Prevalence of Fibromyalgia Syndrome in Migraine Patients

Photobiomodulation therapy combined with static magnetic field is better than placebo in patients with fibromyalgia: a randomized placebo-controlled trial

BACKGROUND

Fibromyalgia is a syndrome characterized by generalized chronic pain and tenderness in specific areas. Photobiomodulation therapy (PBMT) using low-level laser therapy and/or light emitting diode therapy is an electrophysical agent that can be used alone or together with a static magnetic field (PBMT-sMF) to promote analgesia in several health conditions. Little evidence exists regarding the effects of using PBMT and PBMT-sMF in patients with fibromyalgia; this evidence is conflicting.

AIM

We aimed to investigate the effects of using PBMT-sMF versus a placebo on reduction of the degree-of-pain rating, impact of fibromyalgia, pain intensity, and satisfaction with treatment in patients with fibromyalgia.

DESIGN

A prospectively registered, monocentric, randomized placebo-controlled trial, with blinding of patients, therapists, and assessors, was performed.

SETTING

The study was conducted at the Laboratory of Phototherapy and Innovative Technologies in Health (LaPIT) in Brazil, between March and October 2020.

POPULATION

Ninety female patients with fibromyalgia were randomized to undergo either PBMT-sMF (N.=45) or placebo (N.=45) treatment.

METHODS

Patients from both groups received nine treatment sessions, three times a week, for 3 weeks. Clinical outcomes were collected at baseline, the end of treatment, and at the follow-up appointment 4 weeks post-treatment. The primary outcome was the degree-of-pain rating, measured by the reduction of the tender point count.

RESULTS

A decrease in the degree-of-pain rating was observed in patients allocated to the PBMT-sMF group, decreasing the number of tender points when compared to placebo group at the end of treatment (P<0.0001) and at the follow-up assessment (P<0.0001). Patients did not report any adverse events.

CONCLUSIONS

PBMT-sMF is superior to placebo, supporting its use in patients with fibromyalgia.

CLINICAL REHABILITATION IMPACT

PBMT-sMF might be considered an important adjuvant to the treatment regimens of patients with fibromyalgia.

Fatigue, chronic fatigue syndrome and migraine: Intersecting the lines through a cross-sectional study in patients with episodic and chronic migraine

Objectives

Fatigue is a common symptom occurring in a variety of disorders. Chronic fatigue syndrome (CFS) is characterized by debilitating fatigue as the core symptom. The risk of CFS is nearly 1.5 times higher in migraine while headaches have been reported in 59% of cases with CFS. However, details of its occurrence and severity remain largely unexplored. The primary objective of our study was to determine the occurrence and severity of fatigue and CFS in patients with episodic and chronic migraine. The secondary objectives were to define their relationship with other common comorbidities.

Materials and Methods

60 migraine patients (30 each, episodic [EM] and chronic migraine [CM]) were recruited from Neurology Outpatient Department, GIPMER a tertiary referral center in New Delhi, India. Patients' headache severity was analyzed using the Headache impact test-6 (HIT-6) score while fatigue and other migraine accompaniments were assessed using Fatigue severity scale (FSS), Chalder fatigue scale, CDC diagnostic criteria for CFS, American College of Rheumatology Diagnostic Criteria for fibromyalgia, Hamilton Depression Scale, the Generalized Anxiety Disorder 7-Item Scale, and Epworth sleepiness Scale (ESS). Comparative analysis was further done among migraine patients with and without fatigue and CFS.

Results

The mean HIT-6 score was significantly higher in CM versus EM. The CM group had a higher mean FSS score (47.87 vs. 37.3 in EM; P = 0.004), a percentage of patients with severe fatigue (60% vs. 20% in EM; P = 0.004), and a higher percentage of patients with pathological fatigue (83.3% vs. 63.3% in EM; P = 0.04). Around 23.33% of CM patients fulfilled the criteria of CFS. Fatigue correlated positively with severity, frequency, attack duration and chronicity of the migraine episodes, along with depression, anxiety, and excessive daytime sleepiness.

Conclusion

Fatigue and related comorbid disorders are significantly more common in CM than in EM, expanding the morbidity of the condition and underscores the need to address these accompanying symptoms for devising a holistic treatment plan.

Bidirectional Association Between Fibromyalgia and Migraine Among Probands and Unaffected Non-Twin Siblings: A Nationwide Population-Based Study

OBJECTIVE

This study explored the bidirectional relationship between fibromyalgia and migraine among probands with either of the two disorders and their unaffected siblings.

BACKGROUND

Evidence suggests a bidirectional association between fibromyalgia and migraine in individuals and in twins. However, whether a bidirectional association between fibromyalgia and migraine also occurs among siblings remains unknown.

