Obesity and headache: Part II--potential mechanism and treatment considerations

Non-Pharmacological Treatments in Paediatric Migraine

Psychological, social, and biological aspects contribute synergistically to the maintenance and chronicity of pain in primary headaches. An integrated intervention seems to be the most appropriate in the management of these conditions, taking advantage not only of pharmacological strategies, but also of different approaches according to the global assessment and patient necessities. In this perspective, non-pharmacological treatments are becoming increasingly used to overcome these issues also in paediatric migraine treatment. Particularly, nutraceuticals, non-invasive neuromodulation, and behavioural approaches are well tolerated and of potential interest. This paper aims to present the main approaches reported in the literature in the management of migraine in children and adolescents presenting an up-to-date review of the current literature. We therefore performed a narrative presentation for each of these three categories: nutraceuticals (riboflavin; magnesium; melatonin; vitamin D; coenzyme Q10; and polyunsaturated fatty acid); non-invasive neuromodulation (trigeminal nerve stimulator; non-invasive vagal nerve stimulation; transcranial magnetic stimulation; and remote electrical neuromodulation), and behavioural therapies (biofeedback; cognitive behavioural therapy; and mindfulness-based therapy). These approaches are increasingly seen as a valid treatment option in primary headache management also in paediatrics, avoiding medication overuse and drug treatment contraindications.

Non-Pharmacological Treatment of Primary Headaches-A Focused Review

Headache disorders are a significant global health burden, leading to reduced quality of life. While vast pharmacological treatments are available, they may be associated with adverse effects or inadequate efficacy for some patients, therefore there is a need for exploring alternate treatment strategies. This review gives a brief explanation and evaluation of some established and emerging non-pharmacological approaches for headache management, focusing on nutraceuticals and diet, acupuncture, cognitive behavioral therapy (CBT), biofeedback, relaxation techniques, autogenic training, and neuromodulation. Special consideration is given to psychological interventions as they increase patient self-efficacy and provide strategies for managing chronic pain. Future research should focus on optimizing these therapies, identifying patient-specific factors influencing their effectiveness, and integrating them into holistic headache management strategies.

Cardiovascular Risk Factors and Family History of Major Thrombotic Events in Children with Migraine: A 12-Year Retrospective Single-Centre Study

BACKGROUND

Migraine is one of the most frequent primary headaches in childhood. The role of thrombotic predisposition in its pathogenesis is debated. Our aim was to analyse the cardiovascular risk factors and family history of major thrombotic events in children with migraine.

METHODS

A retrospective, single-centre study was performed over 12 years. Our headache centre record database was screened for migraine with aura (MA) and migraine without aura (MO) on the basis of the ICHD-II (until 2013) and III criteria. A control group of otherwise healthy children was recruited. Descriptive and multivariate analyses are provided; significance was set at p < 0.05.

RESULTS

Migraine was diagnosed in 930 children (24.7% MA); 73.3% were 9-14 years old. Children with MA were older (p < 0.001). A family history of cerebral ischemic events at ≤50 years old was more commonly reported by children with MA than those with MO (p < 0.001) and those in the control group (p = 0.001). Children with MA showed a higher risk of a family history of cerebral ischemic events at ≤50 years old than children with MO (OR: 2.6) and those in the control group (OR: 3.1). When comparing the family history of DVT, we observed a significantly increased risk for MA vs. MO (OR: 2.9).

CONCLUSION

A family history of cerebral ischemic events at ≤50 years old leads to an increased risk of MA. Further studies are needed to explore such an association.

Association of obesity with headache among US children and adolescents: Evidence from NHANES 1999-2004

Background

Children and adolescents increasingly commonly suffer from obesity and headache. It has been confirmed that there is an association between obesity and headache in adults; however, evidence of such an association in paediatric populations is still controversial. Therefore, this study examined the relationship between obesity and headache among children and adolescents in the US.

Methods

The cross-sectional data of 3948 participants were obtained from the National Health and Nutrition Examination Survey 1999-2004. Weighted logistic regression models were applied to investigate the association between obesity and headache. Subgroup analysis stratified by sex and age was performed to explore the potential difference in the association of paediatric obesity with headache. The performance of paediatric obesity on headache was assessed by receiver operating characteristic (ROC) curve.

Results

The present study involved 3948 participants, of whom 713 (18.1%) had headache. Compared to those without headache, participants with headache tended to be girls and adolescents, have less calcium intake, and have higher levels of body mass index (BMI), C-reactive protein (CRP), serum ferritin and triglycerides (TGs) (all P < 0.05). After fully adjusting for potential confounders, the ORs with 95% CIs for headache were 1.03 (0.58-1.54) and 1.25 (0.68-2.30) for overweight and obese participants in comparison with normal-weight controls, respectively, implying no association of paediatric obesity with headache independent of other potential confounding factors. In addition, although higher odds of headache were noted in girls and adolescents (aged 10-17 years), no statistically significant difference was found across any subgroups. The area under the ROC (AUC) of paediatric obesity on headache was 0.634.

Conclusions

In summary, our study indicated that obesity is not associated with headache among US children and adolescents. Further prospective studies with larger sample size are needed to validate our findings.

Migraine and obesity: what is the real direction of their association?

INTRODUCTION

In recent decades, studies have addressed the issue of how migraine and obesity are related and have suggested obesity as a risk factor for migraine headache. However, the exact direction of this relationship remains under debate. In this review, the authors summarize the evidence that have suggested migraine as a risk factor for obesity and overweightness.

AREAS COVERED

This article reviews the results of the previous research published on PubMed and Scopus databases (from 2000 to 2020) concerning the association between migraine and obesity to determine the actual direction of their association. Special attention has been given to the common mechanistic pathways involved in the pathophysiology of migraine and obesity.

EXPERT OPINION

The majority of research conducted thus far has considered obesity as a risk factor for migraine. However, because of the cross-sectional design of available research, we cannot be certain of the proposed direction of this association. There is evidence supporting the hypothesis that obesity can serve as a consequence of migraine through the effects of neuropeptides, inflammatory mediators, adipokines, gut microbiota and modifications in eating behavior and lifestyle. However, the real direction of the relationship between migraine and obesity should be further investigated in large prospective studies.

The effect of the lunar cycle on migraine: preliminary findings from a retrospective study

AIM

The purpose of this study was to evaluate the relationship between the lunar cycle and attacks observed in patients diagnosed with migraine and under follow-up in our pediatric neurology clinic.

METHODS

Cases diagnosed with migraine and under follow-up at the Balıkesir University Medical Faculty Pediatric Neurology Clinic, Turkey, undergoing attacks between 01.09.2019 and 01.09.2021, and whose attacks were recorded were included in the study. Patients' migraine attacks were investigated retrospectively, and the stage of the lunar cycle at which they occurred, based on the lunar calendar, was determined.

