Pain from Internal Organs and Headache: The Challenge of Comorbidity

Headache and visceral pain are common clinical painful conditions, which often co-exist in the same patients. Numbers relative to their co-occurrence suggest possible common pathophysiological mechanisms. The aim of the present narrative review is to describe the most frequent headache and visceral pain associations and to discuss the possible underlying mechanisms of the associations and their diagnostic and therapeutic implications based on the most recent evidence from the international literature. The conditions addressed are as follows: visceral pain from the cardiovascular, gastrointestinal, and urogenital areas and primary headache conditions such as migraine and tension-type headache. The most frequent comorbidities involve the following: cardiac ischemic pain and migraine (possible shared mechanism of endothelial dysfunction, oxidative stress, and genetic and hormonal factors), functional gastrointestinal disorders, particularly IBS and both migraine and tension-type headache, primary or secondary dysmenorrhea and migraine, and painful bladder syndrome and headache (possible shared mechanisms of peripheral and central sensitization processes). The data also show that the various visceral pain-headache associations are characterized by more than a simple sum of symptoms from each condition but often involve complex interactions with the frequent enhancement of symptoms from both, which is crucial for diagnostic and treatment purposes.

Could headache in children be a biomarker for dyslipidemia?

AIM

Here we present the patients whose body mass index is in the normal range and who visited with the complaint of headache. The differences in lipid profile in this group compared to healthy children and the risk factors that may be associated with this were investigated.

MATERIALS AND METHODS

195 patients who applied to the Pediatric Neurology outpatient clinic with headache complaints between April 2021 and October 2022 were retrospectively examined. 201 healthy children were included as the control group. The gender, age, headache type, lipid profile blood test after at least 8 h of fasting [total cholesterol, low-density lipoprotein (LDL), high-density lipoprotein (HDL), triglyceride (TG), and TG/HDL ratio], and body mass index (BMI) were recorded. Those patients who had a BMI range of 18.5-24.9 kg/m2 were included in the study.

RESULTS

The study group had 195 patients; 118 girls (60.5%). The average age was 12,57 ± 3,48 years, and 114 patients (58.5%) had tension-type headaches and 81 (41.5%) had migraine-type headaches. There was no significant difference in age and gender between the two groups. Blood pressure, folate, and thyroid function tests were normal. In the lipid profile, a significant difference was observed between total cholesterol, LDL, HDL, and TG in the study group compared to the control group (p < 0.05). However, there was no difference in the TG/HDL ratio between those two groups. No significant statistical difference was observed in the lipid profile and other laboratory findings between headache types.

CONCLUSION

In children presenting with headache complaints, which can be both worrying for families and cause significant loss of functionality, it is detectable (obviously) that headache is an important marker for dyslipidemia; even if BMI is in a normal range. The lipid profile should be seen both to control the complaint with an appropriate diet and to observe the risk of future atherosclerotic processes.

Association of Exposure to Indoor Air Pollution with Unhealthy Symptoms among Middle-aged and Older Adults in India: Evidence from a Large-scale Survey

Background

The usage of solid cooking fuels is widely prevalent in low and middle-income countries, including India, and contributes to indoor air pollution (IAP), which has detrimental health effects. Moreover, time spent inside the house increases as people age. In this context, the present study tried to understand the association between exposure to indoor air pollution and unhealthy symptoms, including shortness of breath, dizziness, headache, fatigue, wheezing, and cough among middle-aged and older adults in India.

Methods

We extracted the unit-level individual data (N = 63 790) from the Longitudinal Aging Study in India (LASI)-Wave 1 (2017-2018). The statistical analyses used were Chi-square test and binary logistic regression, which estimated the odds ratio to identify the determinants of the unhealthy symptoms.

Results

The odds of shortness of breath (adjusted OR: 1.14, 99% CI: 1.05-1.23), dizziness (adjusted OR: 1.28, 99% CI: 1.21-1.35), fatigue (adjusted OR: 1.32, 99% CI: 1.26-1.39), wheezing (adjusted OR: 1.30, 99% CI: 1.19-1.42), and cough (adjusted OR: 1.36, 99% CI: 1.27-1.45) were higher among individuals from households where solid cooking fuels was used. Similarly, the odds of shortness of breath, headache, wheezing, and cough were higher among individuals with a household member who smoked inside the house. The results indicated that the odds of shortness of breath, headache, and cough were significantly lower among participants exposed to incense use.

Conclusion

Based on the results of this study, we suggest developing programs to combat the sources of indoor air pollution and the associated unhealthy symptoms, especially in rural settings. It is also important to bring awareness and practice clean fuel usage at individual and community levels to improve population health.

Association between migraine and cardiovascular disease mortality: A prospective population-based cohort study

OBJECTIVE

The study assessed the association between migraine and cardiovascular disease (CVD) mortality in the US population.

BACKGROUND

Previous studies have drawn different conclusions about the association between migraine and CVD mortality based on different populations; therefore, it is important to explore the relationship between migraine and CVD mortality in the US population.

METHODS

This prospective cohort study included 10,644 participants from the National Health and Nutrition Examination Survey (NHANES) 1999-2004. Participants who reported having severe headache or migraine were classified as having migraine. Mortality data were obtained by linkage of the cohort database to the National Death Index as of December 31, 2019. Based on the International Classification of Diseases, Tenth Revision, CVD mortality includes the following disease codes: I00-I09 (acute rheumatic fever and chronic rheumatic heart diseases), I11 (hypertensive heart disease), I13 (hypertensive heart and renal disease), I20-I25 (ischemic heart diseases), I26-I28 (pulmonary embolism and other acute pulmonary heart diseases), I29 (various cardiovascular diseases caused by different reasons), I30-I51 (other forms of heart disease), and I60-I69 (cerebrovascular diseases). Data were analyzed from October to November 2022.

RESULTS

Among 10,644 adults included in the study (mean age, 46.4 [0.3] years, 5430 men [47.4%]), 2106 (20.4%) had migraine. During a median follow-up period of 201 months, there were 3078 all-cause deaths and 997 CVD deaths. Compared to individuals without migraine, those with migraine had an adjusted hazard ratio (HR) of 1.30 (95% confidence interval [CI], 1.04-1.62; p = 0.019) for CVD mortality and 1.23 (95% CI, 1.13-1.35; p < 0.001) for all-cause mortality. In subgroup analyses, migraine was associated with CVD mortality in participants who were women (HR, 1.43; 95% CI, 1.06-1.93), aged < 45 years (HR, 1.69; 95% CI, 1.04-2.76), non-Hispanic White (HR, 1.42; 95% CI, 1.09-1.86), those with a body mass index < 30 kg/m2 (HR, 1.36; 95% CI, 1.03-1.78), former or current smokers (HR, 1.36; 95% CI, 1.00-1.85), former or current alcohol drinkers (HR, 1.33; 95% CI, 1.03-1.72), and those without metabolic syndrome (HR, 1.31; 95% CI, 1.01-1.71). The association between migraine and CVD mortality was robust in sensitivity analyses, after excluding participants who died within 2 years of follow-up (HR, 1.31; 95% CI, 1.05-1.65) or those with a history of cancer at baseline (HR, 1.28; 95% CI, 1.01-1.62).

CONCLUSIONS

Migraine was associated with a higher CVD mortality rate in the US population.

Advances in Management of the Stroke Etiology One-Percenters

PURPOSE OF REVIEW

Uncommon causes of stroke merit specific attention; when clinicians have less common etiologies of stoke in mind, the diagnosis may come more easily. This is key, as optimal management will in many cases differs significantly from "standard" care.