METHODS

Using the Taiwan National Health Insurance Research Database, we examined the data of 2677 probands with fibromyalgia, 2780 unaffected siblings, and 11120 matched controls to assess the risk of migraine. In contrast, 1830 probands with migraine, 1936 unaffected siblings, and 7744 matched controls to assess the risk of fibromyalgia.

RESULTS

Logistic regression analyses demonstrated that patients with fibromyalgia (odds ratio [OR]: 3.69; 95% confidence interval [CI]: 2.87-4.74) and unaffected siblings (OR: 1.51; 95% CI: 1.08-2.10) were more likely to develop migraine than the controls during the follow-up period. Moreover, patients with migraine and unaffected siblings had a 4.86-fold (95% CI: 3.86-6.09) and 1.59-fold (95% CI: 1.18-2.12) increased risk of fibromyalgia than the controls.

CONCLUSION

The bidirectional association between fibromyalgia and migraine among probands and unaffected siblings suggests a familial coaggregation of these two conditions. Additional studies are required to investigate the genetic and environmental etiologies for this coaggregation.

Effectiveness of peripheral nerve blockage on the symptoms of both diseases in patients with fibromyalgia and chronic migraine coexistence

OBJECTIVE

Peripheral nerve blockage treatments reduce central sensitization and are effective in patients with migraine. We wanted to evaluate the efficacy of peripheral nerve blockage in patients with fibromyalgia and migraine whose etiology may be responsible for central sensitization, and their associations are common.

METHODS

The files of patients with chronic migraine who had peripheral nerve blockage treatment in our clinic and had fibromyalgia were scanned. The patients underwent bilateral great occipital nerve, lesser occipital nerve, and supraorbital nerve blockage at baseline and in the second week. The revised Fibromyalgia Impact Questionnaire, Migraine Disability Assessment Scale, Visual Analog Scale scores, the number of days in pain, and the number of analgesics taken in the last month were recorded.

RESULTS

In the third month, Fibromyalgia Impact Questionnaire, Migraine Disability Assessment Scale, and Visual Analog Scale scores were significantly lower from baseline. While Fibromyalgia Impact Questionnaire scores in the third month were significantly lower than in the first month, no significant difference was observed between Visual Analog Scale scores. In the third month, the number of days in pain and the number of analgesics taken in the last month was significantly lower than the baseline but higher than the first month.

CONCLUSION

Peripheral nerve blockage has been found to be an effective treatment for the symptoms of both diseases in patients with migraine and fibromyalgia coexistence.

Psychosocial Variables and Healthcare Resources in Patients with Fibromyalgia, Migraine and Comorbid Fibromyalgia and Migraine: A Cross-Sectional Study

Fibromyalgia and migraine frequently coexist. We aimed to compare the burden caused by fibromyalgia (FM), migraine (M) and comorbid fibromyalgia and migraine (FM + M) by assessing psychosocial variables and the use of healthcare resources. A survey was posted to the websites of different patients’ associations. It included sociodemographic data, the Patient Health Questionnaire-9, the Insomnia Severity Index, the EuroQOL-5D-5L and a questionnaire evaluating the use of healthcare resources during the past six months. In total, 139 FM patients, 169 M patients and 148 FM + M patients participated in the survey. Mean depression and insomnia scores were clinically relevant in every group and significantly higher in FM + M (16.3 ± 5.4 for depression, 18.5 ± 5.6 for insomnia) than in FM (14.3 ± 5.7 for depression, 16.8 ± 5.5 for insomnia) or M (11.7 ± 5.4 for depression, 13.1 ± 5.9 for depression), where p < 0.001 in both cases. Suicidal ideation was frequent in every group, but significantly more frequent in FM + M (63% vs. 45% in FM and 35% in M; p < 0.001). EQ-5D-5L (0.656 ± 0.1 in FM + M, 0.674 ± 0.1 in FM, 0.827 ± 0.1 in M, p < 0.001) and EQ-5D-5L VAS scores (38.2 ± 21.9 in FM + M, 45.6 ± 21.8 in FM, 63.5 ± 23.7 in M, p < 0.00) were lower than the reported mean population values and the lowest in FM + M. FM and FM + M used more healthcare resources than M. It is concluded that the psychosocial burden was high in the three samples. FM and FM + M had a more relevant impact on patients’ wellbeing and required more medical attention than M. The burden caused by FM + M was higher than in both individual diseases.