RESULTS

The mean age of the patients in the study was 13.39 ± 2.64 (8-17) years. Female gender was observed in the majority of attacks in all lunar cycles, and was most common in the first quarter. Headache was most common in the frontal region during the first quarter and full moon, and auras were also most frequent in the first quarter. Stress and exercise were the most frequent migraine-triggering factors in the first and third quarters, and in the full moon. Migraine attacks were shortest in duration in the full moon, and longest in the first quarter. The frequency of attacks (per week) was highest in the new moon and third quarter, and lowest in the full moon.

CONCLUSIONS

This study investigated the relationship between migraine attack characteristics in children and the lunar cycle. It represents the first such investigation of the association between the lunar cycle and pediatric migraine attacks.

Headaches and obesity

Obesity and headache disorders are two very common conditions in the general population that have been increasing in incidence over the last decades. Recent studies have shown a significant relationship between obesity and headaches, particularly migraine, with an important role in whether the disease is chronic. On the other hand, no such association was found with tension-type headaches. Studies showing an overlapping of hunger-control pathways and those involved in the pathophysiology of migraine may justify the close association between obesity and migraine. Moreover, a secondary headache for which obesity is a strong risk factor is idiopathic Intracranial Hypertension (pseudotumor cerebri), with several studies showing the impact of weight reduction/bariatric surgery in the treatment of the disease. In conclusion, since obesity is a modifiable risk factor, it is important for physicians treating patients with headaches, and particularly migraine, to be aware of the association between these two disorders.

Associação entre comportamento alimentar e hábitos de vida e aumento de crises de migrânea em universitários na pandemia da COVID-19

Introdução: A pandemia da COVID-19 provocou alterações nos hábitos de vida e padrão alimentar da população, importantes gatilhos para as crises migranosas. Objetivo: Avaliar a associação entre comportamento alimentar e hábitos de vida e aumento das crises de migrânea em universitários na pandemia da COVID-19. Material e Métodos: Estudo descritivo, de corte transversal, retrospectivo, realizado com acadêmicos de universidade de Salvador, Bahia, entre dezembro/2020 a junho/2021. Os universitários foram convocados pelo Whatsapp® e pelo e-mail institucional e direcionados ao termo de consentimento livre e esclarecido e questionário, preenchidos via aplicativo de gerenciamento de pesquisa. Esta pesquisa foi aprovada pelo Comitê de Ética em Pesquisa, sob parecer 4.351.573. Dados analisados por meio de estatística descritiva. Resultados: Amostra de 83 indivíduos, 89,2% mulheres, 45,8% sedentários, 51,8% ganharam peso recentemente, 73,4% apresenta baixa ingestão hídrica, 59% têm dificuldade para conciliar e 50,6% têm dificuldade de manutenção do sono. Antes da pandemia, 7,3% relataram 7-14 dias de enxaqueca por mês e, após, aumento para 24,1%. 36,1% dos acadêmicos associaram alimentos às crises de enxaqueca, sendo os principais gatilhos: café (20,5%), chocolate (14,5%), embutidos (12%), álcool (9,6%) e açúcar (6%). O aumento dos dias com enxaqueca associou-se à dificuldade de manutenção do sono (p < 0,002). Conclusão: Apesar do resultado estatisticamente significante apenas entre a dificuldade em conciliar o sono e maior frequência de enxaqueca, as mudanças no estilo de vida e comportamento alimentar ocasionadas pela pandemia da COVID-19 também parecem implicar no aumento de dias com enxaqueca em universitários.

Headache disability, lifestyle factors, health perception, and mental disorder symptoms: a cross-sectional analysis of the 2013 National Health Survey in Brazil

OBJECTIVE

To evaluate the past 2-week headache disability and explore its association with lifestyle factors, health perception, and mental disorder symptoms in the PNS 2013 survey.

BACKGROUND

The prevalence of headache disorders has been associated with lifestyle factors, mental disorders, and health perception. However, less is known regarding their influence on headache-related disability.

METHODS

In a cross-sectional analysis, chi-squared tests and logistic regression models computed the associations between headache-related disability (defined as days lost from work, school, or household chores in the past 2 weeks) and the variables of interest, compared to other disease-related disabilities groups or no day lost group. The adjusted models controlled for the effects of age, sex, income, and educational levels.

RESULTS

In the sample aged ≥ 18 years (n = 145,580), 10,728 (7.4%) participants reported any disease-related disability in the past 2 weeks (median interquartile range (IQR) for age = 47 (33-59) years, 62% women), with the median (IQR) days lost = 5 (2-14). Headache disability represented 5.3% (572/10,728) of all diseases, constituting the 4th most prevalent disease-related disability [median (IQR) days lost = 3 (3-4)]. Among people aged 18-25 years, headache disorders ranked 2nd as the most prevalent disability (13%), headache-related disability positively associated with physical inactivity, poorer health perception, and frequent mental disorders symptoms, and negatively associated with overweight, obesity, and alcohol consumption.

CONCLUSION

Headache disability represents a leading cause of disease-related disability in Brazil and associates with unhealthy lifestyle factors, poorer health perception, and frequent mental disorder symptoms.

Truths and Myths in Pediatric Migraine and Nutrition

The link between migraine and nutrition can be explored from several points of view. Lifestyle and, in particular, aspects of nutrition can have a significant impact on the course of pediatric migraine. In addition, some dietary treatments, such as the ketogenic diet, and some active ingredients present in foods (nutraceuticals) may have a therapeutic effect on migraine. A diet that can control weight gain and obesity has beneficial effects on migraine severity. On the other hand, when we talk about the link between nutrition and headaches, it is also necessary to point out that some public information is actually fake news that has no scientific basis. The purpose of this review is to provide an update on the salient points linking pediatric migraine to nutritional principles, focusing on the relationship between weight and headaches, the therapeutic effect of food for medical purposes, the ketogenic diet as a migraine treatment, and the relationship between migraine and dietary habits.

Dietary alteration of n-3 and n-6 fatty acids for headache reduction in adults with migraine: randomized controlled trial

OBJECTIVE

To determine whether dietary interventions that increase n-3 fatty acids with and without reduction in n-6 linoleic acid can alter circulating lipid mediators implicated in headache pathogenesis, and decrease headache in adults with migraine.

DESIGN

Three arm, parallel group, randomized, modified double blind, controlled trial.

SETTING

Ambulatory, academic medical center in the United States over 16 weeks.

PARTICIPANTS

182 participants (88% women, mean age 38 years) with migraines on 5-20 days per month (67% met criteria for chronic migraine).

INTERVENTIONS

Three diets designed with eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), and linoleic acid altered as controlled variables: H3 diet (n=61)-increase EPA+DHA to 1.5 g/day and maintain linoleic acid at around 7% of energy; H3-L6 diet (n=61)-increase n-3 EPA+DHA to 1.5 g/day and decrease linoleic acid to ≤1.8% of energy; control diet (n=60)-maintain EPA+DHA at <150 mg/day and linoleic acid at around 7% of energy. All participants received foods accounting for two thirds of daily food energy and continued usual care.