RECENT FINDINGS

Randomized controlled trials (RCT) on the best medical therapy in the treatment of cervical artery dissection (CeAD) have demonstrated low rates of ischemia with both antiplatelet and vitamin K antagonism. RCT evidence supports the use of anticoagulation with vitamin K antagonism in "high-risk" patients with antiphospholipid antibody syndrome (APLAS), and there is new evidence supporting the utilization of direct oral anticoagulation in malignancy-associated thrombosis. Migraine with aura has been more conclusively linked not only with increased risk of ischemic and hemorrhagic stroke, but also with cardiovascular mortality. Recent literature has surprisingly not provided support the utilization of L-arginine in the treatment of patients with mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes (MELAS); however, there is evidence at this time that support use of enzyme replacement in patients with Fabry disease. Additional triggers for reversible cerebral vasoconstriction syndrome (RCVS) have been identified, such as capsaicin. Imaging of cerebral blood vessel walls utilizing contrast-enhanced MRA is an emerging modality that may ultimately prove to be very useful in the evaluation of patients with uncommon causes of stroke. A plethora of associations between cerebrovascular disease and COVID-19 have been described. Where pertinent, authors provide additional tips and guidance. Less commonly encountered conditions with updates in diagnosis, and management along with clinical tips are reviewed.

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.

Serum lipid profile in migraine and its association with clinical characteristics

OBJECTIVES

Migraine is one of the most prevalent and disabling conditions worldwide. Dyslipidemia has become an issue of great importance recently in migraine patients. There is still no consensus on the relationship between specific lipid levels with clinical characteristics of migraine and patients' demographic features. In this study, we investigated each serum lipid level in migraine patients and correlated it with migraine and patients' characteristics to understand the contribution of these factors together.

METHODS

In this case-control study, 100 patients with migraine and 76 healthy control subjects were included. Serum lipid levels were calculated and compared with the control group. Also, we analyzed the clinical characteristics of patients and their correlation with lipid levels. Regression analyses were performed to identify the predictors of serum lipid levels.

RESULTS

Total cholesterol (TC), triglyceride (TG), and surprisingly high-density lipoprotein (HDL-c) levels were found significantly higher in the migraine group. Also, low-density lipoprotein (LDL-c) level showed a trend of increase and has become significantly higher in the migraine group after adjusting by age. Moreover, there was a positive correlation only between age and TC, LDL-c, and TG levels among the clinical characteristics of migraine and patients' demographic features.

DISCUSSIONS

Due to accompanying dyslipidemia, migraine might be considered a risk factor for vascular events regardless of its clinical characteristics. Notwithstanding, elevated HDL-c levels may play a protective role for the vascular events. This dilemma needs to be further explored in future trials to reveal potential biological mechanisms of lipids in migraine patients and to find the optimal therapeutic approach to dyslipidemia.

Selected Factors of Vascular Changes: The Potential Pathological Processes Underlying Primary Headaches in Children

Background: The prevalence, social consequences and complicated pathogenesis make headaches in children a significant clinical issue. Studies in adults suggest that primary headaches could be the first sign of atherosclerosis and platelet aggregation. Aim: To analyze the blood levels of selected biomarkers of vascular changes potentially associated with a higher risk of atherosclerosis in children with primary headaches. Methods: The medical family history, brain-derived neurotrophic factor (BDNF), soluble CD40 ligands (sCD40L), endothelial plasminogen activator inhibitor (PAI I), vascular endothelial growth factor (VEGF) and intima-media thickness (IMT) measurements were performed in the 83 children (52 with primary headaches, 31 controls). Selected factors were compared with basic laboratory parameters that are potentially related to atherosclerosis: C-reactive protein (CRP) and lipid concentration. Results: There were no significant differences in biomarkers of vascular changes in the study group and controls in general. In the study group, boys had a higher BDNF level than girls (p = 0.046). Normal-weight migraine patients had significantly higher PAI-I levels than controls (p = 0.034). A positive correlation between PAI-1 and triglycerides (TG) was observed. IMT did not differ between children with primary headaches and controls; however, IMT showed a positive correlation with BMI z-score and TG. Children with headaches had, more often, a positive family history of cardiovascular disease (p = 0.049). Conclusions: There were no clear clinical changes indicative of atherosclerosis in the study population. However, some trends are visible. Primary headaches are more often related to a family history of cardiovascular diseases. IMT is associated with TG levels and BMI z-score. The measured biomarkers of vascular changes show mutual relations.

Vascular Risk Score and Associations With Past, Current, or Future Migraine in Women: Cohort Study

BACKGROUND AND OBJECTIVES

Migraine has consistently been associated with an increased risk of cardiovascular disease (CVD) events. It remains, however, unclear to what extent cardiovascular risk profiles might be linked with migraine activity status and how these profiles relate to the development of migraine.

METHODS

We used data from a cohort study of female health professionals (Women's Health Study, n = 27,539, age ≥45 years at baseline) without a history of CVD or other major diseases and who provided a blood sample at baseline. Framingham risk scores (FRSs) estimating the 10-year risk of coronary heart disease calculated at baseline were used to create vascular risk categories. The presence or development of self-reported migraine was assessed by questionnaires. Women were classified as having no migraine, history of migraine (experienced migraine in the past but did not experience any migraine attacks in the year before enrollment), active migraine at baseline (active), or incident migraine (first report of migraine during follow-up but not at baseline). We used multinomial logistic regression models to calculate ORs for the association between FRS categories and migraine status.

RESULTS

Of the 27,539 participants, a total of 21,927 women did not report migraine, 1,500 women reported a history of migraine, 3,579 had migraine at baseline, and 533 reported migraine for the first time during follow-up. The odds of the probability of having a history of migraine at baseline (vs never migraine) was 76% higher among those with FRS ≥10% compared with FRS ≤1% after adjustment (OR = 1.76, 95% CI 1.39-2.23). In contrast, having FRS ≥10% was associated with reduced odds of having active migraine at baseline (OR = 0.64, 95% CI 0.52-0.80) and with newly reported migraine during follow-up (OR = 0.42, 95% CI 0.22-0.81) when compared with women with FRS category ≤1% and those not reporting migraine. A similar association pattern was observed for FRS categories 5%-9% and 2%-4%.

DISCUSSION

High FRS categories were only observed among women with a history of migraine but not with active migraine at baseline or incident migraine after baseline. Our results suggest that the life course of migraine should be considered when studying associations with the vascular system. Our data further suggest that a relatively healthy vascular system, as assessed by the FRS, is associated with active migraine status or developing migraine in the future.

Primary headaches increase the risk of dementias: An 8-year nationwide cohort study

Background

Headache, a highly prevalent neurological disorder, has consistently been linked with an elevated risk of dementia. However, most studies are focused on the relationship with migraine in limited age groups. Therefore, the objective of this research was to look at the link between various type of headaches and dementias based on longitudinal population-based data.

Methods and results

Participants diagnosed with headache from 2002 to 2005 were selected and major covariates were collected. The diagnoses of Alzheimer’s disease, vascular dementia, and other dementias were observed from 2006 until 2013. The adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) of dementias according to headache type were calculated by Cox proportional hazards regression. A number of 470,652 participants were observed for a mean of 7.6 years (standard deviation: 1.2), for approximately 3.6 million person-years. Both tension type headache (TTH) and migraine elevated the risk of all-cause dementias (TTH, aHR 1.18, 95% CI 1.13–2.24; migraine, aHR 1.18, 95% CI 1.13–2.24). Headaches had a greater influence in females and non-smokers as a risk factor of dementias. Patients with migraine who consumed alcohol had a higher risk of dementia, however this was not true with TTH patients. Among participants without comorbidities, TTH patients were more susceptible to dementia than migraine patients. Headache patients had a higher proportion of females regardless of headache type and approximately 1.5 times more individuals had three or more comorbidities compared to those without headache.

Conclusions

Headache could be an independent predictor for subsequent dementia risk. Future studies should focus on clarifying pathogenic pathways and possible dementia-related preventive measures in headache populations.