Fibromyalgia in patients with migraine: A literature review in the last 20 years

IntroductionPossibly fibromyalgia and migraine share similar pathophysiological mechanisms, generatingan imbalance of neurotransmitters involved in pain modulation, with increased neuronal excitability. The association between these two conditions is frequent, increasing the disability of both.ObjectivesWe aimed to review articles published in the last 20 years about the presence of fibromyalgiain patients with migraine and to analyze the quality of life of these patients.MethodsBased on a literature search in the major medical databases and using the descriptors “migraine” and “fibromyalgia” we include articles published between 2001 and 2021. We found 387 articles, but only five met the inclusion criteria.ResultsIn five articles analyzed, 429 patients with migraine were found, in which fibromyalgiawas present in 31.5% of them, predominantly in women (p<0.0001). In this association, there was a higher risk for depression and worse quality of life.ConclusionsThe association of fibromyalgia in patients with migraine is frequent, increasing the disabilityof these two diseases and generating great social impact. Knowledge of this association and the management of its consequences are necessary in medical practice.

The Frequency of Fibromyalgia in Migraine Patients

BACKGROUND: Fibromyalgia (FM) is a prevailing debilitating ailment that has been described in patients with migraines in several investigations. AIM: The study aimed to investigate the frequency of FM in migraine patients and to study the characteristics of migraine patients with comorbid FM. METHODS: This case–control study was piloted in the Neurology Unit, Department of Medicine in Ibn Sina Teaching Hospital in Mosul, Iraq, between March and November 2020. One hundred consecutive patients with migraine and 100 healthy controls were included in this study. The sociodemographic and headache characteristics of the patients were recorded. RESULTS: The frequency of FM was statistically higher among participants with migraines (27%) when compared to the controls (5%). Migraine patients with FM had a substantially older mean age and a higher ratio of female gender than migraine patients without FM. FM was found to be more common in patients without versus with aura. Patients with comorbid FM had greater headache frequency (p = 0.0002), headache intensity (p = 0.007), and higher scores on the “Headache Impact Test (HIT-6)” (p = 0.0001). CONCLUSIONS: There is a high frequency of FM in patients with migraines. Patients with coexistent “FM” and “migraine” tended to have more depressive symptoms, greater headache intensity, headache frequency, and when compared to healthy people, they are more likely to have a significant headache-related disability.

Migraine Is More Than Just Headache: Is the Link to Chronic Fatigue and Mood Disorders Simply Due to Shared Biological Systems?

Migraine is a symptomatically heterogeneous condition, of which headache is just one manifestation. Migraine is a disorder of altered sensory thresholding, with hypersensitivity among sufferers to sensory input. Advances in functional neuroimaging have highlighted that several brain areas are involved even prior to pain onset. Clinically, patients can experience symptoms hours to days prior to migraine pain, which can warn of impending headache. These symptoms can include mood and cognitive change, fatigue, and neck discomfort. Some epidemiological studies have suggested that migraine is associated in a bidirectional fashion with other disorders, such as mood disorders and chronic fatigue, as well as with other pain conditions such as fibromyalgia. This review will focus on the literature surrounding alterations in fatigue, mood, and cognition in particular, in association with migraine, and the suggested links to disorders such as chronic fatigue syndrome and depression. We hypothesize that migraine should be considered a neural disorder of brain function, in which alterations in aminergic networks integrating the limbic system with the sensory and homeostatic systems occur early and persist after headache resolution and perhaps interictally. The associations with some of these other disorders may allude to the inherent sensory sensitivity of the migraine brain and shared neurobiology and neurotransmitter systems rather than true co-morbidity.

Double-blind, randomized, placebo-controlled crossover trial of alpha-lipoic acid for the treatment of fibromyalgia pain: the IMPALA trial

ABSTRACT

Fibromyalgia is a common and challenging chronic pain disorder with few, if any, highly effective and well-tolerated treatments. Alpha-lipoic acid (ALA) is a nonsedating antioxidant with evidence of efficacy in the treatment of symptomatic diabetic neuropathy that has not been evaluated in the setting of fibromyalgia treatment. Thus, we conducted a single-centre, proof-of-concept, randomized, placebo-controlled, crossover trial of ALA for the treatment of fibromyalgia. Twenty-seven participants were recruited, and 24 participants completed both treatment periods of the trial. The median maximal tolerated dose of ALA in this trial was 1663 mg/day. Treatment-emergent adverse events with ALA were infrequent and not statistically different from placebo. For the primary outcome of pain intensity, and for several other validated secondary outcomes, there were no statistically significant differences between placebo and ALA. A post hoc exploratory subgroup analysis showed a significant interaction between gender and treatment with a significant favourable placebo-ALA difference in pain for men, but not for women. Overall, the results of this trial do not provide any evidence to suggest promise for ALA as an effective treatment for fibromyalgia, which is predominantly prevalent in women. This negative clinical trial represents an important step in a collective strategy to identify new, better tolerated and more effective treatments for fibromyalgia.

