Lifetime prevalence and correlates of migraine among women in a pacific northwest pregnancy cohort study

A Study of the Effect of Treatment On the Clinical Profile, Pain, and Disability in Migraine Patients Seen in a Tertiary Hospital

Background

Migraine is a disabling disease that poses a significant societal burden. Migraine is a major cause of disability. Migraine is the eighth leading disease-causing disability in the population.

Objective

To study the clinical profile and measure the pain and migraine-related disability of patients with all types of migraine using the McGill pain assessment scale and Migraine Disability Assessment (MIDAS) before and after 3 months of effect on the medication.

Methods

A Prospective-Cross sectional study was carried out in a multispecialty hospital with male and female patients between 18 and 65 years. The data were collected from the patients directly through the questionnaire of McGill pain assessment scale-short form (SF) and MIDAS, which was provided before and after the medication.

Results

There were 165 subjects of which 52 were men and 113 were women. The mean age of all the subjects was 43 years. About 26.06% of the subjects had a family history of headaches. The scores of McGill pain and MIDAS assessment before and after medication were as follows: 0-15 were 30.90% and 73.33%, Score 16-30 were 54.54% and 18.18%, the score of 31-45 were 14.54% and 7.87% of the subjects. MIDAS grade I was 17.57% and 50.90%, Grade II 33.93% and 21.81%, Grade III 30.30% and 15.75% Grade IV 18.18% and 11.51% of the subjects.

Discussion

The calculated "t" value between the before and after medication values of McGill and MIDAS by paired 't-test was 13.85 and 17.49 respectively. As the calculated "t" value is more than the table value, the alternate hypothesis is accepted.

Conclusion

This study confirms that there is a significant difference in disability levels before and after acute and preventative treatments when measured over 3 months. In addition, the preponderance of females was high, and the functional disability that affects work and social activity associated with migraine is moderate to severe.

Pharmacotherapy of Chronic Neuropsychiatric Conditions During Pregnancy

Many pregnant persons will experience neuropsychiatric conditions during pregnancy, including migraine, attention deficit disorder, depression, and anxiety. Treatment of each of these conditions requires shared decision-making among the individual, family, and health care team. Although medications may include risk, the benefits often outweigh the potential fetal risks. In this article, we review pharmacologic treatment options for each of these conditions and appropriate use in pregnancy to maintain the stability of conditions and to optimize maternal and fetal outcomes.

Determination of the Frequency of Migraine Attacks in Pregnant Women and the Ways They Cope with Headaches: A Cross-Sectional Study

One out of every five women of reproductive age suffers from migraine. Although headaches subside in most women during pregnancy, attacks continue and even worsen in some women. Pregnant women try to relieve pain with medication or non-pharmacological treatment methods. This descriptive and cross-sectional study was conducted to determine the incidence of migraine attacks in pregnant women diagnosed with migraine and the ways they cope with headaches. The study included 191 pregnant women who were diagnosed with migraine in the pre-pregnancy period. McNemar analysis was performed to test the relationship between descriptive statistical methods and categorical variables when the data were analyzed. The mean gestational age of the participants was 28.31 ± 8.64 weeks, and their mean age at the onset of migraine was 20.74 ± 5.63 years. The comparison of the duration, frequency, and severity of headaches suffered before and during pregnancy demonstrated that there were statistical differences between them (p < 0.05). The frequency of using methods such as taking painkillers, resting in a dark room, and having cold application and massage to relieve headaches before pregnancy decreased statistically significantly during pregnancy (p < 0.05). As a result, the frequency and severity of migraines decrease during pregnancy. The tendency to resort to pharmacological or non-pharmacological methods used to relieve headaches decreases during pregnancy. Although migraine has many adverse effects on pregnancy, pregnant women do not demand satisfactory information from health professionals about migraine headaches during pregnancy.

Migraine and risk of hypertensive disorders of pregnancy: A population-based cohort study

BACKGROUND

Migraine is associated with hypertensive disorders of pregnancy through common pathophysiological features. This study evaluates the association between migraine diagnosis and treatment, and risk of hypertensive disorders of pregnancy.

METHODS

We conducted a prospective cohort study in the Clinical Practice Research Datalink GOLD, a large longitudinal database of patient records in the UK. We analyzed data from liveborn or stillborn singleton deliveries from 1993-2020 with at least 24 months of medical history and no history of cardiovascular disease (n = 1,049,839). We ascertained migraine through diagnosis or prescription codes before 20 weeks of gestation and hypertensive disorders of pregnancy through diagnosis codes between 20 weeks of pregnancy and delivery. We used log-binomial regression models to estimate the risk ratio and 95% confidence intervals, comparing risk of hypertensive disorders of pregnancy among individuals with migraine to those without migraine, adjusting for confounders.

