Caffeine-Withdrawal Headache. The Vågå Study of Headache Epidemiology

Habitual caffeinated beverage consumption and headaches among adults with episodic migraine: A prospective cohort study

OBJECTIVE

To examine the relationship between habitual caffeinated beverage consumption and headache frequency, duration, and intensity in a prospective cohort of adults with episodic migraine.

BACKGROUND

Caffeine is a commonly ascribed headache trigger in adults with migraine and clinicians may counsel patients to avoid caffeinated beverages; however, few studies have examined this association.

METHODS

From March 2016 to August 2017, 101 adults with physician-confirmed episodic migraine completed baseline questionnaires, including information about caffeinated beverage consumption. For 6 weeks, they reported headache onset, duration, and pain intensity (scale 0-100) on twice-daily electronic diaries. Ninety-seven participants completed data collection. We examined associations between self-reported habitual caffeinated beverage consumption at baseline and headache outcomes prospectively captured over the following 6 weeks, adjusting for age, sex, and oral contraceptive use.

RESULTS

The adjusted mean headache days per month was similar among the 20 participants reporting no habitual intake (7.1 days, 95% confidence interval [CI] 5.1-9.2), the 65 participants reporting 1-2 servings/day (7.4 days, 95% CI 6.1-8.7), and the 12 participants reporting 3-4 servings/day (5.9 days, 95% CI 3.3-8.4). Similarly, mean headache duration (no servings/day: 8.6 h, 95% CI 3.8-13.3; 1-2 servings/day: 8.5 h, 95% CI 5.5-11.5; 3-4 servings/day: 8.8 h, 95% CI 2.3-14.9) and intensity (no servings/day: 43.8, 95% CI 37.0-50.5; 1-2 servings/day: 43.1, 95% CI 38.9-47.4; 3-4 servings/day: 46.5, 95% CI 37.8-55.3) did not differ across levels of caffeinated beverage intake, though estimates were imprecise.

CONCLUSIONS

We found no association between habitual caffeinated beverage intake and headache frequency, duration, or intensity. These data do not support a recommendation that patients with episodic migraine should avoid consuming caffeine. Further research is needed to understand whether deviating from usual caffeine intake may trigger migraine attacks.

Weekend Headaches in School-Age Children

Children commonly encounter primary headaches, with various factors playing a role in their onset. The daily routine notably contributes to the occurrence of primary headaches in children. This study aims to profile children experiencing headaches on weekends (WH) in comparison to those primarily having headaches midweek (MWH). Out of 109 children visiting a pediatric headache clinic, 60 prospectively filled out questionnaires regarding their headaches. The average age was 11.8 years, and 63% were of female sex. Most of the children suffered from migraine headaches (60%), while the rest suffered from tension-type headaches (TTH, 15%), mixed headaches (17%), or undetermined headaches (8%). None of the children suffered from a headache only on the weekend. In contrast, 14 (23%) children suffered from a headache exclusively in midweek. Children with learning difficulties were similarly distributed between the WH and the MWH groups (48% and 52%, respectively). Children without learning difficulties suffered significantly more from MWH compared to WH (79% vs. 21%, respectively). In conclusion, children did not suffer from WH alone. Self-reported triggers were not significantly different in WH and MWH patients. Proper profiling of headache types and triggers may lead to more accurate management of these patients.

Caffeine for Headaches: Helpful or Harmful? A Brief Review of the Literature

Consumption of caffeine in the diet, both daily and occasional, has a significant biological effect on the nervous system. Caffeine, through various and not yet fully investigated mechanisms, affects headaches. This is especially noticeable in migraine. In other headaches such as hypnic headache, post-dural puncture headache and spontaneous intracranial hypotension, caffeine is an important therapeutic agent. In turn, abrupt discontinuation of chronically used caffeine can cause caffeine-withdrawal headache. Caffeine can both relieve and trigger headaches.

