/depression, alcohol problems, ADHD, and BD.

LIMITATIONS

The CT subscale alone might include overlapping features with cyclothymic, anxious, irritable, and depressed temperaments, thus increasing the prevalence estimate of CT.

CONCLUSIONS

CT is a strong predictor of occupational failure and associated with more psychiatric impairment in the participants and their families. CT should be assessed in both mood disorder and ADHD patients.

Gray matter correlates of migraine and gender effect: A meta-analysis of voxel-based morphometry studies

BACKGROUND

An increasing number of neuroimaging studies have revealed gray matter (GM) anomalies of several brain regions by voxel-based morphometry (VBM) studies in migraineurs. However, not all the studies reported entirely consistent findings. Our aim is to investigate concurrence across VBM studies to help clarify the structural anomalies underpinning this condition.

METHODS

A systematic search of VBM studies of patients with migraine and healthy controls (HC) published in PubMed and Embase databases from January 2000 to March 2014 was conducted. A quantitative meta-analysis of whole-brain VBM studies in patients with migraine compared with HC was performed by means of anisotropic effect size version of signed differential mapping (AES-SDM) software package.

RESULTS

Nine studies comprising 222 patients with migraine and 230 HC subjects were included in the present study. Compared to HC subjects, the patients group showed consistent decreased GM in the posterior insular-opercular regions, the prefrontal cortex, and the anterior cingulate cortex. Results remained largely unchanged in the following jackknife sensitivity analyses. Meta-regression analysis showed that a higher percentage of females in the patient sample was associated with decreased GM in the right dorsolateral prefrontal cortex.

CONCLUSIONS

This is the first quantitative whole-brain VBM meta-analysis in migraine showing strong evidence of brain GM anomalies within the pain-processing neural network. Further longitudinal investigations are needed to determine whether these structural anomalies are reversible with effective treatment on migraine.

Prevalence and clinical features associated to bipolar disorder-migraine comorbidity: a systematic review

BACKGROUND

The prevalence and clinical features associated with bipolar disorders (BDs)-migraine comorbidity have been reported inconsistently across different studies, therefore warranting a systematic review on the matter.

METHODS

A systematic review was conducted in accordance with the PRISMA statement searching major electronic databases for documents indexed between January, 2000 and July, 2014. Eligible studies were those including quantitative data on prevalence rates and clinical features associated to BD-migraine comorbidity; case reports excluded. Three authors independently conducted searches, quality assessment of the studies and data extraction.

RESULTS

Several cross-sectional studies, and a handful of retrospective follow-up studies or non-systematic reviews assessed the prevalence and/or the clinical correlates of migraine-BD comorbidity. High prevalence rates and a significant burden of BD-migraine comorbidity were common findings, particularly in case of BD-II women (point-prevalence rates up to 77%), migraine with aura (up to 53%) and/or cyclothymic temperament (up to 45% of the cases).

LIMITATIONS

Some of the biases encountered in a few studies accounted by the present review may nonetheless have hampered the generalizability of the overall conclusions drawn herein.

CONCLUSIONS

BD-migraine comorbidity may comprise of a sub-phenotype of BDs requiring patient-tailored therapeutic interventions to achieve an optimal outcome. Specifically, additional studies including longitudinal follow-up studies are aimed in order to shed further light on the actual prevalence rates and clinical features associated to BD-migraine comorbidity, with a special emphasis towards the clinically suggestive potential connection between mixed features, bipolar depression, migraine, and increased risk for suicidality. PROSPERO registration number: CRD42014009335.

Non-right-handedness is associated with migraine and soft bipolarity in patients with mood disorders

BACKGROUND

There is a substantial body of data showing differences in the functioning of the two hemispheres in unipolar depressive and bipolar disorders. Migraine is a frequent co-morbid disorder in these patients, and it has been proposed that migraine may be associated with left-handedness. It would therefore be interesting to study migraine and handedness in a population of patients with mood disorders.