CONCLUSIONS

A history of migraine prior to pregnancy was associated with an increased risk of hypertensive disorders of pregnancy (RR = 1.17, 95% CI: 1.09-1.26). The greatest risk was among those with pre-pregnancy migraine that persisted into the first trimester (RR = 1.84, 95% CI: 1.35-2.50). Use of migraine medication was associated with a higher risk of hypertensive disorders of pregnancy compared to non-migraineurs (RR = 1.50, 95% CI: 1.15-1.97). Results from this study indicate that migraine is a potential risk factor for hypertensive disorders of pregnancy.

Relation and Treatment Approach of Migraine in Pregnancy and Breastfeeding

Headaches are one of the most frequent reasons people visit the neurology department. In 2019, headache issues ranked as the 14th most common cause of disability-adjusted life years globally. According to the International Headache Society, migraine is a particular type of headache that is unilateral, frequently throbbing, associated with vertigo, and sensitive to light, sound, and head movement. A migraine has four stages: premonitory, aura, headache, and postdrome. Migraine is the type of discomfort that most frequently complicates the pregnancy. A migraine is more common in women than in men. Migraines are influenced by increased levels of estrogen during pregnancy and a sharp decrease in those levels during puerperium. Untreated migraine can result in premature labor, hypertension, and low birth weight babies. Menstrual-related events occurred more frequently in migraine sufferers than in non-migraine sufferers. We have explained the relation of sex hormones that trigger migraine. We have also reviewed the therapeutic approach, such as pharmacological and non-pharmacological approaches, for migraine in pregnancy and breastfeeding. A migraine episode during menstruation was slightly more severe and complicated than a headache that wasn't a migraine. Breastfeeding is not prohibited by migraines. The steady estrogen levels brought on by lactating women's lack of menstruation may function as a protective factor. In addition to any required drug therapy, nonpharmacological techniques should always be used as the first line of treatment. Preconception counseling is an essential part of providing headache patients with safe therapy during pregnancy. Supplemental estrogen should not be used by any women who have an aura or who are 35 years of age or older because there is inadequate proof to support any long-term adverse effects. Paracetamol is advised for use in acute therapy during pregnancy. Mothers who used acetaminophen during pregnancy are more likely to have children with hyperkinetic disorders and characteristics resembling attention-deficit/hyperactivity disorder. Menstrual migraine can be treated in a variety of ways, including acute therapy, non-pharmacological therapy, and preconception counseling. Similar tactics are used to treat migraines during pregnancy, but it's important to take the medications' safety rating into account. Migraines and menstrual problems go together. A safeguarding element is a constant estrogen level during pregnancy and breastfeeding. The preferred method of treatment for migraine is non-pharmacological therapy, followed by prenatal counseling. Sumatriptan and acetaminophen are both effective treatments for transient migraine attacks that occur during pregnancy or breastfeeding.

Migraine treatment in pregnancy: A survey of comfort and treatment practices of women's healthcare providers

OBJECTIVE

The objective of this study was to assess women's healthcare providers' treatment practices for pregnant women with migraine.

BACKGROUND

Migraine is associated with several maternal and fetal complications during pregnancy, including preeclampsia and preterm birth. Migraine treatment during pregnancy can present significant challenges due to lack of controlled clinical trials and risks associated with specific medications.

METHODS

Women's healthcare providers were queried regarding practice patterns and comfort with use of acute and preventive migraine treatments during pregnancy. The survey was distributed online.

RESULTS

The survey was completed by 92 women's healthcare providers (response rate 22.9% [92/402]), with most specializing in general obstetrics and gynecology (91% [83/92]). Approximately one-fourth (26% [24/92]) of respondents indicated they counseled women on migraine treatment in pregnancy as early as before pregnancy contemplation, while over one-third (35% [32/92]) counseled on migraine treatment once the patient became pregnant. The majority of respondents reported feeling somewhat or very comfortable with recommending (63% [58/92]) or continuing (64% [59/92]) acute treatments for pregnant patients with migraine, with highest comfort levels for acetaminophen (100% [92/92] for prescribing or continuing) and caffeine (94% [85/90] prescribing, 91% [82/90] continuing). Higher levels of discomfort were reported with triptans (88% [80/91] rarely or never prescribe during pregnancy). Survey respondents felt less comfortable with recommending preventive migraine treatments to pregnant patients (40% [37/92] somewhat or very comfortable), compared with a higher comfort level with continuing preventive medications (63% [58/92] somewhat or very comfortable). Highest comfort levels were reported with use of magnesium (69% [63/91] comfortable prescribing, 82% [75/92] comfortable continuing) and non-pharmacologic approaches (70% [62/89] comfortable prescribing, 84% [75/89] comfortable continuing). Nearly 40% (35/92) of respondents reported that they typically refer to neurologists or headache specialists for migraine treatment during pregnancy.

CONCLUSION

This survey of women's healthcare providers revealed varying levels of comfort regarding migraine management during pregnancy, and highlights the need for additional education regarding migraine treatment safety data during pregnancy.