Caffeine supplementation in the hospital: Potential role for the treatment of caffeine withdrawal

Caffeine use in the population is widespread. Caffeine withdrawal in the hospital setting is an underappreciated syndrome with symptoms including drowsiness, difficulty concentrating, mood disturbances, low motivation, flu-like symptoms, and headache. Withdrawal may occur upon abstinence from chronic daily exposure at doses as low as 100 mg/day and following only 3-7 days of consumption at higher doses. There are limited data investigating how caffeine withdrawal contributes to hospital morbidity. Some studies suggest caffeine withdrawal may contribute to intensive care delirium and that caffeine may promote wakefulness post-anesthesia. Caffeine supplementation has also shown promise in patients at risk of caffeine withdrawal, such as those placed on nil per os (NPO) status, in preventing caffeine withdrawal headache. These data on caffeine supplementation are not entirely consistent, and routine caffeine administration has not been implemented into clinical practice for patients at risk of withdrawal. Notably, caffeine serves a therapeutic role in the hospital for other conditions. Our review demonstrates that caffeine is largely safe in the general population and may be an appropriate therapeutic option for future studies, if administered properly. There is a need for a randomized controlled trial investigating in-hospital caffeine supplementation and the population that this would best serve.

Caffeine does not affect susceptibility to cortical spreading depolarization in mice

Several factors that modulate migraine, a common primary headache disorder, also affect susceptibility to cortical spreading depolarization (CSD). CSD is a wave of neuronal and glial depolarization and thought to underlie the migraine aura and possibly headache. Here, we tested whether caffeine, known to alleviate or trigger headache after acute exposure or chronic use/withdrawal, respectively, modulates CSD. We injected C57BL/6J mice with caffeine (30, 60, or 120 mg/kg; i.p.) once ( acute) or twice per day for one or two weeks ( chronic). Susceptibility to CSD was evaluated by measuring the electrical CSD threshold and by assessing KCl-induced CSD. Simultaneous laser Doppler flowmetry was used to assess CSD-induced cortical blood flow changes. Recordings were performed 15 min after caffeine/vehicle administration, or 24 h after the last dose of chronic caffeine in the withdrawal group. The latter paradigm was also tested in mice carrying the familial hemiplegic migraine type 1 R192Q missense mutation, considered a valid migraine model. Neither acute/chronic administration nor withdrawal of caffeine affected CSD susceptibility or related cortical blood flow changes, either in WT or R192Q mice. Hence, adverse or beneficial effects of caffeine on headache seem unrelated to CSD pathophysiology, consistent with the non-migrainous clinical presentation of caffeine-related headache.

Headaches: a Review of the Role of Dietary Factors

Dietary triggers are commonly reported by patients with a variety of headaches, particularly those with migraines. The presence of any specific dietary trigger in migraine patients varies from 10 to 64 % depending on study population and methodology. Some foods trigger headache within an hour while others develop within 12 h post ingestion. Alcohol (especially red wine and beer), chocolate, caffeine, dairy products such as aged cheese, food preservatives with nitrates and nitrites, monosodium glutamate (MSG), and artificial sweeteners such as aspartame have all been studied as migraine triggers in the past. This review focuses the evidence linking these compounds to headache and examines the prevalence of these triggers from prior population-based studies. Recent literature surrounding headache related to fasting and weight loss as well as elimination diets based on serum food antibody testing will also be summarized to help physicians recommend low-risk, non-pharmacological adjunctive therapies for patients with debilitating headaches.

Factors associated with the presence of postoperative headache in elective surgery patients: a prospective single center cohort study

PURPOSE

Headache is an important cause of minor postoperative morbidity. In this study we evaluated the association of anesthesia and surgery with the occurrence of postoperative headache in elective surgery patients.

METHODS

After obtaining ethical approval, 446 patients were enrolled in this prospective, single-centre cohort study. Participants were interviewed preoperatively, and for five days postoperatively, regarding the appearance of headache, while demographics, lifestyle, type of anesthesia and surgery, the anesthetic drugs administered and intraoperative adverse effects were recorded. Multiple logistic regression analysis was conducted in order to identify independent factors associated with postoperative headache, both in the total sample and in patients without previous history of headache.