MAIN OUTCOME MEASURES

The primary endpoints (week 16) were the antinociceptive mediator 17-hydroxydocosahexaenoic acid (17-HDHA) in blood and the headache impact test (HIT-6), a six item questionnaire assessing headache impact on quality of life. Headache frequency was assessed daily with an electronic diary.

RESULTS

In intention-to-treat analyses (n=182), the H3-L6 and H3 diets increased circulating 17-HDHA (log ng/mL) compared with the control diet (baseline-adjusted mean difference 0.6, 95% confidence interval 0.2 to 0.9; 0.7, 0.4 to 1.1, respectively). The observed improvement in HIT-6 scores in the H3-L6 and H3 groups was not statistically significant (-1.6, -4.2 to 1.0, and -1.5, -4.2 to 1.2, respectively). Compared with the control diet, the H3-L6 and H3 diets decreased total headache hours per day (-1.7, -2.5 to -0.9, and -1.3, -2.1 to -0.5, respectively), moderate to severe headache hours per day (-0.8, -1.2 to -0.4, and -0.7, -1.1 to -0.3, respectively), and headache days per month (-4.0, -5.2 to -2.7, and -2.0, -3.3 to -0.7, respectively). The H3-L6 diet decreased headache days per month more than the H3 diet (-2.0, -3.2 to -0.8), suggesting additional benefit from lowering dietary linoleic acid. The H3-L6 and H3 diets altered n-3 and n-6 fatty acids and several of their nociceptive oxylipin derivatives in plasma, serum, erythrocytes or immune cells, but did not alter classic headache mediators calcitonin gene related peptide and prostaglandin E2.

CONCLUSIONS

The H3-L6 and H3 interventions altered bioactive mediators implicated in headache pathogenesis and decreased frequency and severity of headaches, but did not significantly improve quality of life.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02012790.

Biomarkers in Migraine

Background

Disability from migraine has a profound impact on the world's economy. Research has been ongoing to identify biomarkers to aid in diagnosis and treatment.

Objective

The aim of this study was to highlight the purported diagnostic and therapeutic migraine biomarkers and their role in precision medicine.

Methods

A comprehensive literature search was conducted using PubMed, Google Scholar, and clinicaltrials.gov using keywords: "migraine" OR "headache" combined with "biomarkers" OR "marker." Other keywords included "serum," "cerebral spinal fluid," "inflammatory," and "neuroimaging."

Results

After a review of 88 papers, we find the literature supports numerous biomarkers in the diagnosis of migraine. Therapeutic biomarkers, while not as extensively published, highlight calcitonin gene-related peptide (CGRP) and pituitary adenylate cyclase-activating peptide-38 (PACAP-38) as biomarkers with the most substantiated clinical relevance. Genetic markers mainly focusing on gene mutations with resultant biochemical alterations continue to be studied and show promise.

Conclusion

Although there are several proposed biomarkers for migraine, continued research is needed to substantiate their role in clinical practice.

Obesity, Migraine, and Overlapping Comorbidities in a Rural Pediatric Population

Objective  This study aims to report the prevalence of obesity and overlapping comorbidities in a rural population of children and adolescents with migraine. Design and Methods  A cross-sectional, descriptive, secondary data analysis using a comprehensive patient database from the West Virginia University (WVU) Medicine Epic Clarity system will be reported. A review of electronic medical records of 990 children and adolescents, ages 7 to 17 years, evaluated for headache at a rural clinic from December 1, 2009 to December 31, 2017 was completed. The Chi-square test was used to identify any differences in demographic characteristics (age, gender, and race) and distribution of comorbidities (obstructive sleep apnea syndrome [OSAS], depression, and anxiety) among obese versus nonobese adolescents with migraine. Student's t -test was used to identify any differences in the number of comorbidities between the two groups. Results  A total of 648 children and adolescents with a diagnosis of migraine were identified. Approximately 26.4% of the children and adolescents diagnosed with migraine ( n = 648) met the criteria for being obese with a mean body mass index (BMI) of 30.6 kg/m ² (standard deviation [SD] = 6.5), ranging from 20.0 to 58.5 kg/m ² . There were no significant differences between migraineurs who were categorized as obese versus nonobese in terms of gender ( p = 0.8587), age ( p = 0.1703), race ( p = 0.7655), anxiety ( p = 0.1841), or depression ( p = 0.2793). Obese individuals have more comorbidities than nonobese individuals ( p = 0.015). Additionally, the prevalence of OSAS was significantly higher among obese versus nonobese migraineurs (20 vs. 9.9%, p = 0.0007). Conclusion  Given the prevalence of obesity in rural pediatric populations and the reported neurobiological links between migraine and obesity, BMI needs to be monitored and weight management interventions included in plans of care for rural children and adolescents with migraine.

Allostatic Load in Perimenopausal Women With Migraine

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

Lifestyle Modifications to Help Prevent Headache at a Developmental Age

Headache is the world's seventh most significant cause of disability-adjusted-life in people aged between 10 and 14 years. Therapeutic management is based on pharmacological approaches and lifestyle recommendations. Many studies show associations between each migraine-promoting lifestyle, behavioral triggers, frequency, and intensity of headaches. Nevertheless, the overall aspects of this topic lack any definitive evidence. Educational programs advise that pediatric patients who suffer from migraines follow a correct lifestyle and that this is of the utmost importance in childhood, as it will improve quality of life and assist adult patients in avoiding headache chronicity, increasing general well-being. These data are important due to the scarcity of scientific evidence on drug therapy for prophylaxis during the developmental age. The "lifestyle recommendations" described in the literature include a perfect balance between regular sleep and meal, adequate hydration, limited consumption of caffeine, tobacco, and alcohol, regular physical activity to avoid being overweight as well as any other elements causing stress. The ketogenic diet is a possible new therapeutic strategy for the control of headache in adults, however, the possible role of dietary factors requires more specific studies among children and adolescents. Educational programs advise that the improvement of lifestyle as a central element in the management of pediatric headache will be of particular importance in the future to improve the quality of life of these patients and reduce the severity of cephalalgic episodes and increase their well-being in adulthood. The present review highlights how changes in different aspects of daily life may determine significant improvements in the management of headaches in people of developmental age.

Part 2: Bypassing TBI-Metabolic Surgery and the Link Between Obesity and Traumatic Brain Injury-A Review

Obesity is a common outcome of traumatic brain injury (TBI) that exacerbates principal TBI symptom domains identified as common areas of post-TBI long-term dysfunction. Obesity is also associated with increased risk of later-life dementia and Alzheimer's disease. Patients with obesity and chronic TBI may be more vulnerable to long-term mental abnormalities. This review explores the question of whether weight loss induced by bariatric surgery could delay or perhaps even reverse the progression of mental deterioration. Bariatric surgery, with its induction of weight loss, remission of type 2 diabetes, and other expressions of the metabolic syndrome, improves metabolic efficiency, leads to reversal of brain lesions seen on imaging studies, and improves function. These observations suggest that metabolic/bariatric surgery may be the most effective therapy for TBI.