New onset headache during delivery and postpartum: Clinical characteristics of a case series

Introduction

There are abundant studies on headache and migraine in women but few or none about their occurrence during labor, delivery, and postpartum (2 hours after delivery) owing to the low incidence. A headache attack can be debilitating when a woman is trying to manage labor pain. Research at our Women's Headache Center within the Department of Gynecology and Obstetrics has begun to shed light on this potential association.

Methods

For the present study 474 women with singleton pregnancy were enrolled. A headache questionnaire was administered at two time points. Headache history was investigated on admission to prenatal care at 36 weeks gestation. The women were followed by a midwife who monitored labor progression and recorded the onset and features of headache pain. During examination before hospital discharge at 3 days post-delivery, the headache questionnaire was reviewed by a headache specialist who differentiated headache type according to International Classification of Headache Disorders (3rd edition) criteria.

Results

Data analysis showed that 145/474 women had a history of headache: 65/145 (44.82%) reported a diagnosis of migraine. Eight reported experiencing a probable migraine attack (4 with aura) and one reported probable tension-type headache during labor or postpartum. All nine women who reported migraine/headache attack during labor had no previous history of headache or neurological illness. All had vaginal delivery. No onset of headache pain in patients with a previous history of headache was noted during delivery and postpartum.

Discussion

The onset of a headache attack during labor in women who usually do not experience headache suggests other pathogenic mechanisms underlying the attack and merits further study.

Interrelationships between migraine over the counter (OTC) painkillers and hypertensive disorders of pregnancy: A protocol for systematic review and meta-analysis

BACKGROUND

Migraine during pregnancy is common and has been reported to affect up to 10% of pregnancies. Irrespective of the type of migraine, over the counter (OTC) painkillers are used as a migraine treatment plan. Growing evidence suggests that OTC painkillers have effects on the mother, the child and hypertensive disorders of pregnancy, including hypertension, eclampsia and pre-eclampsia, but inconsistent findings have been reported. The aim of this study is therefore to investigate the association between the use of migraine OTC painkillers and hypertensive disorders during pregnancy.

METHODS

Databases such as Pubmed, Cochrane library, ScienceDirect and google scholar will be searched to identify eligible studies. Studies will be included if they are randomised controlled trials, cohort, and matched cohort, and cross-sectional studies of pregnant women with reported use of OTC painkillers to treat migraines at any stage of their pregnancy. The results will be reported based on the preferred reporting items for systematic reviews and meta-analysis 2009 statement, and article screening and selection process will also be demonstrated through a preferred reporting items for systematic reviews and meta-analysis for protocols flow diagram. The data will then be extracted by 1 reviewer and checked by another for accuracy. The quality and risk of bias of eligible studies will be performed by both reviewers using the Hoy tool and grading of recommendations assessment, development and evaluation tool. The data will be analysed using Review Manager 5.3 (RevMan 5.3) software.

ETHICS AND DISSEMINATION

The review and meta-analysis will not require ethical approval and the findings will be published in peer-reviewed journals and presented at local and international conferences. Findings from this study will help to improve knowledge on the understanding of the effects OCT on hypertensive disorders of pregnancy. This study will also provide new information on the management of migraine during pregnancy.

SYSTEMATIC REVIEW REGISTRATION

International prospective Register of Systematic Reviews (PROSERO) number: CRD42021232232.

The Use of Behavioral Modalities for Headache During Pregnancy and Breastfeeding

Purpose of Review

Migraine is primary headache which commonly affects women of childbearing age. Migraine and other primary headache disorders are also common during pregnancy. Understanding which treatments are effective and can be safely given to patients with primary headache during pregnancy and lactation is essential in supporting these patients before, during, and after childbirth. Behavioral modalities have the potential to improve the health of both mother and baby, while empowering patients to make informed decisions in family planning and creating future treatment plans.

Recent Findings

Research shows that behavioral therapies can be powerful tools to treat pain conditions with minimal side effects. Recent literature prioritizes behavioral therapies in preparation for pregnancy, during pregnancy, and during lactation due to the superior safety profile of such therapies. Digital resources for behavioral therapy are another well-received recent direction supported by growing evidence of both efficacy and safety. Popular with patients and headache specialists, digital behavioral therapy has taken various forms during the pandemic, such as telemedicine, online psychology support groups, and smartphone applications that patients can interact with on their own time.

Summary

In summary, the purpose of this review is to equip providers with important information and updates on the use of behavioral modalities for the treatment of primary headache during pregnancy and lactation.