METHODS

A total of 201 patients with an index episode of either major depression or mania were interviewed with a semi-structured interview based partly on DSM-IV criteria and partly on TEMPS-I for affective temperaments. The criteria of the Headache Classification Committee of the International Headache Society were used to establish the diagnosis of migraine. Hand preference was assessed using the Edinburgh inventory, and the patients were classified as having right-, left-, or mixed-handedness.

RESULTS

In the whole group 117 patients had migraine (58%) and 59 (29%) were classified as having non-right hand preference. There was a significant increased prevalence of non-right-handedness in the migraine group (37% vs. 19%, p=0.021, Chi-square test; OR 2.5; 95% CI 1.3 -4.8, p=0.007). In patients with cyclothymic, hyperthymic or irritable temperaments the prevalence of non-right-handedness (42%) was significantly higher (p=0.013, Chi-square test; OR 2.2, 95% CI 1.2-4.3) compared to patients with a depressive or no affective temperament (24%). The prevalence of non-right-handedness was also significantly higher both in patients with co-morbid eating disorders (48% vs. 26%, p=0.008 Chi-square test; OR 2.7, 95% CI 1.3-5.9, p=0.01) and asthma (45% vs. 26%, p=0.026 Chi-square test; OR 2.3, 95% CI 1.1-5.1, p=0.029).

LIMITATIONS

Non-blind evaluation of affective diagnosis, migraine and handedness.

CONCLUSIONS

Our main finding supports the hypothesis that non-right-handedness is associated with migraine and bipolar affective temperaments ("soft bipolarity") in a sample of patients with major affective disorders.

Emotion and Pain: A Functional Cerebral Systems Integration

Emotion and pain are psychological constructs that have received extensive attention in neuropsychological research. However, neuropsychological models of emotional processing have made more progress in describing how brain regions interact to process emotion. Theories of emotional processing can describe inter-hemispheric and intra-hemispheric interactions during emotional processing. Due to similarities between emotion and pain, it is thought that emotional models can be applied to pain. The following review examines the neuropsychology of emotion and pain using a functional cerebral systems approach. Specific comparisons are made between pain and anger. Attention is given to differences in cerebral function and physiology that may contribute to the processing of emotion and pain. Suggestions for future research in emotion and pain are given.

The Prevalence and Impact of Migraine Headache in Bipolar Disorder: Results From the Canadian Community Health Survey

OBJECTIVE

To report on the prevalence of comorbid migraine in bipolar disorder and the implications for bipolar age of onset, psychiatric comorbidity, illness course, functional outcome, and medical service utilization.

BACKGROUND

Migraine comorbidity is differentially reported in bipolar versus unipolar depressed clinical samples. The bipolar disorder-migraine association and its consequences have been infrequently reported in epidemiological studies.

METHODS

Data for this analysis were derived from respondents (n = 36 984) to the Canadian Community Health Survey - Mental Health and Well-Being (CCHS). Respondents reporting a lifetime WHO-CIDI-defined manic episode and physician-diagnosed migraine (lifetime) were compared to respondents without migraine on sociodemography, course of illness, and medical service utilization indices.

RESULTS

An estimated 2.4% of the sample met criteria for bipolar disorder. Persons with bipolar disorder had a relatively higher prevalence of migraine versus the general population (24.8% vs. 10.3%; P < .05). The sex-specific prevalence of comorbid migraine in bipolar disorder was 14.9% for males and 34.7% for females. Bipolar males with comorbid migraine were more likely to live in a low income household (P < .05); receive welfare and social assistance (P < .05); report an earlier age of onset of bipolar disorder (P < .05); and have a higher lifetime prevalence of comorbid anxiety disorders (P < .05). Bipolar males with comorbid migraine were also more likely to utilize primary (P < .05) and mental health care services (P < .05) . Bipolar females with comorbid migraine had more comorbid medical disorders (P < .05) and were more likely to require help with personal or instrumental activities of daily living when compared to bipolar females without migraine.

CONCLUSION

Bipolar disorder with comorbid migraine is prevalent and associated with greater dysfunction and medical service utilization, notable in males. Opportunistic screening and surveillance for bipolar and comorbid migraine is warranted.