A Review on the Triggers of Pediatric Migraine with the Aim of Improving Headache Education

Although migraines are common in children and adolescents, they have a robustly negative impact on the quality of life of individuals and their families. The current treatment guidelines outline the behavioral and lifestyle interventions to correct common causative factors, such as negative emotional states, lack of exercise and sleep, and obesity; however, the evidence of their effectiveness is insufficient. To create a plan for disseminating optimal pediatric headache education, we reviewed the current evidence for factors correlated with migraine. We assessed three triggers or risk factors for migraines in children and adolescents: stress, sleep poverty, and alimentation (including diet and obesity). While there is a gradual uptick in research supporting the association between migraine, stress, and sleep, the evidence for diet-related migraines is very limited. Unless obvious dietary triggers are defined, clinicians should counsel patients to eat a balanced diet and avoid skipping meals rather than randomly limiting certain foods. We concluded that there is not enough evidence to establish a headache education plan regarding behavioral and lifestyle interventions. Clinicians should advise patients to avoid certain triggers, such as stress and sleep disorders, and make a few conservative dietary changes.

Anxiety, Depression, and Body Weight in Children and Adolescents With Migraine

Background: There is a lack of studies that explore the possible association between body weight, psychological symptoms, and migraine severity in pediatric populations. The purpose of the study was to explore: (1) the association between body weight and the frequency of migraine attacks, (2) the possible differences in anxiety and depression symptoms according to the frequency of attacks and body weight, and (3) the possible mediating role of anxiety and/or depression in the association between body weight and frequency of migraine attacks in children.

Methods: One hundred and eleven children/adolescents with migraine were included (47 boys and 64 girls; mean age 11.7; ±2.4 years). The patients were classified as: (1) high frequency patients, reporting from weekly to daily episodes and (2) low frequency patients, with ≤3 episodes per month. According to their body mass index percentiles, the patients were divided in “Normal weight” (from ≥5 to <85 percentile), “Overweight” (from ≥85 to <95 percentile), and “Obese” (≥95 percentile). Given the low number of obese patients, the overweight and obese groups were considered together in the “Overweight” group. Anxiety and depression symptoms were assessed by the Self-Administered Psychiatric Scales for Children and Adolescents (SAFA).

Results: Fifty-four patients were normal in weight (49.6%), while 56 patients (50.4%) were overweight. The overweight patients showed a higher frequency of migraine attacks (64.7%; p < 0.05). Patients with a high frequency of attacks reported higher scores in all SAFA-Anxiety subscales (SAFA-A Tot: F = 15.107; p = 0.000). Overweight patients showed a significantly higher score in the “Separation anxiety” subscale (F = 7.855; p = 0.006). We found a mediating role between the overweight and high frequency for total anxiety (z = 2.11 ± 0.03; p < 0.05) and social anxiety (z = 2.04 ± 0.03; p < 0.05).

Conclusions: Our results suggest that, among the children suffering from migraine, the overweight status is associated with a higher frequency of attacks and separation anxiety symptoms. In particular, our study provides the first evidence of the role of anxiety in linking overweight and the frequency of migraine attacks in children and adolescents.

Bypassing TBI: Metabolic Surgery and the Link between Obesity and Traumatic Brain Injury-a Review

Obesity is a common outcome of traumatic brain injury (TBI) that exacerbates principal TBI symptom domains identified as common areas of post-TBI long-term dysfunction. Obesity is also associated with increased risk of later-life dementia and Alzheimer's disease. Patients with obesity and chronic TBI may be more vulnerable to long-term mental abnormalities. This review explores the question of whether weight loss induced by bariatric surgery could delay or perhaps even reverse the progression of mental deterioration. Bariatric surgery, with its induction of weight loss, remission of type 2 diabetes, and other expressions of the metabolic syndrome, improves metabolic efficiency, leads to reversal of brain lesions seen on imaging studies, and improves function. These observations suggest that metabolic/bariatric surgery may be a most effective therapy for TBI.

Headache in Medical Residents: A Cross-Sectional Web-Based Survey

BACKGROUND

Although a common complaint and related to factors frequently present in medical residency such as psychological distress, depression, and anxiety, headache is an issue poorly explored among medical residents.

METHODS

This was a cross-sectional study enrolling medical residents from all geographic regions of Brazil. We applied an online structured survey with demographic and residency program-related questions, as well as validated tools to assess burnout, diurnal somnolence, anxiety, depression, and migraine.

RESULTS

The link to the survey received 1989 clicks, of which 1421 individuals completed the questionnaire (71.4% of all clicks). The prevalence of at least 1 headache attack in the last 3 months was 1236/1419 (87.1%); migraine occurred in 400/1419 (28.2%). Frequent headache attacks (headaches occurring daily or often) were associated with female sex (OR = 1.80 [95%CI = 1.36-2.37]), substantial weight gain (1.93 [1.38-2.70]), migraine (5.49 [4.16-7.24]), anxiety (1.45 [1.06-1.98]), depression (1.98 [1.47-2.67]), emotional exhaustion domain of burnout (1.49 [1.09-2.04]), and diurnal somnolence symptoms (1.32 [1.00-1.76]). Headaches with functional impact were associated with female sex (1.39 [1.10-1.74]), clinical training areas (1.32 [1.06-1.65]), anxiety (1.74 [1.38-2.21]), an unsatisfactory work-life balance (1.57 [1.17-2.09]), the emotional exhaustion component of burnout (1.49 [1.14-1.94]), and an unsatisfactory subjective learning curve (1.30 [1.02-1.67]). Migraine was associated with female sex (3.10 [2.34-4.13]), anxiety (2.53 [1.94-3.31]), more than 60 hours duty-hours in residency (1.66 [1.29-2.15]), psychological abuse from patients (1.42 [1.06-1.90]) and a clinical training area (1.34 [1.04-1.73]).

CONCLUSION

Headaches among medical residents are frequent and are related not only to depression, anxiety, burnout, and diurnal somnolence, but also to aspects closely related to residency training such as the occurrence of mistreatment, longer duty-hours, a poor work-life balance, and an unsatisfactory learning curve.

Headache in Children: Selected Factors of Vascular Changes Involved in Underlying Processes of Idiopathic Headaches

Headaches are common complaints in children. The International Classification of Headache Disorders, 3^rd edition (beta version), defines more than 280 types of headaches. Primary headaches refer to independent conditions that cause pain and include migraine, tension-type headaches (TTH), and trigeminal autonomic cephalalgias (TACs). Several agents are involved in the pathogenesis of headaches. The factors associated with predisposition to atherosclerosis seem to be particularly important from the clinical point of view. The influence of obesity on the incidence of headaches has been well established. Moreover, idiopathic headaches, especially migraine, are thought to be one of the first signs of disorders in lipid metabolism and atherosclerosis. The risk of migraine increases with increasing obesity in children. Another factor that seems to be involved in both obesity and headaches is the adiponectin level. Recent data also suggest new potential risk factors for atherosclerosis and platelet aggregation such as brain-derived neurotrophic factor (BDNF), sCD40L (soluble CD40 ligand), serpin E1/PAI I (endothelial plasminogen activator inhibitor), and vascular endothelial growth factor (VEGF). However, their role is controversial because the results of clinical studies are often inconsistent. This review presents the current knowledge on the potential markers of atherosclerosis and platelet aggregation, which may be associated with primary headaches.