Intervention Therapies to Reduce Pain-Related Fear in Fibromyalgia Syndrome: A Systematic Review of Randomized Clinical Trials

OBJECTIVE

This systematic review aimed to evaluate the effectiveness of different interventions at reducing pain-related fear in people with fibromyalgia and to analyze whether the included trials reported their interventions in full detail.

DESIGN

Systematic review.

SETTING

No restrictions.

METHODS

The Cochrane Library, CINAHL, EMBASE, PsycINFO, PubMed, and Scopus were searched from their inception to April 2020, along with manual searches and a gray literature search. Randomized clinical trials were included if they assessed pain-related fear constructs as the primary or secondary outcome in adults with fibromyalgia. Two reviewers independently performed the study selection, data extraction, risk-of-bias assessment, Template for Intervention Description and Replication (TIDieR) checklist assessment, and grading the quality of evidence.

RESULTS

Twelve randomized clinical trials satisfied the eligibility criteria, including 11 cohorts with a total sample of 1,441 participants. Exercise, multicomponent, and psychological interventions were more effective than controls were in reducing kinesiophobia. However, there were no differences in decreasing kinesiophobia when self-management and electrotherapy were used. There were also no differences between groups with regard to the rest of the interventions and pain-related constructs (fear-avoidance beliefs, fear of pain, and pain-related anxiety). However, a serious risk of bias and a very serious risk of imprecision were detected across the included trials. This caused the overall certainty of the judged evidence to be low and very low. Additionally, the included trials reported insufficient details to allow the full replication of their interventions.

CONCLUSIONS

This systematic review shows that there are promising interventions, such as exercise, multicomponent, and psychological therapies, that may decrease one specific type of fear in people with fibromyalgia, i.e., kinesiophobia. However, because of the low-very low certainty of the evidence found, a call for action is needed to improve the quality of randomized clinical trials, which will lead to more definitive information about the clinical efficacy of interventions in this field.

OnabotulinumtoxinA Is an Effective Treatment for Chronic Migraine in Patients With Comorbid Fibromyalgia

Introduction: Fibromyalgia (FM) is a frequent comorbidity in patients with chronic migraine (CM). PREEMPT trials, which demonstrated the efficacy of OnabotulinumtoxinA (OnabotA) on CM, excluded patients with FM. Our aim was to evaluate the effectiveness of OnabotA in a series of patients with CM and FM.

Methods: We analyzed patients with a previous diagnosis of CM and FM who had received sessions of OnabotA quarterly between January 2014 and January 2020 in a specialized Headache Clinic. Primary endpoint was the reduction in moderate to severe headache days at 3, 6, 9, and 12 months.

Results: Data were collected from 31 patients with CM and FM that received OnabotA (100% females). Mean age at first procedure was 50.2 ± 11.3 years. Depression (93.5%), other central sensitization syndromes (irritable bowel syndrome, interstitial cystitis, multiple chemical sensitivity, endometriosis, and chronic fatigue syndrome) (48.4%), and medication overuse headache (90.3%) were frequent comorbidities. 48.4% of patients had failed ≥3 preventives previously. The percentage of patients who achieved ≥30 and ≥50% moderate-severe headache reduction on the third month was 65.4 and 48.2%, respectively. Twenty-three patients completed four cycles of treatment, with 13.4 fewer headache days per month than at baseline (p < 0.001). By 1 year, 69.5% had ≥50% reduction of headache frequency and 39.1% had a ≥75% reduction. In 4 cases (21%), OnabotA was interrupted due to a lack of response. Only mild adverse effects were recorded.

Conclusion: OnabotA is an effective treatment for CM in patients with FM.

Lasmiditan in patients with common migraine comorbidities: a post hoc efficacy and safety analysis of two phase 3 randomized clinical trials

OBJECTIVE

Determine whether common migraine comorbidities affect the efficacy and safety of lasmiditan, a 5-HT_1F receptor agonist approved in the United States for the acute treatment of migraine.