Ibero-American Endometriosis Patient Phenome: Demographics, Obstetric-Gynecologic Traits, and Symptomatology

Background: An international collaborative study was conducted to determine the demographic and clinical profiles of Hispanic/Latinx endometriosis patients from Latin America and Spain using the Minimal Clinical Questionnaire developed by the World Endometriosis Research Foundation (WERF) Endometriosis Phenome and Biobanking Harmonization Project (EPHect). Methods: This is a cross-sectional study to collect self-reported data on demographics, lifestyle, and endometriosis symptoms of Hispanic/Latinx endometriosis patients from April 2019 to February 2020. The EPHect Minimal Clinical Questionnaire (EPQ-M) was translated into Spanish. Comprehension and length of the translated survey were assessed by Spanish-speaking women. An electronic link was distributed via social media of endometriosis patient associations from 11 Latin American countries and Spain. Descriptive statistics (frequency, means and SD, percentages, and proportions) and correlations were conducted using SPSSv26. Results: The questionnaire was completed by 1,378 participants from 23 countries; 94.6% had self-reported diagnosis of endometriosis. Diagnostic delay was 6.6 years. Most participants had higher education, private health insurance, and were employed. The most common symptoms were back/leg pain (85.4%) and fatigue (80.7%). The mean number of children was 1.5; 34.4% had miscarriages; the mean length of infertility was 3.7 years; 47.2% reported pregnancy complications. The most common hormone treatment was oral contraceptives (47.0%). The most common comorbidities were migraines (24.1%), polycystic ovary syndrome (PCOS) (22.2%), and irritable bowel syndrome (21.1%). Most participants (97.0%) experienced pelvic pain during menses; for 78.7%, pain was severe; 86.4% reported dyspareunia. The mean age of dysmenorrhea onset was 16.2 years (SD ± 6.1). Hormone treatments were underutilized, while impact was substantial. Pain catastrophizing scores were significantly correlated with pain intensity (p < 0.001). Conclusion: This is the first comprehensive effort to generate a clinical-demographic profile of Hispanic/Latinx endometriosis patients. Differences in clinical presentation compared to other cohorts included higher prevalence and severity of dysmenorrhea and dyspareunia and high levels of pain catastrophizing. Though future studies are needed to dissect the impact of race and ethnicity on pain and impact, this profile is the first step to facilitate the recognition of risk factors and diagnostic features and promote improved clinical management of this patient population. The EPHect questionnaire is an efficient tool to capture data to allow comparisons across ethnicities and geographic regions and tackle disparities in endometriosis research.

An Unusual Case of Migraine Preconception and Severe Postpartum Headache and Intracranial Hemorrhage

Migraine affects many women in their childbearing years and gets worse during pregnancy, probably due to fluctuations in reproductive hormones. Similar changes in maternal physiology due to pregnancy increase the susceptibility toward secondary headache disorders and can cause the return of migraines in the postpartum period. Increased occurrence of headaches is also associated with the administration of epidural anesthesia, which decreases cerebrospinal fluid pressure. However, the less common causes such as secondary headache disorders related to cerebrovascular disorders and hypertension should be considered for differential diagnosis in this group of patients. In this case report, we discuss the case history of a 36-year-old woman, with a past history of migraine without aura, who presented at 1 week postpartum with headache, confusion, dizziness, right-sided weakness, and urinary incontinence. Brain imaging studies revealed global hypoxic ischemic injury to the brain. This case report discusses her presentation, investigations, management, and etiology of migraine, leading to stroke and death postpartum.

Polypharmacy and comorbidities during pregnancy in a cohort of women with migraine

OBJECTIVE

To describe longitudinal patterns of medication use throughout pregnancy in women with migraine.

METHODS

We used the IBM MarketScan healthcare claims database in the US to create a cohort of pregnancies enrolled between 2011-2015 resulting in live or stillbirth. Migraine headache was identified based on ICD-9-CM diagnosis codes or procedure codes recorded in clinical encounters. Outcomes were patterns of prescriptions filled for medications that may be used to prevent migraine (antiepileptics, antihypertensives, antidepressants) or treat acute episodes (opioids, triptans, acetaminophen) and of other comorbid conditions (hypertension, psychiatric diagnoses, epilepsy). We used group-based multi-trajectory models to cluster women into similar longitudinal patterns of prescription fills.

RESULTS

Of 859,501 pregnancies, 8168 had migraine. Within migraineurs, before pregnancy, the most commonly filled prescription was for a triptan (43.2%), followed by opioids (26.7%), acetaminophen (26.2%), antidepressants (24.9%), antiepileptics (18.6%) and antihypertensives (12.3%). Antiepileptics, antidepressants, and triptans were frequently discontinued early in pregnancy with few new users, while antihypertensives were discontinued by some users, but continued or initiated by a minority of users late in pregnancy. Opioids and acetaminophen were used intermittently throughout pregnancy. Comorbidities included hypertension (10.8%), epilepsy (4.7%), depression (14.0%), and anxiety (15.6%). Polypharmacy involving both preventive and acute medications was most common before pregnancy (31.4%) and declined in first trimester (14.7%). In all, 25.9% of women filled prescriptions for two or more acute medications before pregnancy.