Associations between lifestyle intervention-related changes in dietary targets and migraine headaches among women in the Women's Health and Migraine (WHAM) randomized controlled trial

BACKGROUND

Migraine and obesity are comorbid particularly in women of reproductive age. Obesity treatment involves reducing energy intake and improving dietary quality but the effect of these changes on migraine is largely unknown.

OBJECTIVE

To determine if adherence to dietary intervention targets (ie, total energy, dietary fat intake, and dietary quality) were associated with improvements in migraine and weight.

METHODS

Eighty-four women with overweight/obesity and migraine were randomized to and completed either a 16-week behavioral weight loss (BWL) or a migraine education (ME) intervention. For 28 days at baseline and posttreatment, women recorded monthly migraine days, duration, and maximum pain intensity via smartphone-based diary. At each assessment, weight was measured and dietary intake (total energy intake, percent (%) energy from fat, and diet quality, as measured by the Healthy Eating Index, 2010 [HEI-2010]) was assessed using three nonconsecutive 24-hour diet recalls.

RESULTS

There were no significant group differences in change mean migraine days per month (BWL: -2.6+4.0, ME: -4.0+4.4; p = 0.1). Participants in BWL significantly reduced their percent fat intake 3.8% (p = 0.004) and improved total diet quality (HEI-2010) by 6.7 points (p = 0.003) relative to baseline and those in ME (%fat: +0.3%; p = 0.821; HEI-2010: +0.7; p = 0.725). After controlling for race/ethnicity and weight change, changes in dietary intake were not related to changes in migraine characteristics or weight loss among BWL participants (p's > 0.05).

CONCLUSIONS

Changes in dietary intake among participants were small and may have been insufficient to improve migraine in women with overweight/obesity and migraine.

Excess abdominal fat is associated with cutaneous allodynia in individuals with migraine: a prospective cohort study

OBJECTIVE

To investigate the specific relationship between cutaneous allodynia (CA) and the percentages of body fat (BF) and abdominal fat in migraineurs. Additionally, we compared serum levels of inflammatory biomarkers in patients with and without CA.

BACKGROUND

Excess abdominal fat might facilitate progressive changes in nociceptive thresholds causing central sensitization, clinically reflected as CA, which could drive migraine progression.

METHODS

This prospective cohort study included 80 patients with migraine (mean age 39 years, 81.2% female) and 39 non-migraine controls. We analysed each participant's height, body weight, and body mass index (BMI). The amount and distribution of BF was also assessed by air displacement plethysmography (ADP) and ViScan, respectively. We analysed serum levels of markers of inflammation, during interictal periods.

RESULTS

We studied 52 patients with episodic migraine (EM) and 28 with chronic migraine (CM). Of the 80 patients, 53 (53.8%) had CA. Migraineurs with CA had a higher proportion of abdominal fat values than patients without CA (p = 0.04). The independent risk factors for CA were the use of migraine prophylaxis (OR 3.26, 95% CI [1.14 to 9.32]; p = 0.03), proportion of abdominal fat (OR 1.13, 95% CI [1.01 to 1.27]; p = 0.04), and presence of sleep disorders (OR 1.13, 95% CI [00.01 to 1.27]; p = 0.04). The concordance correlation coefficient between the ADP and BMI measurements was 0.51 (0.3681 to 0.6247). CA was not correlated with the mean plasma levels of inflammatory biomarkers.

CONCLUSIONS

There is a relation between excess abdominal fat and CA. Abdominal obesity might contribute to the development of central sensitization in migraineurs, leading to migraine chronification.

Headache Hygiene in Pediatrics: Brushing Up on the Basics

Headache hygiene refers to self-management behaviors and practices aimed at reducing headache-related disability and improving self-efficacy. Although self-management interventions have an established place in the management of a wide range of chronic conditions, there is still not a standardized approach to this in pediatric headache. In this article, we focus on headache hygiene approaches including education, lifestyle interventions, and psychologic interventions. We also present our center's resource compilation, made available to patients by quick response code technology, as an example of a structured approach to headache hygiene. Further work should explore a standardized approach to headache hygiene and strategies to support adherence, including the use of technology as an innovative health care delivery pathway.

Association of rs2651899 Polymorphism in the Positive Regulatory Domain 16 and Common Migraine Subtypes: A Meta-Analysis

BACKGROUND

Migraine is a neurovascular disease with recurrent headache attacks. A polymorphism (rs2651899) of the PRDM16 gene, which is associated with migraine, was identified in recent genome-wide association studies. The potential role of the PRDM16 rs2651899 polymorphism in migraine is still unknown. Therefore, we conducted this systematic review and meta-analysis to examine this issue.

METHODS

We performed a comprehensive literature search of the PubMed, Embase, and Google Scholar databases to identify eligible studies published before October 2018. Individual odds ratio and 95% confidence interval was used to estimate the pooled strength of the association between the PRDM16 rs2651899 polymorphism and common migraine subtypes, including migraine with aura (MA) and migraine without aura (MO).

RESULTS

Six studies with 2853 cases and 9319 controls that fulfilled the inclusion and exclusion criteria were selected for this meta-analysis. Of the 6 included studies, 4 studies had available data for MWA and another 4 studies had data for MWoA. Overall, significant migraine risks of 1.257, 1.305, and 1.419 were found under allele model (C vs T), dominant model (C/C+T/C vs T/T), and recessive model (C/C vs T/C+T/T), respectively. In the recessive model, significantly increased risks of 1.454 and 1.546 were found for MA and MO, respectively.

CONCLUSION

Our major findings suggest that PRDM16 rs2651899 polymorphism is associated with the risk of migraine. Furthermore, we found that PRDM16 rs2651899 polymorphism is significantly related to common migraine subtypes (MA and MO).

Obesity and Migraine in Childhood

PURPOSE OF REVIEW

The purpose of this work was to review the current literature on the epidemiology and pathophysiology of pediatric obesity and migraine, underlying pathogenic mechanisms that may explain the association between the two disorders, and the effects of treatment.

RECENT FINDINGS

In children and adolescents, the bulk of the available data support an association between obesity and headache disorders in general, though a small number of studies contradict these findings. Relative to the adult population, however, few studies have focused specifically on migraine, and no wide-ranging meta-analyses have been conducted to date. It seems that the pathophysiology of obesity and migraine in adults holds true for the pediatric population as well. The association between obesity and migraine in the pediatric population is likely to be multifactorial and to involve both central and peripheral mechanisms. More attention is currently being addressed to the role of the hypothalamus and the bioactive neurotransmitters and neuropeptides that modulate energy homeostasis, namely serotonin, orexin, and the adiponectins, in migraine. A few innovative studies have demonstrated some benefit for migraine from weight reduction treatments such as exercise and lifestyle management. Many open questions remain regarding the modifiable nature of the obesity-migraine relationship and its implications in clinical practice. Further studies of these issues are needed.