RESULTS

The observed overall frequency of postoperative headache was 28.3% (N = 126) in the total sample. In patients with previous history of headache, the frequency of postoperative headache was 41% (N = 89), while in those with no history the frequency of postoperative headache was 16.2% (N = 37). Female gender [p = 0.024; odds ratio (OR) = 2.1], sevoflurane administration (p < 0.001; OR = 3.66), intraoperative hypotension (p = 0.008; OR = 2.12) and smoking (p = 0.006; OR = 1.74) were independently associated with postoperative headache. In patients without previous history, female gender (p = 0.005; OR = 4.77), sevoflurane administration (p = 0.001; OR = 6.9), intraoperative hypotension (p = 0.006; OR = 6.7) and caffeine consumption (p = 0.041; OR = 5.28) presented greater likelihood for postoperative headache, while smoking revealed no association.

CONCLUSION

Female gender, sevoflurane, smoking and intraoperative hypotension were documented as independent risk factors for postoperative headache. In patients with no previous history of headache, caffeine consumption was an additional independent factor for postoperative headache, while smoking revealed no association.

Influence of pro-algesic foods on chronic pain conditions

This paper examines current knowledge about putative "pro-algesic" dietary components, and discusses whether limiting the intake of these substances can help improve chronic pain. Although there is a common impression that numerous food components, natural and synthetic, can cause or worsen pain symptoms, very few of these substances have been investigated. This article focuses on four substances, monosodium glutamate, aspartame, arachidonic acid, and caffeine, where research shows that overconsumption may induce or worsen pain. For each substance, the mechanism whereby it may act to induce pain is examined, and any clinical trials examining the effectiveness of reducing the intake of the substance discussed. While all four substances are associated with pain, decreased consumption of them does not consistently reduce pain.

Caffeine and headache: specific remarks

Caffeine is the most widely used psychostimulant worldwide. Excessive caffeine consumption induces a series of both acute and chronic biological and physiological changes that may give rise to cognitive decline, depression, fatigue, insomnia, cardiovascular changes, and headache. Chronic consumption of caffeine promotes a pro-nociceptive state of cortical hyperexcitability that can intensify a primary headache or trigger a headache due to excessive analgesic use. This review offers an in-depth analysis of the physiological mechanisms of caffeine and its relationship with headache.

Influences of smoking and caffeine consumption on trigeminal pain processing

Background

Many human and animal studies have shown the influence of nicotine and caffeine on pain perception and processing. This study aims to investigate whether smoking or caffeine consumption influences trigeminal pain processing.

Methods

Sixty healthy subjects were investigated using simultaneous recordings of the nociceptive blink reflex (nBR) and pain related evoked potentials (PREP) following nociceptive electrical stimulation on both sides of the forehead (V1). Thirty subjects were investigated before and after smoking a cigarette, as well as before and after taking a tablet of 400 mg caffeine.

Results

After smoking PREP showed decreased N2 and P2 latencies indicating central facilitation at supraspinal (thalamic or cortical) level. PREP amplitudes were not changed. NBR showed a decreased area under the curve (AUC) indicating central inhibition at brainstem level. After caffeine intake no significant changes were observed comparing nBR and PREP results before consumption.

Conclusions

Smoking influences trigeminal pain processing on supraspinal and brainstem level. In the investigated setting, caffeine consumption does not significantly alter trigeminal pain processing. This observation might help in the further understanding of the pathophysiology of pain disorders that are associated with excessive smoking habits such as cluster headache. Previous smoking has to be taken into account when performing electrophysiological studies to avoid bias of study results.

[Caffeine in analgesics--myth or medicine?]