CONCLUSIONS

Medication use patterns during pregnancy for women with migraine are complex. Patterns of polypharmacy and comorbidity during pregnancy highlight an under-studied area relevant for maternal and child health outcomes.

Managing migraine in pregnancy and breastfeeding

The disproportionate prevalence of migraine among women in their reproductive years underscores the clinical significance of migraine during pregnancy. This paper discusses how migraine evolves during pregnancy, secondary headache disorders presenting in pregnancy and puerperium, and acute and preventive options for migraine management during pregnancy and lactation. Migraine is influenced by rising estrogen levels during pregnancy and their sharp decline in puerperium. Migraine, and migraine aura, can present for the first time during pregnancy and puerperium. There is also a higher risk for the development of preeclampsia and cerebrovascular headache during these periods. New or refractory headache, hypertension, and abnormal neurological signs are important "red flags" to consider. This paper reviews the diagnostic utility of neuroimaging studies and the risks of each during pregnancy. Untreated migraine can itself lead to preterm delivery, preeclampsia, and low birth weight infants. Behavioral interventions and lifestyle modifications are the cornerstone for migraine treatment during pregnancy. In addition, one should consider the risks and efficacy of each treatment during pregnancy on an individual basis. The protective nature of breastfeeding for migraine is debated, but there is no evidence to suggest breastfeeding worsens migraine. Acute and preventive migraine treatment options are available for nursing mothers. Neuromodulation and neurostimulation devices are additional options for treatment during pregnancy and lactation, while the safety of using calcitonin gene-related peptide receptor antagonists during these times remains to be determined.

The Association Between Parental Migraine and Infant Colic: A Cross-Sectional, Web-Based, U.S. Survey Study

BACKGROUND

Infant colic, or excessive crying in an otherwise healthy infant, is common, although the cause(s) are not known. This study aimed to determine whether parental migraine is associated with infant colic.

METHODS

This was a cross-sectional online survey study of biological parents of 4-8 week olds in the United States during February and March 2017 and October 2017-April 2018. Parents self-reported information about their and their infant's health using validated instruments wherever possible. Parents were recruited using social media advertisements and completed the survey online. Migraine was identified with a validated screener using modified International Classification of Headache Disorders 3rd edition criteria. Parental depression and anxiety were screened with the Patient Health Questionnaire-2 (PHQ-2) and Generalized Anxiety Disorder Scale-2 (GAD-2). Parental seasonal allergies and asthma were assessed by self-report. Infant colic was determined based on parental response to the question, "Has your baby cried for at least 3 hours on at least 3 days in the last week?"

RESULTS

A total of 1,715 surveys were completed over 2 recruitment periods; 1,419 formed the analysis set. Eight hundred twenty-seven were completed by biological mothers and 592 by biological fathers. Mean (SD) maternal age: 28.9 (5.1) years; 33.5% had migraine/probable migraine. Maternal migraine was associated with increased odds of infant colic: OR 1.7 (1.3-2.4). Among mothers with migraine, headache frequency ≥15 days/month was associated with higher risk of infant colic (OR 2.5 (1.2-5.3)); and anxiety was borderline associated (OR 1.7 (1.0-2.9)). Mean (SD) paternal age was 31.6 (4.5) years; 20.8% had migraine/probable migraine. Paternal migraine was not associated with infant colic: OR 1.0 (0.7-1.5). Fathers with depression (OR 2.4 (1.4-4.3)) or anxiety (OR 1.7 (1.1-2.7)) were more likely to have a baby with colic but having a girl infant was protective: (OR 0.7 (0.5-0.97)).

CONCLUSIONS

Mothers with migraine are more likely to have a baby with colic, while fathers with migraine are not. Further research is needed to determine the mechanisms underlying these findings. In the meantime, clinicians may wish to counsel parents with a maternal history of migraine about the increased possibility of having a colicky infant and provide resources and education about infant crying.

Serotonin-estrogen interactions: What can we learn from pregnancy?

We have reviewed the scientific literature related to four diseases in which to serotonin (5-HT) is involved in the etiology, herein named 5-HT-linked diseases, and whose prevalence is influenced by estrogenic status: depression, migraine, irritable bowel syndrome and eating disorders. These diseases all have in common a sex-dimorphic prevalence, with women more frequently affected than men. The co-occurrence between these 5-HT-linked diseases suggests that they have common physiopathological mechanisms. In most 5-HT-linked diseases (except for anorexia nervosa and irritable bowel syndrome), a decrease in the serotonergic tone is observed and estrogens are thought to contribute to the improvement of symptoms by stimulating the serotonergic system. Human pregnancy is characterized by a unique 5-HT and estrogen synthesis by the placenta. Pregnancy-specific disorders, such as hyperemesis gravidarum, gestational diabetes mellitus and pre-eclampsia, are associated with a hyperserotonergic state and decreased estrogen levels. Fetal programming of 5-HT-linked diseases is a complex phenomenon that involves notably fetal-sex differences, which suggest the implication of sex steroids. From a mechanistic point of view, we hypothesize that estrogens regulate the serotonergic system, resulting in a protective effect against 5-HT-linked diseases, but that, in turn, 5-HT affects estrogen synthesis in an attempt to retrieve homeostasis. These two processes (5-HT and estrogen biosynthesis) are crucial for successful pregnancy outcomes, and thus, a disruption of this 5-HT-estrogen relationship may explain pregnancy-specific pathologies or pregnancy complications associated with 5-HT-linked diseases.