Behavioral Weight Loss Intervention for Migraine: A Randomized Controlled Trial

OBJECTIVE

The objective of this study was to test whether behavioral weight loss (BWL) intervention decreases headaches in women with comorbid migraine and overweight or obesity.

METHODS

This randomized, single-blind trial allocated women 18 to 50 years old with 4 to 20 migraine days per month and a BMI = 25.0-49.9 kg/m2 to 16 weeks of BWL (n = 54), which targeted exercise and eating behaviors for weight loss, or to migraine education control (ME, n = 56), which delivered didactic instruction on migraine and treatments. Participants completed a 4-week smartphone headache diary at baseline, posttreatment (16-20 wk), and follow-up (32-36 wk). The primary outcome was posttreatment change in migraine days per month, analyzed via linear mixed effects models.

RESULTS

Of 110 participants randomly assigned, 85 (78%) and 80 (73%) completed posttreatment and follow-up. Although the BWL group achieved greater weight loss (mean [95% CI] in kilograms) than the ME group at posttreatment (-3.8 [-2.5 to -5.0] vs. + 0.9 [-0.4 to 2.2], P < 0.001) and follow-up (-3.2 [-2.0 to -4.5] vs. + 1.1 [-0.2 to 2.4], P < 0.001), there were no significant group (BWL vs. ME) differences (mean [95% CI]) in migraine days per month at posttreatment (-3.0 [-2.0 to -4.0] vs. -4.0 [-2.9 to -5.0], P = 0.185) or follow-up (-3.8 [-2.7 to -4.8] vs. -4.4 [-3.4 to -5.5], P = 0.378).

CONCLUSIONS

Contrary to hypotheses, BWL and ME yielded similar, sustained reductions in migraine headaches. Future research should evaluate whether adding BWL to standard pharmacological and/or nonpharmacological migraine treatment approaches yields greater benefits.

A systematic literature review of observational studies of the bidirectional association between metabolic syndrome and migraine

AIMS

To evaluate all epidemiological evidence in the literature linking the metabolic syndrome (MetS) and migraine in adults.

METHODS

Database (Medline, Embase; published reports up to November 2017) and manual searches were performed. Information on data collection, sample characteristics, study design, MetS and migraine assessment, and results was extracted from each relevant publication. The methodological quality of each study was also assessed.

RESULTS

A total of 15 observational epidemiological studies in adults, published between 2009 and 2017, were retrieved. Of these, one employed a prospective design, while the rest had a cross-sectional (13 studies) or case-control (one study) design. Five studies assessed the presence of migraine in individuals with MetS, whereas 10 studies assessed the presence or risk of MetS in migraineurs. Most participants were female hospital outpatients. The sole prospective cohort study reported 11-year MetS incidence of 21.8% in migraineurs with aura, 16.8% in migraineurs without aura and 14.5% in subjects without headaches. Most studies (60%) provided no statistical estimates of association. Methodological flaws included selection biases, lack of power analysis, unsuitable research plans and no multivariable analyses. Meta-analysis was not feasible with the available data.

CONCLUSION

Our systematic review has identified major gaps in knowledge and weaknesses in research that should provide an impetus for future epidemiological investigations using more rigorous methodology, large general-population prospective cohorts, and substantial data on dietary behaviours and lifestyle.

Association Between Obesity and Migraine in Women

PURPOSE OF REVIEW

Migraine is a common and highly disabling condition that is particularly prevalent among women and especially women of reproductive age. The tremendous rise in adiposity in the Western world has led to an epidemic of obesity in women. The particular effects of obesity on women with migraine of various ages are the focus of this review.

RECENT FINDINGS

Conflicting findings from various studies with different approaches and populations have made challenging definitive conclusions about associations between migraine and obesity. While the association between obesity and migraine frequency has been consistently demonstrated and obesity is considered a risk factor for progression from episodic to chronic migraine, the association between obesity and migraine prevalence is still somewhat debated and appears to be dependent on gender and age, with the most consistent effects observed in women younger than 55 years of age. Association between migraine and obesity is most commonly observed in women of reproductive age. The multimodal changes associated with age and hormonal change in women likely play a role in this relationship, as obesity does not appear to be related to migraine in women over 55 years of age. Future studies focusing on the migraine-obesity relationship in women should examine the effects of age, endogenous hormonal state, and exogenous hormones on migraine and obesity.

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.

Behavioral Weight Loss Treatments for Individuals with Migraine and Obesity

Migraine and obesity are each prevalent disorders involving significant personal and societal burden. Epidemiologic research demonstrates a link between migraine and obesity that is further substantiated by putative behavioral, psychosocial, and physiological mechanisms. As obesity is considered a modifiable risk factor for exacerbation of migraine, weight loss may be a particularly useful treatment option for people with comorbid migraine and obesity. Behavioral weight loss interventions complement existing behavioral treatments for migraine and offer patients evidence-based effective strategies for achieving weight loss that could help reduce frequency, severity, and impact of migraine attacks.

Diet and nutraceutical interventions for headache management: A review of the evidence

Background

The use of complementary and alternative medicines (CAM) is common among patients with primary headaches. In parallel, CAM research is growing. Diet interventions comprise another category of non-pharmacologic treatment for primary headache that is of increasing clinical and research interest.

Methods

A literature search was carried out to identify studies on the efficacy of diet and nutraceutical interviews for primary headache in the pediatric and adult populations. MEDLINE, Embase and EBM Reviews—Cochrane Central Register of Controlled Trials were searched to identify studies.

Results

There is a growing body of literature on the potential use of CAM and diet interventions for primary headache disorders. This review identified literature on the use of a variety of diet and nutraceutical interventions for headache. Most of the studies assessed the efficacy of these interventions for migraine, though some explored their role in tension-type headache and cluster headache. The quality of the evidence in this area is generally poor.

Conclusions

CAM is becoming more commonplace in the headache world. Several interventions show promise, but caution needs to be exercised in using these agents given limited safety and efficacy data. In addition, interest in exploring diet interventions in the treatment of primary headaches is emerging. Further research into the efficacy of nutraceutical and diet interventions is warranted.