METHODS

In SPARTAN and SAMURAI (double-blind Phase 3 clinical trials), patients with migraine were randomized to oral lasmiditan 50 mg (SPARTAN only), 100mg, 200 mg, or placebo. Lasmiditan increased the proportion of pain-free and most bothersome symptom (MBS)-free patients at 2 h after dose compared with placebo. Most common treatment-emergent adverse events (TEAEs) were dizziness, paraesthesia, somnolence, fatigue, nausea, muscular weakness, and hypoesthesia. Based upon literature review of common migraine comorbidities, Anxiety, Allergy, Bronchial, Cardiac, Depression, Fatigue, Gastrointestinal, Hormonal, Musculoskeletal/Pain, Neurological, Obesity, Sleep, and Vascular Comorbidity Groups were created. Using pooled results, efficacy and TEAEs were assessed to compare patients with or without a given common migraine comorbidity. To compare treatment groups, p-values were calculated for treatment-by-subgroup interaction, based on logistic regression with treatment-by-comorbidity condition status (Yes/No) as the interaction term; study, treatment group, and comorbidity condition status (Yes/No) were covariates. Differential treatment effect based upon comorbidity status was also examined. Trial registration at clinicaltrials.gov: SAMURAI (NCT02439320) and SPARTAN (NCT02605174).

RESULTS

Across all the Comorbidity Groups, with the potential exception of fatigue, treatment-by-subgroup interaction analyses did not provide evidence of a lasmiditan-driven lasmiditan versus placebo differential treatment effect dependent on Yes versus No comorbidity subgroup for either efficacy or TEAE assessments.

CONCLUSIONS

The efficacy and safety of lasmiditan for treatment of individual migraine attacks appear to be independent of comorbid conditions.

Prevalence of Migraine and Neuropathic Pain in Rheumatic Diseases

To investigate the physiopathology of pain in chronic inflammatory rheumatic diseases (CIRDs), we assessed the prevalence of migraine and neuropathic pain in 499 patients with CIRDs. We studied 238 patients with rheumatoid arthritis, 188 with spondyloarthritis (SpA), 72 with psoriatic arthritis (PsA), and 1 unclassified. Migraine was diagnosed according to IHS migraine diagnostic criteria. Neuropathic pain was diagnosed when patients scored at least 3 on the DN4 questionnaire. Participants completed a validated self-assessment questionnaire. Migraine prevalence was 34% (165/484), and it was highest in PsA. Risk factors for migraine were a high level of anxiety, female sex, young age, and TNF-alpha inhibitor treatment (OR = 1.90 (1.13–3.25)). Besides, high disease activity was a risk factor in SpA. Blood CRP level was not significantly associated with migraine. Of 493 patients with CIRDs, 21.5% had chronic pain with neuropathic characteristics. Compared to the French general population, these patients had significantly higher prevalences of migraine (two-fold) and neuropathic pain (three-fold). This study showed that migraine and neuropathic pain frequently occurred in patients with rheumatic diseases. Therefore, upon reporting residual pain, these patients should be checked for the presence of migraine or neuropathic pain, despite adequate clinical control of rheumatic disease.

Real-world healthcare resource utilization related to migraine treatment failure: a panel-based chart review in France, Germany, Italy, and Spain

Aims: This retrospective chart review examined the six-month migraine-related healthcare resource use (HRU) among European patients who had ≥4 migraine days per month and previously failed at least two prophylactic migraine treatments. Methods: Neurologists, headache specialists, and pain specialists in France, Germany, Italy, and Spain who treated ≥10 patients with migraine in 2017 were recruited (April-June 2018) to extract anonymized patient-level data. Eligible physicians randomly selected charts of up to five adult patients with clinically-confirmed migraine, ≥4 migraine days in the month prior to the index date, and had previously failed at least two prophylactic migraine treatments. Treatment failure was defined as discontinuation due to lack of efficacy and/or tolerability. Demographic and disease characteristics as of the index date, and migraine-related HRU incurred during the 6-month study period, were recorded. Results: A total of 104 physicians contributed 168 charts for patients (63% female). On average, patients were 38 years old and failed 2.3 prophylactic treatments as of the index date. During the study period, 83% of patients had ≥1 outpatient visit for migraine in the physician's office, and 27% went to the ER/A&E. Approximately 5% of patients were hospitalized for migraine, with an average of one hospitalization and an average length of stay of 3 days. Approximately 39% of patients had ≥1 blood test, 22% had ≥1 magnetic resonance imaging, 17% had ≥1 electroencephalogram, and 13% had ≥1 computerized tomography scan. Visits to other healthcare providers were common. Limitations: This study is subject to the limitations of chart review studies, such as errors in data entry. Conclusions: Across four European countries, the HRU burden of migraine among patients who previously failed at least two prophylactic treatments was high, indicating a need for more effective prophylactic treatments to appropriately manage migraine and reduce the HRU burden attributable to this common disorder.

Bidirectional association between migraine and fibromyalgia: retrospective cohort analyses of two populations

OBJECTIVE

Fibromyalgia (FM) and migraine are common pain disorders that tend to coexist. This study determined whether these two conditions exhibited any mutual influences.

SETTING

Cohort study.