Migraine Treatment in Pregnant Women Presenting to Acute Care: A Retrospective Observational Study

OBJECTIVE

To assess the acute treatment of pregnant women presenting to a hospital with migraine.

BACKGROUND

Migraine is a common problem in pregnancy; however, migraine treatment is challenging in pregnant women for fears of medication teratogenicity and lack of data in this population. To date, no study has directly explored physician practices for treatment of acute migraine in pregnant women.

METHODS

We conducted a retrospective chart review of medication administration for pregnant women who presented to an acute care setting with a migraine attack and received neurology consultation between 2009 and 2014.

RESULTS

We identified 72 pregnant women with migraine who were treated with pain medications. Fifty-one percent (37/72) were in the third trimester of pregnancy, 39% (28/72) in the second trimester, and 10% (7/72) in the first trimester. Thirty-two percent (23/72) had not tried any acute medications at home before coming to the hospital, and 47% (34/72) presented in status migrainosus. Patients received treatment in the hospital for a median of 23 hours (interquartile range = 5-45 hours). The most common medications prescribed were metoclopramide in 74% (53/72) of patients (95% confidence interval [CI] 62-82%) and acetaminophen in 69% (50/72) of patients (95% CI 58-79%). Metoclopramide was administered along with diphenhydramine in 81% (44/53) of patients (95% CI 71-91%). Acetaminophen was the most frequent medicine administered first (53%, 38/72). Patients were often treated with butalbital (35%, 25/72) or opioids (30%, 22/72), which were used as second- or third-line treatments in 29% of patients (20/72). Thirty-eight percent (27/72) received an intravenous (IV) fluid bolus, 24% received IV magnesium (17/72), and 6% (4/72) had peripheral nerve blocks performed.

CONCLUSIONS

While the majority of pregnant women with acute migraine received medications considered relatively safe in pregnancy, there was variation in treatment choice and sequence. Some acute medications considered potentially hazardous for fetal health and less effective for migraine (opioids and butalbital) were used frequently, whereas other treatments that may have low teratogenic risk (nerve blocks, IV fluid boluses, and triptans) were used less or not at all. These results indicate a need for developing guidelines and protocols to standardize acute treatment of migraine in pregnancy.

Chronic pain, pain severity and analgesia use in Australian women of reproductive age

BACKGROUND

The increasing prevalence and adverse outcomes associated with opioid analgesia use in women of reproductive age have become a significant public health issue internationally, with use during pregnancy potentially affecting maternal and infant health outcomes.

OBJECTIVE

This study aims to provide national estimates of chronic pain, pain severity and analgesia use in Australian women of reproductive age by pregnancy status.

METHOD

Data were obtained from the Australian Bureau of Statistics 2011-12 National Health Survey (n=20,426). Weighting was applied to sample data to obtain population estimates. For this study data were analysed for pregnant (n=166, N=192,617) and non-pregnant women (n=4710, N=5,256,154) of reproductive age (15-49 years).

RESULTS

Chronic or reoccurring pain was reported in 5.1% of pregnant women and 9.7% of non-pregnant women, and 0.7% and 2.6% of pregnant and non-pregnant women reported recent opioid analgesia use respectively. Moderate-to-very severe pain was more common in pregnant than non-pregnant women taking opioid analgesics, and no pain and very mild-to-mild pain in non-pregnant women.

CONCLUSION

Approximately 1 in 20 pregnant Australian women have chronic or reoccurring pain. Opioid analgesia was used by around 1% of Australian pregnant women during a two-week period, with use associated with moderate-to-very severe pain. Given that the safety of many analgesic medications in pregnancy remains unknown, pregnant women and health professionals require accurate, up-to-date information on the risks and benefits of analgesic use during pregnancy. Further evidence on the decision-making processes of pregnant women with pain should assist health professionals maximise outcomes for mothers and infants.

Pregnancy outcomes after maternal betahistine exposure: A case series

OBJECTIVE

To investigate the pregnancy outcomes of women who were exposed to betahistine during their pregnancies.

METHODS

We identified and evaluated the outcomes of 27 pregnant women who were referred to Terafar (Teratology Information Service, Izmir, Turkey) for a teratological risk assessment.