Diet-induced obesity alters dural CGRP release and potentiates TRPA1-mediated trigeminovascular responses

Background Clinical studies suggest a link between obesity and the primary headache disorder migraine. In our study we aimed to reveal the effect of obesity on meningeal nociceptor function in rats receiving a high-fat, high-sucrose diet. Methods Transient receptor potential ankyrin 1 (TRPA1) receptor activation-induced changes in meningeal blood flow, release of calcitonin gene-related peptide (CGRP) from trigeminal afferents and TRPA1 protein expression in the trigeminal ganglia were measured in control and obese rats. Metabolic parameters of the animals were assessed by measuring glucose and insulin homeostasis as well as plasma cytokine concentrations. Results The present experiments revealed an enhanced basal and TRPA1 receptor agonist-induced CGRP release from meningeal afferents of obese insulin-resistant rats and an attenuated CGRP release to potassium chloride. Obesity was also associated with an augmented vasodilatation in meningeal arteries after dural application of the TRPA1 agonist acrolein, a reduction in TRPA1 protein expression in the trigeminal ganglia and elevations in circulating proinflammatory cytokines IL-1β and IL-6 in addition to increased fasting blood glucose and insulin concentrations. Conclusions Our results suggest trigeminal sensitisation as a mechanism for enhanced headache susceptibility in obese individuals after chemical exposure of trigeminal nociceptors.

A Pilot Study of Obesogenic Eating Behaviors in Children With Migraine

We studied associations between migraine severity and obesogenic eating behaviors in children with a prospective cross-sectional, clinic-based study. Migraine severity was quantified using the PedMIDAS tool and attack frequency. Eating behaviors were assessed using the Dutch Eating Behaviour Questionnaire and the Child Eating Behaviour Questionnaire. Food intake was assessed using a Food Intake Questionnaire. Statistical tests of association between eating behavior, food intake, and adiposity with migraine severity were performed. Sixty children (mean age = 10.9 years, standard deviation = 3.1; 26 males) were recruited. There was a positive correlation between the Child Eating Behaviour Questionnaire desire to drink subscale and PedMIDAS scores (r = 0.41, P = .01). Attack frequency was associated with higher intake of high fat or sugar content food and drink (r = 0.27, P = .04). No association between migraine severity and adiposity was found. Suggestion that migraine severity in children is associated with certain obesogenic eating behaviors requires further large study investigation.

Adipokines and Migraine: A Systematic Review

BACKGROUND

Migraine is comorbid with obesity. Recent research suggests an association between migraine and adipocytokines, proteins that are predominantly secreted from adipose tissue and which participate in energy homeostasis and inflammatory processes.

OBJECTIVES

In this review, we first briefly discuss the association between migraine and obesity and the importance of adipose tissue as a neuroendocrine organ. We then present a systematic review of the extant literature evaluating circulating levels of adiponectin and leptin in those with migraine.

METHODS

A search of the PubMed database was conducted using the keywords "migraine," "adiponectin," and "leptin." In addition reference lists of relevant articles were reviewed for possible inclusion. English language studies published between 2005 and 2015 evaluating circulating blood concentration of adiponectin or leptin in those with migraine were included.

CONCLUSIONS

While the existing data are suggestive that adipokines may be associated with migraine, substantial study design differences and conflicting results limit definitive conclusions. Future research utilizing carefully considered designs and methodology is warranted. In particular careful and systematic characterization of pain states at the time of samples, as well as systematic consideration of demographic (e.g., age, sex) and other vital covariates (e.g., obesity status, lipids) are needed to determine if adipokines play a role in migraine pathophysiology and if any adipokine represents a viable, novel migraine biomarker, or drug target.

Clinical Pain Catastrophizing in Women With Migraine and Obesity

OBJECTIVE/BACKGROUND

Obesity is related to migraine. Maladaptive pain coping strategies (eg, pain catastrophizing) may provide insight into this relationship. In women with migraine and obesity, we cross-sectionally assessed: (1) prevalence of clinical catastrophizing; (2) characteristics of those with and without clinical catastrophizing; and (3) associations of catastrophizing with headache features.

METHODS

Obese women migraineurs seeking weight loss treatment (n = 105) recorded daily migraine activity for 1 month via smartphone and completed the Pain Catastrophizing Scale (PCS). Clinical catastrophizing was defined as total PCS score ≥30. The six-item Headache Impact Test (HIT-6), 12-item Allodynia Symptom Checklist (ASC-12), Headache Management Self-Efficacy Scale (HMSE), and assessments for depression (Centers for Epidemiologic Studies Depression Scale) and anxiety (seven-item Generalized Anxiety Disorder Scale) were also administered. Using PCS scores and body mass index (BMI) as predictors in linear regression, we modeled a series of headache features (ie, headache days, HIT-6, etc) as outcomes.

RESULTS

One quarter (25.7%; 95% confidence interval [CI] = 17.2-34.1%) of participants met criteria for clinical catastrophizing: they had higher BMI (37.9 ± 7.5 vs 34.4 ± 5.7 kg/m(2) , P = .035); longer migraine attack duration (160.8 ± 145.0 vs 97.5 ± 75.2 hours/month, P = .038); higher HIT-6 scores (68.7 ± 4.6 vs 64.5 ± 3.9, P < .001); more allodynia (7.0 ± 4.1 vs 4.5 ± 3.5, P < .003), depression (25.4 ± 12.4 vs 13.3 ± 9.2, P < .001), and anxiety (11.0 ± 5.2 vs 5.6 ± 4.1, P < .001); and lower self-efficacy (80.1 ± 25.6 vs 104.7 ± 18.9, P < .001) compared with participants without clinical catastrophizing. The odds of chronic migraine were nearly fourfold greater in those with (n = 8/29.6%) vs without (n = 8/10.3%) clinical catastrophizing (odds ratio = 3.68; 95%CI = 1.22-11.10, P = .021). In all participants, higher PCS scores were related to more migraine days (β = 0.331, P = .001), longer attack duration (β = 0.390, P < .001), higher HIT-6 scores (β = 0.425, P < .001), and lower HMSE scores (β = -0.437, P < .001). Higher BMI, but not higher PCS scores, was related to more frequent attacks (β = -0.203, P = .044).

CONCLUSIONS

One quarter of participants with migraine and obesity reported clinical catastrophizing. These individuals had more frequent attacks/chronicity, longer attack duration, higher pain sensitivity, greater headache impact, and lower headache management self-efficacy. In all participants, PCS scores were related to several migraine characteristics, above and beyond the effects of obesity. Prospective studies are needed to determine sequence and mechanisms of relationships between catastrophizing, obesity, and migraine.

Migraine and body mass index categories: a systematic review and meta-analysis of observational studies

BACKGROUND

Several studies have assessed the associations between migraine and underweight, pre-obesity or obesity, with conflicting results. To assess the consistency of the data on the topic, we performed a systematic review and meta-analysis of the available observational studies.

METHODS

Multiple electronic databases were systematically searched up to October 2014 for studies assessing the association between migraine and body mass index categories (underweight, pre-obesity, or obesity).

RESULTS

Out of 2,022 records, we included 15 studies. When considering the 11 studies following the World Health Organization BMI cutoffs, we found an increased risk of having migraine in underweight subjects (pooled adjusted effect estimate [PAEE] 1.21; 95% CI, 1.07-1.37; P = 0.002) and in obese women (PAEE 1.44; 95% CI, 1.05-1.97; P = 0.023) as compared with normal weight subjects; additionally, pre-obese subjects had an increased risk of having chronic migraine (PAEE 1.39; 95% CI, 1.13-1.71; P = 0.002). When considering all the 15 studies, we additionally found an increased risk of having migraine in obese as compared with normal weight subjects (PAEE 1.14; 95% CI, 1.02-1.27; P = 0.017); additionally, obese subjects had an increased risk of having chronic migraine (PAEE 1.75; 95% CI, 1.33-2.29; P < 0.001). The pooled analysis did not indicate an increased risk of having migraine in pre-obese subjects.