PARTICIPANTS

A retrospective, longitudinal cohort study was conducted using data obtained from a nationwide healthcare database. This study had two arms. Arm 1 comprised 33 216 patients with FM and arm 2 consisted of 7420 patients with migraine; all of these patients were diagnosed between 2000 and 2010. Using the aforementioned database, control subjects who had neither FM nor migraine and were matched with the FM and migraine patients by sex, age and index date of diagnosis were recruited. Each control cohort was four times the size of the corresponding study cohort. Follow-up for the control and study cohorts was conducted until the end of 2011.

RESULTS

The incidence rates of FM and migraine were calculated in arms 1 and 2, respectively. The overall incidence of migraine was greater in the FM cohort than in the corresponding control cohort (4.39 vs 2.07 per 1000 person-years (PY)); crude HR=2.12, 95% CI=1.96 to 2.30; adjusted HR (aHR)=1.89, 95% CI=1.75 to 2.05). After adjustment for sex, age and comorbidities, the overall incidence of FM in the migraine cohort was 1.57 times greater than that in the corresponding control cohort (7.01 vs 4.49 per 1000 PY; aHR=1.52, 95% CI=1.39 to 1.65).

CONCLUSIONS

The present study revealed a bidirectional link between FM and migraine.

A phase 3, long-term, open-label safety study of Galcanezumab in patients with migraine

BACKGROUND

Galcanezumab, a humanized monoclonal antibody that selectively binds to the calcitonin gene-related peptide, has demonstrated in previous Phase 2 and Phase 3 clinical studies (≤6-month of treatment) a reduction in the number of migraine headache days and improved patients' functioning. This study evaluated the safety and tolerability, as well as the effectiveness of galcanezumab for up to 12 months of treatment in patients with migraine.

METHODS

Patients diagnosed with episodic or chronic migraine, 18 to 65 years old, that were not exposed previously to galcanezumab, were randomized to receive galcanezumab 120 mg or 240 mg, administered subcutaneously once monthly for a year. Safety and tolerability were evaluated by frequency of treatment-emergent adverse events (TEAEs), serious adverse events (SAEs), and adverse events (AEs) leading to study discontinuation. Laboratory values, vital signs, electrocardiograms, and suicidality were also analyzed. Additionally, overall change from baseline in the number of monthly migraine headache days, functioning, and disability were assessed.

RESULTS

One hundred thirty five patients were randomized to each galcanezumab dose group. The majority of patients were female (> 80%) and on average were 42 years old with 10.6 migraine headache days per month at baseline. 77.8% of the patients completed the open-label treatment phase, 3.7% of patients experienced an SAE, and 4.8% discontinued due to AEs. TEAEs with a frequency ≥ 10% of patients in either dose group were injection site pain, nasopharyngitis, upper respiratory tract infection, injection site reaction, back pain, and sinusitis. Laboratory values, vital signs, or electrocardiograms did not show anyclinically meaningful differences between galcanezumab dosesOverall mean reduction in monthly migraine headache days over 12 months for the galcanezumab dose groups were 5.6 (120 mg) and 6.5 (240 mg). Level of functioning was improved and headache-related disability was reduced in both dose groups.

CONCLUSION

Twelve months of treatment with self-administered injections of galcanezumab was safe and associated with a reduction in the number of monthly migraine headache days. Safety and tolerability of the 2 galcanezumab dosing regimens were comparable.

TRIAL REGISTRATION

ClinicalTrials.gov as NCT02614287 , posted November 15, 2015. These data were previously presented as a poster at the International Headache Congress 2017: PO-01-184, Late-Breaking Abstracts of the 2017 International Headache Congress. (2017). Cephalalgia, 37(1_suppl), 319-374.

Myofascial trigger points in migraine and tension-type headache

BACKGROUND

A myofascial trigger point is defined as a hyperirritable spot in skeletal muscle that is associated with a hypersensitive palpable nodule in a taut band. It has been suggested that myofascial trigger points take part in chronic pain conditions including primary headache disorders. The aim of this narrative review is to present an overview of the current imaging modalities used for the detection of myofascial trigger points and to review studies of myofascial trigger points in migraine and tension-type headache.