Inflammation and endothelial dysfunction in pediatric migraine patients

BACKGROUND

Inflammation and endothelial dysfunction are the suggested underlying mechanisms in migraine. Pentraxins, C-reactive protein, erythrocyte sedimentation rate, neutrophil to lymphocyte ratio, platelet to lymphocyte ratio are good indicators of inflammation. Alterations in insulin levels and insulin sensitivity may trigger endothelial dysfunction. This study evaluates the association between migraine and serum biomarkers of inflammation and endothelial dysfunction in children.

METHODS

Children with migraine and healthy subjects were recruited. Serum samples were obtained in an attack-free period. We collected data on serum levels of complete blood cell count, C-reactive protein, erythrocyte sedimentation rate, pentraxin-3, and data from biochemical investigations. We compared these with clinical data such as age, sex, disease duration, attack frequency, attack duration, analgesic use, family history, and Pediatric Migraine Disability Assessment Questionnaire scores.

RESULTS

We assessed samples from 32 children (11 boys, 21 girls) with migraine and 19 healthy controls (8 boys, 11 girls). We found significantly higher pentraxin-3, insulin, and insulin resistance in patients with migraine (P = 0.001, P = 0.032, and P = 0.008, respectively). A positive directional correlation is found between pentraxin-3 and Pediatric Migraine Disability Assessment Questionnaire scores. The best cut-off values for pentraxin-3 is determined between 12.75 pg/mL to 15 pg/mL in migraineurs.

CONCLUSIONS

In conclusion increased pentraxin-3 levels support the suggestions that inflammation plays a role in pediatric migraine. The vascular endothelial dysfunction is observed by a rise in insulin and insulin resistance levels. Our findings support the idea that ongoing inflammation and vascular endothelial dysfunction between attacks may play a role in migraine pathogenesis in children.

Headache and mental disorders in a nationally representative sample of American youth

The objective of this study is to examine the association between headache and mental disorders in a nationally representative sample of American youth. We used the National Comorbidity Survey-Adolescent Supplement to assess sex-specific prevalence of lifetime migraine and non-migraine headache using modified International Headache Society criteria and examine associations between headache subtypes and DSM-IV mental disorders. Adolescent report (n = 10,123) was used to identify headache subtypes and anxiety, mood, eating, and substance use disorders. ADHD and behavior disorder were based on parent report (n = 6483). Multivariate logistic regression analyses controlling for key demographic characteristics were used to examine associations between headache and mental disorders. Headache was endorsed by 26.9% (SE = 0.7) of the total sample and was more prevalent among females. Youth with headache were more than twice as likely (OR 2.74, 95% CI 1.94-3.83) to meet criteria for a DSM-IV disorder. Migraine, particularly with aura, was associated with depression and anxiety (adjusted OR 1.90-2.90) and with multiple classes of disorders. Adolescent headache, particularly migraine, is associated with anxiety, mood, and behavior disorders in a nationally representative sample of US youth. Headache is highly prevalent among youth with mental disorders, and youth with headache should be assessed for comorbid depression and anxiety that may influence treatment, severity, and course of both headache and mental disorders.

Electrocardiographic findings in migraineurs: results of the Finnish Health 2000 survey

BACKGROUND

The precise relation between migraine and cardiovascular diseases remains unknown, but cardiac autonomic regulation as reflected by electrocardiography is poorly studied in migraineurs.

AIMS OF THE STUDY

To search whether electrocardiographic findings may elucidate the mechanisms linking migraine with cardiovascular diseases.

METHODS

We compared electrocardiographic findings in headache-free subjects (n=5,317) and people with migraine (n=490) in a Finnish population cohort.

RESULTS

The frequency of cardiac rhythm and conduction disorders did not differ between the groups but left ventricular hypertrophy was more often seen in migraineurs than in non-migraineurs (odds ratio (OR)=1.32, 95% confidence interval (CI) 1.0; 1.74, p<0.05). In migraineurs reporting frequent attacks, cardiovascular diseases were associated with longer QTc intervals (p<0.05). After excluding confounders, migraineurs had longer PR intervals (160.3 vs 159.8 ms, mean difference (MD)=3.14, 95% CI 0.65; 5.62, p<0.05) than non-migraineurs. PR intervals (MD=6.6, CI 1.51; 11.68, p<0.05) and the probability of left ventricular hypertrophy (OR=1.98, CI 1.2; 3.26, p<0.05) were different in males with and without migraine, especially in patients with frequent attacks, but not in females.

CONCLUSIONS

Our findings support the notion that there are interactions between migraine and cardiovascular disorders and suggest that electrocardiographic screening in migraineurs should be considered during clinical work-up.

Migraine and atrial fibrillation: a systematic review

BACKGROUND AND PURPOSE

Patients with migraine are at increased risk of stroke. The aim was to systematically review the current literature on the association between migraine and atrial fibrillation, which is a relevant risk factor for stroke.

METHODS

PubMed was searched for 'migraine' AND 'atrial fibrillation' and selected original investigations on the association of migraine and atrial fibrillation for our analysis. Articles without original data, such as guidelines, narrative reviews, editorials and others, were excluded.

RESULTS

In all, 109 publications were found. Twenty-two were included and analysed for this review. The population-based Atherosclerosis Risk in Communities study showed a significant association of migraine with visual aura and incident atrial fibrillation (hazard ratio 1.30, 95% confidence interval 1.03-1.62, p = 0.02), but not for migraine without aura, compared to non-headache persons after multivariable adjustment for vascular risk factors. An even larger population-based study in Denmark confirmed this association (odds ratio 1.25, 95% confidence interval 1.16-1.36). Studies investigating patients with ischaemic stroke and migraine are methodologically insufficient and provide contradictory results. Ablation therapy for atrial fibrillation in patients with migraine might reduce migraine attacks, but transient post-ablation new-onset migraine-like headaches in persons without a history of migraine have also been reported.

CONCLUSION

Population-based studies indicate a significant association of migraine with aura and atrial fibrillation. In practical terms, screening for atrial fibrillation in patients who have a long history of migraine might be reasonable, whereas in patients with stroke or other disorders and migraine extensive screening for atrial fibrillation should be performed as in all patients without migraine.

The association of cerebrospinal fluid pressure with optic nerve head and macular vessel density

The present study aims to investigate the effect of temporary cerebrospinal fluid pressure (CSFP) reduction on optic nerve head (ONH) and macular vessel density (VD) using optical coherence tomography angiography. Forty-four eyes of 44 adults with diagnostic lumbar puncture and CSFP reduction were recruited. Thirty-two eyes of 32 healthy volunteers were controls. ONH and macular VD images were evaluated differences between baseline and after CSFP reduction. The results showed that the mean CSFP decreased from (11.6±2.1) mmHg to (8.2±3.4) mmHg (P<0.001). VD in the macular regions decreased significantly after CSFP reduction in the study group (all P<0.05). The control group showed no significant changes in macular VD (all P>0.05). In the study group, decreased VD in the macular parainferior region was associated with CSFP reduction (R²=0.192, P=0.003), the reduction of macular VD in parafoveal (R²=0.098, P=0.018), parainferior (R²=0.104, P=0.021), parasuperior (R²=0.059, P=0.058), paranasal (R²=0.057, P=0.042), paratemporal (R²=0.079, P=0.026) was associated with mean ocular perfusion pressure decrease following CSFP reduction. ONH vessel density did not differ after CSFP reduction (all P>0.05). In conclusion, macular vessel density decreased in association with CSFP reduction. Retinal vessel density in the macular region is more sensitive than that in peripapillary region after CSFP reduction.

Hypertension and Migraine: Time to Revisit the Evidence

PURPOSE OF REVIEW

It was reported that migraine was associated with increased vascular risks, and the association between high blood pressure (BP) and migraine was believed by some to be the missing link. The current review focused on the associations between migraine and hypertension and BP per se, and evidence on the directionality of the associations was also reviewed.