RESULTS

Of 24 pregnancies with known outcomes, 21 resulted in live births (including two pairs of twins) whereas two ended with miscarriage and three with elective terminations. Among the 20 live births for whom the malformation details were available, there were 17 normal outcomes, one major and two minor congenital malformations.

CONCLUSIONS

Despite a number of limitations, this case series may be of value regarding counseling pregnant women with inadvertent betahistine exposure. Further epidemiological studies with larger sample sizes and control groups are necessary to draw more definite conclusions.

Body composition status and the risk of migraine: A meta-analysis

OBJECTIVE

To evaluate the association between migraine and body composition status as estimated based on body mass index and WHO physical status categories.

METHODS

Systematic electronic database searches were conducted for relevant studies. Two independent reviewers performed data extraction and quality appraisal. Odds ratios (OR) and confidence intervals (CI) were pooled using a random effects model. Significant values, weighted effect sizes, and tests of homogeneity of variance were calculated.

RESULTS

A total of 12 studies, encompassing data from 288,981 unique participants, were included. The age- and sex-adjusted pooled risk of migraine in those with obesity was increased by 27% compared with those of normal weight (odds ratio [OR] 1.27; 95% confidence interval [CI] 1.16-1.37, p < 0.001) and remained increased after multivariate adjustments. Although the age- and sex-adjusted pooled migraine risk was increased in overweight individuals (OR 1.08; 95% CI 1.04, 1.12, p < 0.001), significance was lost after multivariate adjustments. The age- and sex-adjusted pooled risk of migraine in underweight individuals was marginally increased by 13% compared with those of normal weight (OR 1.13; 95% CI 1.02, 1.24, p < 0.001) and remained increased after multivariate adjustments.

CONCLUSIONS

The current body of evidence shows that the risk of migraine is increased in obese and underweight individuals. Studies are needed to confirm whether interventions that modify obesity status decrease the risk of migraine.

Managing Migraine During Pregnancy and Lactation

While over half of women with migraine report improvement during pregnancy, having a history of migraine may increase the chance of negative health outcomes. The state of pregnancy increases the risk of several dangerous secondary headache disorders, especially those associated with hypertensive disorders of pregnancy, and providers need to know the red flags to diagnose and treat emergently. Non-pharmacological migraine treatments can be instituted in advance of pregnancy as many are considered the safest options during pregnancy, but understanding the safety of medications and dietary supplements ensures appropriate care for the refractory migraine patient. New controversy exists over the safety of several historically routine and safe migraine treatment options in pregnancy, such as magnesium, acetaminophen, ondansetron, and butalbital. While it is not clear if breastfeeding decreases the postpartum recurrence of migraine, understanding safe treatment options during lactation can allow women to continue breastfeeding while achieving migraine relief.

Clinical profile and functional disability of patients with migraine

Background:

Migraine is a common disabling primary headache disorder. Globally, migraine was ranked as the seventh highest cause of disability.

Aim:

The aim of the study was to explore the clinical profile and functional disability of patients with migraine.

Settings and Design:

A cross-sectional survey was conducted at the neurology outpatient department of a tertiary care hospital in Karnataka.

Materials and Methods:

Using a consecutive sampling technique, 60 patients were recruited for the study. Descriptive and inferential statistics were used to analyze the data.

Results:

Majority of the participants were in the age group of 18–40 years with a mean age 35.22 years. There was a female preponderance with 70% of study participants being females. The various symptoms experienced by patients include throbbing pain (90%), photophobia (93.3%), phonophobia (85%), nausea (76.7%), and vomiting (41.7%). Most of the subjects (73.3%) under the study belonged to moderate to severe levels of functional disability. About 53.3% of patients were in the category of episodic migraine and 46.7% were in the category of chronic migraine.

Conclusion:

Migraine is associated with moderate to severe functional disability. Frequency of migraine has a positive correlation with the levels of disability/migraine disability assessment scores of migraineurs.

The Frequent Unusual Headache Syndromes: A Proposed Classification Based on Lifetime Prevalence

BACKGROUND

There is no agreement on a single cutoff point or prevalence for regarding a given disease as rare. The concept of what is a rare headache disorder is even less clear and the spectrum from a very frequent, frequent, occasional to rare headache syndrome is yet to be established.

OBJECTIVE

An attempt has been made to estimate the lifetime prevalence of each of the headache subtypes classified in the ICHD-II.

METHOD

Using the ICHD-II, 199 different headache subtypes were identified. The following classification was made according to the estimated lifetime prevalence of each headache disorder: very frequent (prevalence >10%); frequent (between 1 and 10%); occasional (between 0.07 and 1%); and unusual or rare (<0.07%).

RESULTS

One hundred and fifty-four of 199 (77%) were categorized as unusual headache disorders, 7/199 (4%) as very frequent, 9/199 (5%) as frequent, and 29/199 (15%) as occasional forms of headache disorder.