CONCLUSIONS

The meta-analysis of the available observational studies suggested an association between migraine and obesity likely mediated by gender and migraine frequency. Further studies taking into account gender, migraine type, frequency, activity, and duration could provide more robust evidence.

Dietary intake patterns and diet quality in a nationally representative sample of women with and without severe headache or migraine

OBJECTIVE/BACKGROUND

The role of diet in migraine is not well understood. We sought to characterize usual dietary intake patterns and diet quality in a nationally representative sample of women with and without severe headache or migraine. We also examined whether the relationship between migraine and diet differs by weight status.

METHODS

In this analysis, women with migraine or severe headache status was determined by questionnaire for 3069 women, ages 20-50 years, who participated in the National Health and Nutrition Examination Study, 1999-2004. Women who experienced severe headaches or migraines were classified as migraine for the purposes of this analysis. Dietary intake patterns (micro- and macronutrient intake and eating frequency) and diet quality, measured by the Healthy Eating Index, 2005, were determined using one 24-hour dietary recall.

RESULTS

Dietary intake patterns did not significantly differ between women with and without migraine. Normal weight women with migraine had significantly lower diet quality (Healthy Eating Index, 2005 total scores) than women without migraine (52.5 ± 0.9 vs. 45.9 ± 1.0; P < .0001).

CONCLUSIONS

Whereas findings suggest no differences in dietary intake patterns among women with and without migraine, dietary quality differs by migraine status in normal weight women. Prospective analyses are needed to establish how diet relates to migraine onset, characteristics, and clinical features in individuals of varying weight status.

Ictal adipokines are associated with pain severity and treatment response in episodic migraine

OBJECTIVE

To evaluate ictal adipokine levels in episodic migraineurs and their association with pain severity and treatment response.

METHODS

This was a double-blind, placebo-controlled trial evaluating peripheral blood specimens from episodic migraineurs at acute pain onset and 30 to 120 minutes after treatment with sumatriptan/naproxen sodium vs placebo. Total adiponectin (T-ADP), ADP multimers (high molecular weight [HMW], middle molecular weight, and low molecular weight [LMW]), leptin, and resistin levels were evaluated by immunoassays.

RESULTS

Thirty-four participants (17 responders, 17 nonresponders) were included. In all participants, pretreatment pain severity increased with every quartile increase in both the HMW:T-ADP ratio (coefficient of variation [CV] 0.51; 95% confidence interval [CI]: 0.08, 0.93; p = 0.019) and resistin levels (CV 0.58; 95% CI: 0.21, 0.96; p = 0.002), but was not associated with quartile changes in leptin levels. In responders, T-ADP (CV -0.98; 95% CI: -1.88, -0.08; p = 0.031) and resistin (CV -0.95; 95% CI: -1.83, -0.07; p = 0.034) levels decreased 120 minutes after treatment as compared with pretreatment. In addition, in responders, the HMW:T-ADP ratio (CV -0.04; 95% CI: -0.07, -0.01; p = 0.041) decreased and the LMW:T-ADP ratio (CV 0.04; 95% CI: 0.01, 0.07; p = 0.043) increased at 120 minutes after treatment. In nonresponders, the LMW:T-ADP ratio (CV -0.04; 95% CI: -0.07, -0.01; p = 0.018) decreased 120 minutes after treatment. Leptin was not associated with treatment response.

CONCLUSIONS

Both pretreatment migraine pain severity and treatment response are associated with changes in adipokine levels. Adipokines represent potential novel migraine biomarkers and drug targets.

Weight regain after discontinuation of topiramate treatment in patients with migraine: a prospective observational study

PURPOSE

To monitor weight regain after therapy discontinuation in patients with migraine experiencing weight loss during topiramate (TPM) treatment.

METHODS

Patients with migraine without aura were enrolled in this observational prospective study. Weight, body mass index (BMI), waist circumference, systolic and diastolic blood pressure, plasma levels of total cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, triglycerides, leptin, and ghrelin, and homeostatic model assessment of insulin resistance (HOMA-IR) were evaluated before starting TPM (T1), at 3 (T2) and 6 (T3) months of treatment and 6 months after withdrawal of TPM (T4). Weight loss/regain was considered as a change of </>5% of pre-TPM body weight.

RESULTS

A total of 241 patients were analyzed. Of these, 87 (36%) patients experienced weight loss on TPM medication. During TPM therapy significant reductions in mean values of weight (p<0.001), BMI (p<0.001), waist circumference (p<0.01), HOMA-IR (p<0.01), and leptin (p<0.01) were observed. After TPM discontinuation, all of these parameters showed a clear trend to increase at T4, achieving pre-TPM values in 27 patients. Among potential predictors, only HOMA-IR before starting TPM (parameter estimate=1.36, effect size=0.75; p=0.006) was significantly associated with weight regain after therapy discontinuation.

CONCLUSIONS

Loss of body weight is a reversible effect, which at 6 months after TPM discontinuation shows a clear trend to return to baseline values. HOMA-IR is the only predictive factor of weight regain.

Objectively measured physical activity in obese women with and without migraine

AIM

The aim of this article is to cross-sectionally compare objectively measured physical activity (PA) levels and their association with migraine characteristics in obese women with and without migraine.

METHODS

Obese women seeking weight loss treatment were divided into migraine (n = 25) and control (n = 25) groups matched by age and body mass index (BMI). Participants wore the SenseWear Armband monitor for seven days to objectively evaluate daily light-(LPA) and moderate-to-vigorous intensity PA (MVPA). Migraine diagnosis was confirmed by a neurologist using ICHD-3-beta criteria. Migraine characteristics were tracked daily using a smartphone-based diary over a four-week period immediately preceding the objective PA assessment.

RESULTS

Migraine participants spent 57.9 fewer minutes/day in LPA (141.1 ± 56.4 vs. 199.1 ± 87.7, p = 0.019) and 24.5 fewer minutes/day in MVPA (27.8 ± 17.0 vs. 52.3 ± 26.0, p < 0.001), compared to controls. Migraine participants reported 4.8 ± 3.1 migraine days/month (mean duration = 17.1 ± 8.9 hours; mean maximum pain severity = 6.4 ± 1.7 on a 0-10 scale). Higher BMI (p < 0.05), but not migraine characteristics, were related to lower total PA. Additionally, total objectively measured PA was not associated with how often PA was reported to exacerbate migraine attacks during the four-week diary assessment.

CONCLUSIONS

Obese women with migraine spent nearly 1.5 hours/day less in PA compared to controls; however, lower PA was not related to migraine characteristics. Further research is needed to identify PA barriers and effective interventions in obese women with migraine.