RECENT FINDINGS

In cross-sectional studies, the findings regarding whether migraine was associated with hypertension were inconsistent, and positive, neutral, or even inverse associations were reported. When individual BP parameters were examined separately, migraine was associated with higher diastolic BPs, and perhaps lower pulse pressures, although the associations with systolic BPs were incongruent. When studies mainly recruiting elderly patients are excluded, it appeared that studies reporting a positive association between migraine and high BPs, particularly high diastolic BPs, outnumbered those with an inverse or neutral association. In longitudinal studies, there was evidence that migraine patients were at increased risks of developing hypertension at follow-up. However, studies examining whether high BP could predict new-onset migraine yielded conflicting results. The association between migraine and hypertension is still a controversial issue, and a firm conclusion is precluded by the heterogeneities in methodologies and study populations. Migraine patients are at increased risk of developing hypertension. However, whether hypertension predicts migraine remains inconclusive. Further studies are needed to clarify the complicated association between BP and migraine.

Comorbidities of primary headache disorders: a literature review with meta-analysis

Background

Primary headache disorders are common and burdensome conditions. They are associated to several comorbidities, such as cardiovascular or psychiatric ones, which, in turn, contribute to the global burden of headache. The aim of this study is to provide a comprehensive description of the pooled prevalence of comorbidities of primary headache disorders using a meta-analytical approach based on studies published between 2000 and 2020.

Methods

Scopus was searched for primary research (clinical and population studies) in which medical comorbidities were described in adults with primary headache disorders. Comorbidities were extracted using a taxonomy derived from the Global Burden of Disease (GBD) study. We compared prevalence of comorbidities among headache sufferers against general population using GBD-2019 estimates, and compared comorbidities’ proportions in clinical vs. population studies, and by age and gender.

Results

A total of 139 studies reporting information on 4.19 million subjects with primary headaches were included: in total 2.75 million comorbidities were reported (median per subject 0.64, interquartile range 0.32–1.07). The most frequently addressed comorbidities were: depressive disorders, addressed in 51 studies (pooled proportion 23 %, 95 % CI 20–26 %); hypertension, addressed in 48 studies (pooled proportion 24 %, 95 % CI 22–26 %); anxiety disorders addressed in 40 studies (pooled proportion 25 %, 95 % CI 22–28 %). For conditions such as anxiety, depression and back pain, prevalence among headache sufferers was higher than in GBD-2109 estimates. Associations with average age and female prevalence within studies showed that hypertension was more frequent in studies with higher age and less females, whereas fibromyalgia, restless leg syndrome, and depressive disorders were more frequent in studies with younger age and more female.

Conclusions

Some of the most relevant comorbidities of primary headache disorders – back pain, anxiety and depression, diabetes, ischemic heart disease and stroke – are among the most burdensome conditions, together with headache themselves, according to the GBD study. A joint treatment of headaches and of these comorbidities may positively impact on headache sufferers’ health status and contribute to reduce the impact of a group of highly burdensome diseases.

Supplementary Information

The online version contains supplementary material available at 10.1186/s10194-021-01281-z.

Metabolic Aspects of Migraine: Association With Obesity and Diabetes Mellitus

Migraine is a disabling neurovascular disorder, characterized by moderate to severe unilateral headaches, nausea, photophobia, and/or phonophobia, with a higher prevalence in women than in men, which can drastically affect the quality of life of migraine patients. In addition, this chronic disorder is related with metabolic comorbidities associated with the patient's lifestyle, including obesity and diabetes mellitus (DM). Beyond the personal and socioeconomic impact caused by migraine, obesity and DM, it has been suggested that these metabolic disorders seem to be related to migraine since: (i) they are a risk factor for developing cardiovascular disorders or chronic diseases; (ii) they can be influenced by genetic and environmental risk factors; and (iii) while clinical and epidemiological studies suggest that obesity is a risk factor for migraine, DM (i.e., type 1 and type 2 DM) have been reported to be either a protective or a risk factor in migraine. On this basis, and given the high worldwide prevalence of migraine, obesity, and DM, this article provides a narrative review of the current literature related to the association between the etiology and pathophysiology of migraine and these metabolic disorders, considering lifestyle aspects, as well as the possible involvement of neurotransmitters, neuropeptides, and/or sex hormones. While a link between migraine and metabolic disorders has been suggested, many studies are contradictory and the mechanisms involved in this association are not yet sufficiently established. Therefore, further research should be focused on understanding the possible mechanisms involved.

Left ventricular hypertrophy and other cardiac risk factors in migraineurs

BACKGROUND

The influence of cardiovascular risk factors on the probability of cardiovascular diseases in migraineurs is still being discussed.

AIMS OF THE STUDY

To further elucidate the mechanisms of these relationships, we assessed the associations between migraine and cardiovascular risk factors, including those that have been recently shown to improve the prediction of cardiovascular events.

METHODS

We used the data of the Finnish Health 2000 Survey (BRIF8901), consisting of 5737 subjects aged 30 years or older. In total, 488 participants reported migraine. In addition to conventional cardiovascular risk factors, educational attainment, presence of electrocardiographic signs of left ventricular hypertrophy and hemoglobin A1c were also included in the logistic regression analyses.

RESULTS

Migraine was found to be associated with female sex (Odds ratio (OR) = 3.75, p < .001), lower age (B = 0.99, p < .001), lower high-density lipoprotein cholesterol (OR = 1.23, p < .05), higher diastolic blood pressure (OR = 1.31, p < .05), and left ventricular hypertrophy (OR = 1.32, p < .05), the probability of the last one increasing with migraine attack frequency.

CONCLUSIONS

Left ventricular hypertrophy, most probably as a consequence of migraine-related arterial hypertension and dyslipidemia, may play a role in the relationship between migraine and cardiovascular events. The nature of this finding calls for further studies.

Headache - A Window to Dementia: An Unexpected Twist

Migraine and other types of headaches have several symptoms associated with them. The association between migraine and dementia has been considered. It is a topic of discussion and appears to be multifactorial. Dementia is a cluster of symptoms, with memory loss and cognitive dysfunction being the prominent symptoms. In this review, we discussed the association of headache and cognitive dysfunction in a broader context and how the practiced treatment of headaches may silently lead to dementia. We conducted a thorough literature search using PubMed as our main database. The articles exploring the association between headache (both migraine and non-migraine) and dementia were included. Some risk factors like migraine-induced stroke and inherent vascular diseases in migraine patients channeling to stroke and dementia were not considered. A total of 28 studies were included for review. All the reviewed studies put together showed an association between headache and cognitive dysfunction of any form. They showed that the frequency and duration of headache is a determinant for dementia. Few studies also focused on how treating headaches with certain drugs can lead to dementia. The reviewed published literature showed that headaches of any sort and their treatment are potentially linked to dementia. Not all headache patients will require medical treatment, as the benefit might outweigh the risk sometimes. It is interim to understand these facts and formulate a better protocol for treating headache patients. However, due to some discordant results, further studies are needed.

The Association of Acute Cerebrospinal Fluid Pressure Reduction with Choroidal Thickness

PURPOSE

To investigate the changes in choroidal thickness (CT) after acute cerebrospinal fluid pressure (CSFP) reduction in human subjects.

METHODS

Before and 15 minutes after diagnostic lumbar puncture (LP), 44 patients underwent measurement of CT by swept-source optical coherence tomography. Thirty-two healthy volunteers imitated the body posture of LP procedure and underwent the same measurement before and 15 minutes after body posture change.

RESULTS

After CSFP reduction from 10.9 ± 2.1 mmHg at baseline to 8.1 ± 1.5 mmHg (p < 0.001), CT decreased in subfoveal region (p = 0.005), small to medium vessel layer (SMVL, p < 0.001), peripapillary regions in temporal (p = 0.001), nasal (p < 0.001), superior (p < 0.001) and inferior (p < 0.001), respectively. However, no significant change in CT in the control group after body posture change (all p > 0.05). A significant association between CSFP and the ratio of small to medium vessel layer to total choroidal thickness was found (p = 0.009). The CSFP reduction rate was associated with the change rate of SMVL to total CT portion, for each percent decrease in CSFP was associated with a decrease by 0.22% in the rate of SMVL to total CT portion (R² = 0.125, p = 0.018).