FINDINGS

Different modalities have been used to assess myofascial trigger points including ultrasound, microdialysis, electromyography, infrared thermography, and magnetic resonance imaging. Ultrasound is the most promising of these modalities and may be used to identify MTrPs if specific methods are used, but there is no precise description of a gold standard using these techniques, and they have yet to be evaluated in headache patients. Active myofascial trigger points are prevalent in migraine patients. Manual palpation can trigger migraine attacks. All intervention studies aiming at trigger points are positive, but this needs to be further verified in placebo-controlled environments. These findings may imply a causal bottom-up association, but studies of migraine patients with comorbid fibromyalgia syndrome suggest otherwise. Whether myofascial trigger points contribute to an increased migraine burden in terms of frequency and intensity is unclear. Active myofascial trigger points are prevalent in tension-type headache coherent with the hypothesis that peripheral mechanisms are involved in the pathophysiology of this headache disorder. Active myofascial trigger points in pericranial muscles in tension-type headache patients are correlated with generalized lower pain pressure thresholds indicating they may contribute to a central sensitization. However, the number of active myofascial trigger points is higher in adults compared with adolescents regardless of no significant association with headache parameters. This suggests myofascial trigger points are accumulated over time as a consequence of TTH rather than contributing to the pathophysiology.

CONCLUSIONS

Myofascial trigger points are prevalent in both migraine and tension-type headache, but the role they play in the pathophysiology of each disorder and to which degree is unclarified. In the future, ultrasound elastography may be an acceptable diagnostic test.

Fibromyalgia in migraine: a retrospective cohort study

Background

Migraine is a common and disabling disorder. Fibromyalgia has been shown to be commonly comorbid in patients with migraine and can intensify disability. The aim of this study was to determine if patients with co-morbid fibromyalgia and migraine report more depressive symptoms, have more headache related disability, or report higher intensity of headache as compared to patients with migraine only. Cases of comorbid fibromyalgia and migraine were identified using a prospectively maintained headache database at Mayo Clinic Rochester. One-hundred and fifty seven cases and 471 controls were identified using this database and the Mayo Clinic electronic medical record.

Findings

Depressive symptoms as assessed by PHQ-9, intensity of headache, and migraine related disability as assessed by MIDAS were primary measures used to compare migraine patients with comorbid fibromyalgia versus those without. Patients with comorbid fibromyalgia reported significantly higher PHQ-9 scores (OR 1.08, p < .0001) and headache intensity scores (OR 1.149, p = .007). There was no significant difference in migraine related disability (OR 1.002, p = .075). Patients with fibromyalgia were more likely to score in a higher category of depression severity (OR 1.467, p < .0001) and more likely to score in a higher category of migraine related disability (OR 1.23, p = .004).

Conclusion

Patients with comorbid fibromyalgia and migraine report more depressive symptoms, higher headache intensity, and are more likely to have severe headache related disability as compared to controls without fibromyalgia. Clinicians who care for patients with migraine may consider screening for comorbid fibromyalgia particularly in patients with moderate to severe depressive symptoms, high headache intensity and/or high headache related disability. This is the first matched study to look at these characterisitcs, and it replicates previous findings from unmatched studies.

The Impact of Fibromyalgia on Disability, Anxiety, Depression, Sleep Disturbance, and Quality of Life in Patients with Migraine

Introduction

The aim of the present study was to assess the impact of fibromyalgia (FM) comorbidity on disability, anxiety, depression, sleep disturbance, and quality of life in patients with migraine.

Methods

Eighty-six consecutive migraine patients (age, 35.4±10.3 years; 69 women and 17 men) were enrolled in the study. The headache characteristics of the patients were recorded. FM was diagnosed based on the 1990 American College of Rheumatology classification criteria for the diagnosis of FM. All patients were asked to complete selfreport questionnaires, including the Fibromyalgia Impact Questionnaire (FIQ), Headache Impact Test (HIT-6), Migraine Disability Assessment Questionnaire (MIDAS), Pittsburgh Sleep Quality Index (PSQI), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), and the 36- Item Short Form Survey (SF-36) to assess their pain-related disability, migraine-related disability, depression, anxiety, sleep disturbance, and quality of life.

Results

Of the migraine patients, 28 (32.6%) met the criteria for FM. Migraine patients with FM showed significantly increased migraine frequency and BDI, BAI, and PSQI scores and decreased quality of life scores for all eight domains of the SF-36 compared to patients with migraine alone, whereas the mean HIT-6 and MIDAS values did not differ between the groups. FIQ score showed statistically significant positive correlations with BDI, BAI, PSQI, and MIDAS scores and with headache frequency (p<0.001, r=0.657; p<0.001, r=0.730; p<0.001, r=0.754; p=0.005, r=0.300; p=0.008, r=0.286, respectively); FIQ score showed negative correlations with scores for all domains of the SF-36. In multivariate linear regression analysis, BDI, BAI, and PSQI scores independently predicted FIQ score.

Conclusion

Our study results demonstrate the significant impact of FM comorbidity on anxiety, depression, sleep disturbance, and quality of life in this population. FM evaluation and treatment should be considered in the routine care of patients with migraine to globally improve the patient's quality of life.