CONCLUSION

The unusual headache syndromes do not appear to be as infrequent in clinical practice as has been generally believed. About three-fourths of the classified headache disorders found in the ICHD-II can be considered as rare. This narrative review article may be regarded as an introduction to the concept of unusual headaches and a proposed classification of all headaches (at least those listed in the ICHD-II).

Depression, anxiety and stress among pregnant migraineurs in a pacific-northwest cohort

BACKGROUND

The co-occurrence of migraine and unipolar psychiatric disorders has been well documented in non-pregnant populations, however little is known in pregnant populations.

METHODS

A cohort of 1321 women was interviewed during the first trimester of pregnancy. At the time of interview lifetime migraine status was ascertained using International Classification of Headache Disorders diagnostic criteria (ICHD-II). Information regarding unipolar depression, anxiety and stress during pregnancy was collected using the Patient Health Questionnaire Depression Module-9 (PHQ-9), and the Depression Anxiety Stress Scales 21-item Short Form (DASS-21). Multivariable logistic regression procedures were used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the association of migraine and mood disorders during pregnancy.

RESULTS

Approximately 28.2% (N=372) were classified as having a lifetime history of migraine; among migraineurs 122 were classified as migraineurs with aura and 250 as migraineurs without aura. Compared with non-migraineurs, migraineurs were associated with 1.60-fold increased odds of depression as measured by a PHQ-9 score ≥10 (AOR=1.60; 95% CI: 1.12-2.31). Overall, migraine with aura was more strongly associated with depression than was migraine without aura. Migraineurs, as compared with non-migraineurs, also had higher odds of mood disorders as measured by the DASS-21.

CONCLUSIONS

The comorbidity of mood and migraine disorders in pregnant populations supports the need for integrated mental and physical clinical evaluation, increased vigilance, and treatment of patients with such disorders.

[Current approaches to treatment of migraine during pregnancy]

Migraine is one of the most common complaints in the majority of pregnant women. Migraine without aura is the most frequent cause of headache. Improvement of this disease is reported in 50-80% of patient. However, about one third of pregnant women have severe prolonged attacks with marked concomitant symptoms and maladaptation that necessarily need treatment. Authors consider the issues of differential diagnosis and principles of management of these patients.

Risks of neurobehavioral teratogenicity associated with prenatal exposure to valproate monotherapy: a systematic review with regulatory repercussions

Beyond its formal indications (epilepsy, bipolar disorder, and migraine), valproate sodium (VPA) is widely used in a number of other clinical conditions. Recently, however, the U.S. Food and Drug Administration (FDA) issued a warning regarding a decrease in IQ scores in children prenatally exposed to the drug. For patients with migraine, the pregnancy labeling of VPA will be changed from Category "D" to "X." VPA products will remain in pregnancy category "D" for treating epilepsy and manic episodes associated with bipolar disorder. Thus, this article aims to assess (through a computerized Medline/PubMed search) the neurobehavioral teratogenicity of valproate monotherapy, in order to evaluate alternative regulatory decisions. Reviewed information suggests a detrimental impact of antenatal valproate exposure on the global child neurodevelopment. Affected areas include not just reduced IQ scores, but also behavioral problems and a potential increase in the risk for a future diagnosis of attention-deficit/hyperactivity disorder. An increased risk of developing autism-spectrum disorders has also been reported. Thus, in my opinion, VPA should be assigned definitively to the Category "X," independent of any considerations about its clinical indications, and should be strictly avoided during pregnancy, due to the demonstrated risk of both neurobehavioral and neurocognitive teratogenicity.

Agreement of self-reported physician diagnosis of migraine with international classification of headache disorders-II migraine diagnostic criteria in a cross-sectional study of pregnant women

BACKGROUND

Migraine, a common chronic-intermittent disorder among reproductive age women, has emerged as a novel risk factor for adverse perinatal outcomes. Diagnostic reliability of self-report of physician-diagnosed migraine has not been investigated in pregnancy cohort studies. We investigated agreement of self-report of physician-diagnosed migraine with the diagnostic criteria promoted by the International Classification of Headache Disorders, 2nd edition (ICHD-II).

METHODS

The cross-sectional study was conducted among 500 women who provided information on a detailed migraine questionnaire that allowed us to apply all ICHD-II diagnostic criteria.

RESULTS

Approximately 92% of women reporting a diagnosis of migraine had the diagnosis between the ages of 11 and 40 years (<10 years 6.8%; 11-20 years 38.8%; 21-30 years 42.7%; 31-40 years 10.7%; and >40 years 1.0%). We confirmed self-reported migraine in 81.6% of women when applying the ICHD-II criteria for definitive migraine (63.1%) and probable migraine (18.5%).

CONCLUSION

There is good agreement between self-reported migraine and ICHD-II-based migraine classification in this pregnancy cohort. We demonstrate the feasibility of using questionnaire-based migraine assessment according to full ICHD-II criteria in epidemiological studies of pregnant women.