CONCLUSIONS

A significant decrease in subfoveal CT, small to medium vessel layer and peripapillary region were observed following acute CSFP reduction. The CSFP reduction rate was associated with the change rate of small to medium vessel layer to total CT portion.

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.

Migraine and risk of stroke

Migraine and stroke are two common and heterogeneous neurovascular disorders responsible for a significant burden for those affected and a great economic cost for the society. There is growing evidence that migraine increases the overall risk of cerebrovascular diseases. In this review, based on available literature through a PubMed search, we found that ischaemic stroke in people with migraine is strongly associated with migraine with aura, young age, female sex, use of oral contraceptives and smoking habits. The risk of transient ischaemic attack also seems to be increased in people with migraine, although this issue has not been extensively investigated. Although migraine appears to be associated with haemorrhagic stroke, the migraine aura status has a small influence on this relationship. Neuroimaging studies have revealed a higher prevalence of asymptomatic structural brain lesions in people with migraine. They are also more likely to have unfavourable vascular risk factors; however, the increased risk of stroke seems to be more apparent among people with migraine without traditional risk factors. The mechanism behind the migraine-stroke association is unknown. In light of the higher risk of stroke in people with migraine with aura, it is important to identify and modify any vascular risk factor. There is currently no direct evidence to support that a migraine prophylactic treatment can reduce future stroke in people with migraine.

Framingham Risk Stratification of Middle-Aged Migraineurs

Introduction. Migraine is a common primary headache disorder involving about 10-15% of the whole population. Several epidemiological and prospective studies showed a link between migraine (especially migraine with aura) and cardio- and cerebrovascular events.

Migraine without Aura and Subclinical Atherosclerosis in Young Females: Is Gut Microbiota to Blame?

Background and Objectives: Migraine with aura (MA) could be considered a risk factor for developing atherosclerosis and cardio-vascular events. However, less is known about the relation between migraine without aura (MWA) and atherosclerosis. Our study aimed to assess whether young female migraineurs, with alterations of gut microbiota could associate early atherosclerosis. Materials and Methods: We conducted an exploratory cross-sectional, pilot study concerning 105 consecutive young females having MWA, with recent normal brain scans, that were free of cardio-vascular risk factors, non-smokers, not on oral contraception, not pregnant, and without thyroid or parathyroid diseases, chronic organ failure, cancer, or on probiotic or antibiotic treatment. Consecutive to assessment of gut microbiota, patients were assigned to two groups: dysbiosis positive (n = 45) and dysbiosis negative (n = 60). All study participants underwent clinical examinations with an assessment of migraine severity, body mass index and carotid intima-media thickness (CIMT), as well as laboratory workups. Statistical analysis was performed using a chi-squared test (χ2), a two-tailed t-test and a nonparametric Spearman's correlation test. Results: The dysbiosis positive migraineurs showed a significant increase in CIMT along with several anthropometrical, biological and clinical particularities. Significant positive correlations between dysbiosis and CIMT, glycosylated hemoglobin, migraine severity and duration, tumor necrosis factor-alpha, and body mass index were found. Conclusions: Young female migraineurs with significant alterations of gut microbiota experienced early signs of atherosclerosis and displayed severe migraine disability, as well as multiple biological and clinical particularities.

A Comprehensive Assessment of Vascular and Nonvascular Risk Factors Associated with Migraine

INTRODUCTION

 Migraine is a chronic disabling neurological disease, with an estimated expense of $15-20 million/year. Several studies with a small number of patients have studied risk factors for migraine such as cardiovascular disorders, stroke, smoking, demographic, and genetic factors but this is the first comprehensive study for evaluation of vascular and nonvascular risk factors. It is important to evaluate all the risk factors that help to prevent the healthcare burden related to migraine.  Methodology: We performed a retrospective cross-sectional analysis of the Nationwide Inpatient Sample (NIS) (years 2013-2014) in adult (>18-years old) hospitalizations in the United States. Migraine patients were identified using ICD-9-CM code to determine the demographic characteristics, vascular, and nonvascular risk factors. Univariate analysis was performed using the chi-square test and a multivariate survey logistic regression analysis was performed to identify the prevalence of the risk factors and evaluate the odds of prevalence of risk factors amongst migraine patients compared to nonmigraine patients, respectively.

RESULTS

 On weighted analysis, after removing missing data of age, gender and race, from years 2013 to 2014, of the total 983,065 (1.74%) migraine patients were identified. We found that younger (median age 48-years vs. 60-years), female (82.1% vs. 58.5%; p<0.0001), white population (76.8% vs. 70.5%; p<0.0001), and privately insured (41.1% vs. 27.4%; p<0.0001) patients were more likely to have migraine than others. Cerebral atherosclerosis, diabetes mellitus, ischemic heart disease, atrial fibrillation, and alcohol abuse were not significantly associated with migraine. Migraineurs had higher odds of having hypertension [odds ratio (OR): 1.44; 95% confidence interval (CI): 1.43-1.46; 44.49% vs. 52.84%], recent transient ischemic attack (TIA) (OR: 3.13; 95%CI: 3.02-3.25; 1.74% vs. 0.67%), ischemic stroke (OR: 1.40; 95%CI: 1.35-1.45; 2.06% vs. 1.97%), hemorrhagic stroke (OR: 1.11; 95%CI: 1.04-1.19; 0.49% vs. 0.46%), obesity (OR: 1.46; 95%CI: 1.44-1.48; 19.20% vs. 13.56%), hypercholesterolemia (OR: 1.33; 95%CI: 1.30-1.36; 5.75% vs. 5.54%), substance abuse (OR: 1.51; 95%CI: 1.48-1.54; 7.88% vs. 4.88%), past or current consumption of tobacco (OR: 1.40; 95%CI: 1.38-1.41; 31.02% vs. 27.39%), AIDS (OR: 1.13; 95%CI: 1.04-1.24; 0.33% vs. 0.41%), hypocalcemia (OR: 1.09; 95%CI: 1.03-1.14; 0.77% vs. 0.89%), and vitamin D deficiency (OR: 1.93; 95%CI: 1.88-1.99; 2.47% vs. 1.37%) than patients without migraine. Female patients were at a higher risk of migraine (OR: 3.02; 95%CI: 2.98-3.05) than male.

CONCLUSION

 In this study, we have identified significant risk factors for migraine hospitalizations. Early identification of these risk factors may improve the risk stratification in migraine patients.

Global, regional, and national burden of migraine and tension-type headache, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016

Background

Through the Global Burden of Diseases, Injuries, and Risk Factors (GBD) studies, headache has emerged as a major global public health concern. We aimed to use data from the GBD 2016 study to provide new estimates for prevalence and years of life lived with disability (YLDs) for migraine and tension-type headache and to present the methods and results in an accessible way for clinicians and researchers of headache disorders.

Methods

Data were derived from population-based cross-sectional surveys on migraine and tension-type headache. Prevalence for each sex and 5-year age group interval (ie, age 5 years to ≥95 years) at different time points from 1990 and 2016 in all countries and GBD regions were estimated using a Bayesian meta-regression model. Disease burden measured in YLDs was calculated from prevalence and average time spent with headache multiplied by disability weights (a measure of the relative severity of the disabling consequence of a disease). The burden stemming from medication overuse headache, which was included in earlier iterations of GBD as a separate cause, was subsumed as a sequela of either migraine or tension-type headache. Because no deaths were assigned to headaches as the underlying cause, YLDs equate to disability-adjusted life-years (DALYs). We also analysed results on the basis of the Socio-demographic Index (SDI), a compound measure of income per capita, education, and fertility.