Caffeine as an analgesic adiuvant has been discussed for many years. In a recent Cochrane review based on 19 studies with a total of 7238 patients, caffeine enhanced the efficacy of paracetamol, ibuprofen or aspirin with a number needed to treat (NNT) of about 16, comparable to the effect of doubling the dose of the primary analgesic, reported by other authors. Analgesia by caffeine is best explained by antagonism at adenosine receptors. Recent studies confirmed a favourable tolerability profile of caffeine when consumed in "normal" quantities (e.g. 300 mg or about 3 cups of coffee per day), including possible cardiovascular risks, effects on bone density, and exposure in pregnancy. Beneficial effects are known,e.g.,in Parkinson's disease and liver cirrhosis and fibrosis. Caffeine remains an analgesic adiuvant with a favourable risk-benefit balance.

High dietary caffeine consumption is associated with a modest increase in headache prevalence: results from the Head-HUNT Study

The aim of this study was to investigate the association between caffeine consumption and headache type and frequency in the general adult population. The results were based on cross-sectional data from 50,483 (55%) out of 92,566 invited inhabitants aged ≥20 years who participated in the Nord-Trøndelag Health Survey. In the multivariate analyses, adjusting for age, gender, smoking, and level of education as confounding factors, a weak but significant association (OR = 1.16, 95% CI 1.09–1.23) was found between high caffeine consumption and prevalence of infrequent headache. In contrast, headache >14 days/month was less likely among individuals with high caffeine consumption compared to those with low caffeine consumption. The results may indicate that high caffeine consumption changes chronic headache into infrequent headache due to the analgesic properties of caffeine. Alternatively, chronic headache sufferers tend to avoid intake of caffeine to not aggravate their headaches, whereas individuals with infrequent headache are less aware that high caffeine use can be a cause.

Caffeine and headaches

Caffeine is the most widely consumed psychostimulant drug in the world. With intermittent exposures, caffeine may act as a mild analgesic for headache or as an adjuvant for the actions of other analgesics. Chronic repetitive exposures to caffeine increase the risks for development of analgesic-overuse headache, chronic daily headache, and physical dependency. Cessation of caffeine use after chronic exposures leads to a withdrawal syndrome with headache as a dominant symptom. At dosages achieved by common dietary intake, caffeine acts as a potent antagonist of central and peripheral nervous system adenosine receptors. The complex effects of caffeine on headache disorders suggest important roles for adenosine in these disorders and in the induction of caffeine dependency.

A critical review of caffeine withdrawal: empirical validation of symptoms and signs, incidence, severity, and associated features

RATIONALE

Although reports of caffeine withdrawal in the medical literature date back more than 170 years, the most rigorous experimental investigations of the phenomenon have been conducted only recently.

OBJECTIVES

The purpose of this paper is to provide a comprehensive review and analysis of the literature regarding human caffeine withdrawal to empirically validate specific symptoms and signs, and to appraise important features of the syndrome.

METHODS

A literature search identified 57 experimental and 9 survey studies on caffeine withdrawal that met inclusion criteria. The methodological features of each study were examined to assess the validity of the effects.

RESULTS

Of 49 symptom categories identified, the following 10 fulfilled validity criteria: headache, fatigue, decreased energy/activeness, decreased alertness, drowsiness, decreased contentedness, depressed mood, difficulty concentrating, irritability, and foggy/not clearheaded. In addition, flu-like symptoms, nausea/vomiting, and muscle pain/stiffness were judged likely to represent valid symptom categories. In experimental studies, the incidence of headache was 50% and the incidence of clinically significant distress or functional impairment was 13%. Typically, onset of symptoms occurred 12-24 h after abstinence, with peak intensity at 20-51 h, and for a duration of 2-9 days. In general, the incidence or severity of symptoms increased with increases in daily dose; abstinence from doses as low as 100 mg/day produced symptoms. Research is reviewed indicating that expectancies are not a prime determinant of caffeine withdrawal and that avoidance of withdrawal symptoms plays a central role in habitual caffeine consumption.

CONCLUSIONS

The caffeine-withdrawal syndrome has been well characterized and there is sufficient empirical evidence to warrant inclusion of caffeine withdrawal as a disorder in the DSM and revision of diagnostic criteria in the ICD.