Findings

Almost three billion individuals were estimated to have a migraine or tension-type headache in 2016: 1·89 billion (95% uncertainty interval [UI] 1·71–2·10) with tension-type headache and 1·04 billion (95% UI 1·00–1·09) with migraine. However, because migraine had a much higher disability weight than tension-type headache, migraine caused 45·1 million (95% UI 29·0–62·8) and tension-type headache only 7·2 million (95% UI 4·6–10·5) YLDs globally in 2016. The headaches were most burdensome in women between ages 15 and 49 years, with migraine causing 20·3 million (95% UI 12·9–28·5) and tension-type headache 2·9 million (95% UI 1·8–4·2) YLDs in 2016, which was 11·2% of all YLDs in this age group and sex. Age-standardised DALYs for each headache type showed a small increase as SDI increased.

Interpretation

Although current estimates are based on limited data, our study shows that headache disorders, and migraine in particular, are important causes of disability worldwide, and deserve greater attention in health policy debates and research resource allocation. Future iterations of this study, based on sources from additional countries and with less methodological heterogeneity, should help to provide stronger evidence of the need for action.

Funding

Bill & Melinda Gates Foundation.

Gepants for the treatment of migraine

INTRODUCTION

Migraine is the most common of all neurological disorders. A breakthrough in migraine treatment emerged in the early nineties with the introduction of 5-HT1B/D receptor agonists called triptans. Triptans are used as the standard of care for acute migraine; however, they have significant limitations such as incomplete and inconsistent pain relief, high rates of headache recurrence, class- specific side effects and cardiovascular contraindications. First- and second-generation calcitonin gene-related peptide (CGRP) receptor antagonists, namely gepants, is a class of drugs primarily developed for the acute treatment of migraine. CGRP is the most evaluated target for migraine treatments that are in development.

AREAS COVERED

This article reviews the available data for first- and second-generation CGRP receptor antagonists, the role of CGRPs in human physiology and migraine pathophysiology and the possible mechanism of action and safety of CGRP-targeted drugs.

EXPERT OPINION

Available data suggest that second generation of gepants has clinical efficacy similar to triptans and lasmiditan (5-HT1F receptor agonist) and has improved tolerability. Future studies will assess their safety, especially in specific populations such as patients with cardiovascular disease and pregnant women.

Lipid levels and selected biomarkers of vascular changes in children with idiopathic headaches - a preliminary report

INTRODUCTION

Elevated lipid concentrations were observed in adults with headaches. However, studies in children are scarce. Recent data suggest new potential risk factors for atherosclerosis, which may be associated with headaches. The aim of the study was to analyse the blood levels of lipids and new markers of atherosclerosis in children with idiopathic headaches.

MATERIAL AND METHODS

The study population comprised 65 children (39 with idiopathic headaches and 26 healthy children). Total cholesterol (TC), high-density lipoprotein (HDL), low-density lipoprotein (LDL) cholesterol and triacylglycerol (TG) levels were measured in every patient. Brain-derived neurotrophic factor (BDNF), soluble CD40 ligand (sCD40L), endothelial plasminogen activator inhibitor (serpin E1/PAI I) and vascular endothelial growth factor (VEGF) blood level measurements were performed in 34 children.

RESULTS

Children with headaches had higher BMI z-scores (0.2 vs. -1.14; p = 0.006). TC level was lower in patients with headaches (121.04 mg/dl vs. 146.87 mg/dl, p = 0.019). No differences in concentrations of TG, HDL or LDL were found. BDNF was significantly higher in the studied group (171.57 pg/ml vs. 64.04 pg/ml, p = 0.012). The VEGF was higher in boys with headaches than in girls (368.27 pg/ml vs. 142.86 pg/ml, p = 0.011). There were no differences in levels of VEGF, sCD40L or PAI-1 between groups.

CONCLUSIONS

Children with headaches have lower total cholesterol and higher BDNF levels than controls. No significant difference in levels of triacylglycerols, HDL cholesterol, LDL cholesterol, VEGF, sCD40L or PAI-1 was found between children with headaches and controls.

Headache disorder and the risk of dementia: a systematic review and meta-analysis of cohort studies

Background

Until now, headache disorders have not been established as a risk factor for dementia. The aim of this study was to determine whether headache was associated with an increased risk of dementia.

Methods

We systematically searched electronic databases, including PubMed, Embase, and Web of Science, for studies investigating the association between headache and dementia. We then conducted a meta-analysis to determine a pooled-effect estimate of the association.

Results

We identified 6 studies (covering 291,549 individuals) to investigate the association between headache and the risk of all-cause dementia or Alzheimer’s disease (AD). Pooled analyses showed that any headache was associated with a 24% greater risk of all-cause dementia (relative risk [RR] = 1.24; 95% confidential interval [CI]: 1.09–1.41; P = 0.001), and that any headache was not statistically significantly associated with an increased risk of AD (RR = 1.47; 95% CI: 0.82–2.63; P = 0.192).

Conclusions

Our results indicated that any headache was associated with an increased risk of all-cause dementia. However, additional studies are warranted to further confirm and understand the association.

Electronic supplementary material

The online version of this article (10.1186/s10194-018-0925-4) contains supplementary material, which is available to authorized users.

Migraine and Headache Prevalence and Associated Comorbidities in a Large Saudi Sample

Background: We aimed to assess the prevalence of headache and migraine, along with comorbidities, in a large ­Saudi sample. Methods: Self-reported information was collected about headache, migraine and migraine comorbidities including depression, restless legs syndrome (RLS), syncope, bruxism, hypertension and ischaemic disease. The OR was estimated using logistic regression for any associations with headache and migraine. We then analyzed to find a trend of increasing migraine symptoms for each significant comorbidity. Results: Out of 4,943 respondents, 4,158 (84.12%) had recurring headaches. Migraine was present in 1,333 (26.97%), with female predominance (ratio of 1: 2.9). There were statistically significant ORs between migraine and female sex, current smokers, higher income, hypertension, depression, syncope, RLS and bruxism. Non-migraine headaches were significantly associated with female sex, age, RLS and ischaemic disease. Migraine with aura was significantly associated with syncope, ischaemic disease, higher income and BMI. There was an overall significant trend of increasing migraine features in the presence of depression, syncope, RLS, bruxism and hypertension. Conclusions: Headache in general and migraine in particular are associated with multiple comorbidities in comparison to non-headache participants in our cohort, with an estimated prevalence similar to that of western countries.

Migraine and the risk of incident hypertension among women

Background Few studies have examined whether migraine is associated with an increased risk of incident hypertension. Methods We performed a prospective cohort study among 29,040 women without hypertension at baseline. Women were classified as having active migraine with aura, active migraine without aura, a past history of migraine, or no history of migraine. Incident hypertension was defined as new physician diagnosis or newly self-reported systolic or diastolic blood pressure ≥140 mmHg or ≥90 mmHg respectively. Cox proportional hazards models were used to evaluate the association between migraine and incident hypertension. Results During a mean follow-up of 12.2 years, 15,176 incident hypertension cases occurred. Compared to those with no history of migraine, women who experience migraine with aura had a 9% increase in their risk of developing hypertension (95% CI: 1.02, 1.18); women who experience migraine without aura had a 21% increase in their risk of developing hypertension (95% CI: 1.14, 1.28); and women with a past history of migraine had a 15% increase in their risk of developing hypertension (95% CI: 1.07, 1.23). Conclusions Women with migraine have a higher relative risk of developing hypertension compared to women without migraine.

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.

Migraine and Stroke: What's the Link? What to Do?

Migraine and stroke are common, disabling neurologic disorders, with a high socioeconomic burden. A link between them has been proposed years ago, and various theories have been proposed to explain this bidirectional relation. However, the precise causes remain unclear. We briefly summarize existing hypotheses of this correlation seeking for recommendations for stroke prevention in migraineurs, if any exist. Among the strongest suggested theories of migraine-stroke association are cortical spreading depression, endovascular dysfunction, vasoconstriction, neurogenic inflammation, hypercoagulability, increased prevalence of vascular risk factors, shared genetic defects, cervical artery dissection, and patent foramen ovale. There is no evidence that any preventive therapy in migraineurs should be used to decrease stroke risk, even in most predisposed subset of patients. However, a woman with migraine with aura should be encouraged to cease smoking and avoid taking oral contraceptives with high estrogen doses. We need further investigation to better understand the complexity of migraine-stroke association and to make firm recommendations for the future.

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.

The relationship between migraine and lipid sub-fractions among individuals without cardiovascular disease: A cross-sectional evaluation in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil)

Introduction

Recent studies have explored the relationship between dyslipidemia and migraine in a cardiovascular context. Thus, we aimed to evaluate the possible association between lipids, lipoprotein subfractions and migraine according to aura symptoms in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

Methods

1,560 women and 1,595 men, without CVD or lipid disorders requiring medication, underwent a baseline clinical assessment. Total-cholesterol and its sub-fractions (LDL, VLDL and HDL subclass cholesterol); triglycerides and triglyceride-rich lipoprotein cholesterol [TRL-C (VLDL1+2-C VLDL3-C + IDL-C)] were determined by vertical auto profile (VAP). We also calculated logarithmic LDL density ratio [LLDR = ln ((LDL3-C + LDL4-C)/(LDL1-C + LDL2-C))], T-Chol/HDL-C and triglycerides/HDL-C ratios. Odds ratios (OR) with 95% confidence intervals (CI) were obtained to evaluate the relationship between lipids tertiles and migraine for both sexes.

Results

Main findings revealed positive associations between migraine without aura (MO) and the highest tertiles of VLDL-C (OR, 1.61; 95%CI, 1.07–2.40) and TRL-C (OR, 1.55; 95% CI, 1.03–2.34) in women. In men, the highest tertile of VLDL3-C (OR, 3.87; 95%CI, 1.23–12.19) was positively associated with MO, as well.

Conclusions

In middle-aged participants without CVD or lipid disorders requiring medication, the worst lipid profile was determined by the highest levels of TRL-C and their cholesterol-rich remnants in migraineurs without aura for both sexes.

Hypercoagulability and Migraine

BACKGROUND

A growing body of literature suggests that migraineurs, particularly those with aura, have an increased risk for ischemic stroke, but not via enhanced atherosclerosis. The theory that micro-emboli induced ischemia provokes cortical spreading depression (ie, symptomatic aura) in migraineurs but transient ischemic attacks in others highlights a potential role for hypercoagulability as a link between migraine (with aura) and stroke.

AIM

Our objective is to summarize the literature evaluating the association of migraine with various acquired or inheritable thrombophilic states, including those related to elevated estrogen levels, endothelial activation and dysfunction, antiphospholipid antibodies (aPL), deficiency of coagulation inhibitors, and presence of certain genetic polymorphisms.

FINDINGS

Although definitive studies are lacking, a preponderance of available evidence links migraine, and especially aura, to increased levels of estradiol (eg, oral contraceptive pill [OCP] use, pregnancy), thrombo- and erythrocytosis, von Willebrand factor (vWF) antigen, fibrinogen, tissue plasminogen activator (tPA) antigen, and endothelial microparticles. Studies of a link to migraine are conflicting for aPL, homocysteine, Protein S, and the methylenetetrahydrofolate reductase (MTHFR) C677T polymorphism. No association with migraine was found in meta-analyses of Factor V Leiden, and of prothrombin gene mutation. Within a large, young ischemic stroke sample, migraine with aura was associated with a thrombophilic state and with patent foramen ovale (PFO). In the non-stroke population, meta-analyses show an association of PFO and migraine with aura (MA), but two population-based studies do not support the link.

RECOMMENDATIONS

For persons with MA and (1) a personal history or family history of thrombosis, or (2) MRI evidence of micro-vascular ischemia or of stroke, an evaluation for hypercoagulability is warranted. In cases of MA alone, consider screening for markers of endothelial activation (eg, vWF, high sensitivity c-reactive protein [hs CRP], and fibrinogen). Rigorous management of other stroke risk factors is paramount, but efficacy of anti-thrombotic agents in the treatment of migraine is unproven. Closure of PFO is not routinely recommended based on negative randomized trials.

Migraine as a risk factor for young patients with ischemic stroke: a case-control study

Studies have suggested a possible association of migraine and increased risk of ischemic stroke in young adults, particularly in smokers and in women who use oral contraceptive drugs. We aimed to analyze the association between migraine and ischemic stroke in young population in a hospital-based cohort. We included 202 consecutive patients with the diagnosis of ischemic stroke who were between 15 and 50 years and age- and gender-matched 250 volunteers with no history of stroke. All participants were interviewed using a questionnaire for migraine. Localization of ischemic lesion was classified as anterior and posterior circulation according to neuroimaging findings. The cause of ischemic lesion and all risk factors were recorded. Undetermined etiology was the most frequent (43.1%) and the most common determined cause was cardioembolism (22.3%) in young stroke patients. Frequency of migraine was 30.2% among patients with stroke whereas 16.8% of healthy subjects had migraine (p = 0.001). Migraine with aura was significantly more common among patients with stroke compared to healthy subjects (18.3 vs 4.4%; p = 0.000) whereas the frequency of migraine without aura was similar in both groups (11.9 vs 12.4%). Using logistic regression, migraine with aura was shown to be an independent risk factor for ischemic stroke in young population (p = 0.000) and separate analysis for gender demonstrated that it was only a risk factor for women (p = 0.009) but not for men (p = 0.107). Migraine with aura was found to be more common in ischemic stroke in young patients. It was an independent risk factor in women.

Screening for the metabolic syndrome in subjects with migraine

Background

Metabolic syndrome (MetS) and migraine are known to be associated. This study assessed the risk of MetS and its clinical characteristics in migraine with aura (MA) and without aura (MO) based on a large-scale cross-sectional survey.

Methods

The study material consisted of 751 participants in the Nutrition, Environment and CardioVascular Health (NESCaV) survey. Diagnosis of migraine was based on the ef-ID migraine questionnaire and MetS was defined according to the Revised-Adult Treatment Panel III criteria. Sociodemographic and risk factors were also recorded. Weighted logistic regression was used to assess the risk of MetS.

Results

After adjusting for stratification (gender, age, district) and other factors (smoking status, sedentary lifestyle, family history of stroke, myocardial infarction and hypertension), MA subjects were at higher risk of MetS (OR 3.45; 95% CI: 1.63–7.29) while MO individuals were not, when compared to non-migraineurs. When considering MetS components, MA was positively associated with low HDL-cholesterol (OR 2.26; 95% CI: 1.08–4.74), hyperglycemia (OR 2.77; 95% CI: 1.30–5.88) and abdominal obesity (OR 2.03; 95% CI: 1.07–3.86).

Conclusion

Migraineurs with aura are at higher risk of MetS, suggesting that these subjects, already more exposed to stroke, may benefit from a systematic screening for the metabolic syndrome.

Migraine and endothelial function: The HUNT3 Study

Background

Reduced endothelial function is associated with elevated risk of cardiovascular disease, but evidence on the association between migraine and endothelial function is conflicting. The aim of this population-based study was to examine the relationship between flow-mediated dilatation (FMD) and migraine with aura, migraine without aura and tension-type headache.

Methods

In the third Nord-Trøndelag Healthy Study (HUNT3) FMD was measured by ultrasound during reactive hyperaemia of the brachial artery in a sample of 4739 healthy adult participants, 3929 of whom answered headache questions. The cross-sectional association between different headache diagnoses and FMD was evaluated by logistic regression, using a categorical approach.

Results

Mean FMD did not differ between the headache groups and headache-free controls. In multi-adjusted analyses, no consistent association was found between FMD quintiles and headache groups.

Conclusions

There was no relationship between FMD and migraine or other headache diagnoses in this large cross-sectional study of otherwise healthy respondents including freedom from pulmonary and cardiovascular diseases.

Prevalence of primary headache disorders in a population aged 60 years and older in a rural area of Northern China

BACKGROUND

Primary headache disorders are among the most common neurological complaints worldwide, and are significant causes of disability. Data are limited on the prevalence of primary headaches among individuals aged 60 years and older in China. The purpose of our study was to investigate the prevalence and characteristics of primary headaches among people aged 60 years and older in a rural area of northern China.

METHODS

A door-to-door survey was conducted in Ji County of Tianjin Province. A total of 5248 residents aged 60 years and older were visited from 2014 to 2015, unannounced, and basic sociodemographic and headache diagnostic information was collected via a questionnaire. Primary headache was classified tension-type headaches, migraines, chronic headache, and unclassified headache.

RESULTS

The 1-year prevalence for primary headaches in Ji county is 10.30 %. The 1-year prevalence of tension-type headaches, migraines, chronic headache, and unclassified headache is 2.02 %, 0.85 %, 3.79 %, and 3.63 %. The 1-year prevalence of primary headache was higher in women than in men. The 1-year prevalence of primary headache was decreased with increasing age. The 1-year prevalence of tension-type headaches and chronic headache were decreased with higher education. Headache in the elderly was mild to moderate and not serious.

CONCLUSIONS

In a population older than 60 years of age in rural, northern China, we found the 1-year prevalence of primary headache was 10.30 %, of tension-type headaches was 2.02 %, of migraines was 0.85 %, of chronic headache was 3.79 %, and of unclassified headache was 3.63 %. The prevalence of all of these was much lower than those observed in previous studies examining prevalence rates in the general population. The results of our study also indicated that women are more likely to have primary headache than men. We also found that chronic headache was frequent among the elderly. Participants with higher education levels were more predisposed than healthy participants to tension-type headaches. We also found that respondents who did not participate in social activities had a decreased predisposition for primary headache in general, as well as for unclassified headache. Lastly, we found that participants who had heart disease were more likely than healthy participants to experience primary headache, tension-type headache, chronic headache, and unclassified headache.

Migraine and subclinical atherosclerosis in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil)

Introduction

The relationship between migraine and coronary heart disease (CHD) remains controversial. We aimed to investigate the association of subclinical atherosclerosis and migraine with or without aura compared to a non-migraine subgroup (reference) in a large Brazilian multicentric cohort study, the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil).

Methods

Migraine diagnostic was based on International Headache Society criteria, and aura symptoms were validated by a medical doctor in a sub-sample of the ELSA-Brasil, who also underwent coronary artery calcium score (CAC) and carotid intima-media thickness (C-IMT) evaluations. Subclinical atherosclerosis indexes (CAC and C-IMT) were analyzed as dependent variables and migraine (all, with aura, without aura) as an independent variable in the linear and multinomial logistic regression models adjusted for possible confounders.

Results

Of 3217 ELSA participants free from CVD at baseline, we found a migraine frequency of 11.9% (5.1% with aura and 6.8% without aura). Overall, migraineurs were mostly women, younger and had lower frequency of CV risk factors, such as hypertension, diabetes and low HDL-cholesterol, compared to non-migraineurs. The strongest inverse correlation between migraine and subclinical atherosclerosis was verified with CAC score. However, all associations lost their significance after multivariate adjustment.

Conclusions

In this cross-sectional evaluation of the ELSA study, migraine was not associated with subclinical atherosclerosis, regardless of aura symptoms.

Are migraine and non-migrainous headache risk factors for stroke in the elderly? Findings from a 12-year cohort follow-up

BACKGROUND AND PURPOSE

There is evidence that migraine is a risk factor for stroke but little is known about this association in elderly people. Furthermore, non-migrainous headache (NMH) has received little attention despite being the most frequently reported type of headache. Late-life migraine and NMH were examined as candidate risk factors for stroke in a community-dwelling elderly sample over a 12-year follow-up.

METHODS

One thousand nine hundred and nineteen non-institutionalized subjects aged 65+, without dementia (Diagnostic and Statistical Manual of Mental Disorders, 4th edition, DSM-IV criteria) and with no stroke history at baseline, were drawn from the Three-City Montpellier cohort (recruitment 1999-2001) for longitudinal analysis. Ischaemic and haemorrhagic stroke was reported at baseline and at each of the five follow-ups, with cases validated by a panel of experts, according to ICD-10 criteria (International Classification of Diseases, 10th revision). Migraine and NMH were determined at baseline during a neurological interview and examination using 1988 International Headache Society criteria.

RESULTS

A total of 110 (5.4%) cases of migraine and 179 (8.9%) cases of NMH were identified at baseline. During the median 8.8-year follow-up, incident stroke was observed in 1.9% of baseline migrainers, 6.2% of NMH and 3.6% of those with no lifetime history of headache. Cox proportional hazard models indicated that migraine was not a risk factor for stroke; however, NMH sufferers were twice as likely to have a stroke (hazard ratio 2.00, 95% confidence interval 1.00-3.93, P = 0.049).

CONCLUSIONS

This study is one of the first to suggest that late-life NMH rather than migraine could be an independent risk factor for stroke and a warning sign. The incidence of stroke in elderly migrainers, seldom reported, is particularly low.

Headache as a predictor for dementia: The HUNT Study

BACKGROUND

The impact of headache on dementia is largely unknown. This study examined the association between headache and dementia using data from a large population-based study.

METHODS

This population-based study used data from the Nord-Trøndelag Health Surveys performed in 1995-1997 (HUNT2) and 2006-2008 (HUNT3). The reference group (controls) was participants aged ≥55 years who answered the headache questions in HUNT2 and later participated in HUNT3 (n = 15,601). The association with headache status in HUNT2 was investigated in sample of confirmed non-demented elderly evaluated with psychometric tests after HUNT3 (n = 96), and HUNT2 participants later diagnosed with dementia during 1997-2011 (n = 746). The association with headache was evaluated by logistical regression with adjustment for age, gender, level of education, comorbidity, smoking, and anxiety and depression.

RESULTS

Any headache was more likely to be reported in HUNT2 among those who later were included in the dementia registry (OR 1.24; 95 % CI 1.04-1.49) compared to the reference group, but less likely among the confirmed non-demented individuals (OR 0.62; 95 % CI 0.39-0.98). This relationship was even stronger for non-migrainous headache, whereas such association was not found for migraine.

CONCLUSIONS

Compared to the reference group, individuals with dementia were more likely to report non-previous migrainous headache in HUNT2, whereas a sample of confirmed non-demented were less likely to report previous non-migrainous headache.

Migraine and risk of stroke in older adults: Northern Manhattan Study

OBJECTIVE

To examine the association between migraine and stroke/vascular outcomes in a racially/ethnically diverse, older cohort.

METHODS

Participants from the Northern Manhattan Study, a population-based cohort study of stroke incidence, were assessed for migraine symptoms using a self-report questionnaire based on criteria from the International Classification of Headache Disorders, second edition. We estimated the association between migraine and combined vascular events including stroke and stroke only over a mean follow-up of 11 years, using Cox models adjusted for sociodemographic and vascular risk factors.

RESULTS

Of 1,292 participants (mean age 68 ± 9 years) with migraine data followed prospectively for vascular events, 262 patients (20%) had migraine and 75 (6%) had migraine with aura. No association was found between migraine (with or without aura) and risk of either stroke or combined cardiovascular events. There was an interaction between migraine and current smoking (p = 0.02 in relation to stroke and p = 0.03 for combined vascular events), such that those with migraine and smoking were at an increased risk. The hazard ratio of stroke for migraine among current smokers was 3.17 (95% confidence interval [CI] 1.13-8.85) and among current nonsmokers was 0.77 (95% CI 0.44-1.35). In relation to combined vascular events, the hazard ratio for migraine vs no migraine among current smokers was 1.83 (95% CI 0.89-3.75) and among current nonsmokers was 0.63 (95% CI 0.43-0.94).

CONCLUSION

In our racially/ethnically diverse population-based cohort, migraine was associated with an increased risk of stroke among active smokers but not among nonsmokers.