Characterization of migraineurs presenting interictal widespread pressure hyperalgesia identified using a tender point count: a cross-sectional study

BACKGROUND

Migraineurs exhibit pain hypersensitivity throughout the body during and between migraine headaches. Migraine is classified as a central sensitivity syndrome, typified by fibromyalgia showing widespread pressure hyperalgesia determined by a tender point. This study was performed to examine whether: 1) there is a subgroup of episodic migraineurs with widespread pressure hyperalgesia during and between attacks; 2) if such a subgroup exists, what is the prevalence and what is the difference between groups with interictal widespread hyperalgesia and acute allodynia regarding the demographic and clinical characteristics of migraine.

METHODS

This was a cross-sectional study. A total of 176 consecutive episodic migraineurs and 132 age- and sex-matched controls were recruited. The presence of widespread pressure hyperalgesia was investigated using manual tender point survey. To classify a subject's response as widespread pressure hyperalgesia, the cutoff value for responders was defined as the positive tender point count below which 95% of controls responded.

RESULTS

Based on the number of positive tender points in controls, the cutoff value of tender point count for pressure hyperalgesia responders was 7. Of the 176 subjects, interictal widespread pressure hyperalgesia and acute allodynia were observed in 74 (42%) and 115 (65.3%) patients, respectively. Univariate analysis indicated that risk factors associated with interictal widespread pressure hyperalgesia were female gender, younger age at migraine onset, higher frequency of migraine attacks, severe headache impact, cutaneous allodynia and depression. Multivariate logistic regression analysis confirmed that independent risk factors associated with interictal widespread pressure hyperalgesia were female gender, higher frequency of migraine attack and younger age at onset.

CONCLUSION

Interictal widespread pressure hyperalgesia was common (42%) in the episodic migraineurs and was associated with younger age at onset, female gender, and higher frequency of headache, but not duration of migraine illness. Presence of interictal widespread pressure hyperalgesia is assumed to be an indicator of genetic susceptibility to migraine attacks. We expect that a tender point count, as an alternative to quantitative sensory testing, will become useful as a diagnostic indicator of interictal hyperalgesia in migraineurs to predict susceptibility to migraine attacks and to permit tailored treatment.

Current management: migraine headache

Migraine varies in its frequency, severity, and impact; treatment should consider these variations and the patient's needs and goals. Migraine pharmacologic treatment may be acute (abortive) or preventive (prophylactic), and patients often require both. New medication devices are available or in development, including an intracutaneous, microneedle system of zolmitriptan and sumatriptan, and breath-powered powder sumatriptan intranasal treatment. Lasmiditan, a 5-HT1F receptor agonist, is in development for acute treatment, as are small molecule calcitonin gene-related peptide (CGRP) receptor antagonists (Gepants) for acute and preventive treatment. Antibodies to CGRP and its receptor are being developed for migraine prevention. All 4 treatments are effective and have, as of yet, no safety concerns.

Innovations in the Management of Musculoskeletal Pain With Alpha-Lipoic Acid (IMPALA Trial): Study protocol for a Double-Blind, Randomized, Placebo-Controlled Crossover Trial of Alpha-Lipoic Acid for the Treatment of Fibromyalgia Pain

BACKGROUND

Fibromyalgia is a common disorder characterized by chronic widespread pain, sleep disturbance, fatigue, depression, and cognitive dysfunction, resulting in substantial disability. As current analgesics provide incomplete relief and disabling side effects that aggravate fatigue and cognitive dysfunction, there is a need for new pain treatments with better efficacy and tolerability. Alpha-lipoic acid (ALA) is an antioxidant proven effective in painful diabetic neuropathy with minimal side effects.

OBJECTIVE

We hypothesize that this agent will provide benefits in fibromyalgia because of several similarities with neuropathic pain and also because it does not cause sedation, fatigue, or mental-slowing. To test this, we have designed a clinical trial that will assess pain, side effects, and other outcomes in participants with fibromyalgia.

METHODS

Using a crossover design, 24 adults with fibromyalgia will be randomly allocated to 1 of the 2 sequences of ALA and placebo. Participants will take capsules containing ALA or placebo for 4 weeks followed by a 1-week washout followed by a second 4-week treatment and 1-week washout period. ALA (or matching placebo) capsules will be titrated to 1800 mg/day over each 4-week period. The primary outcome will be mean daily pain intensity (0-10) during week 4 of each period. Secondary outcomes, assessed during week 4 of each period, will include global improvement, adverse events, mood, and quality of life.

RESULTS

This trial was registered in the International Standard Randomized Controlled Trial registry March 15, 2016 (Number ISRCTN58259979), and it attained ethics approval on December 3, 2016 (Queen's University Health Sciences & Affiliated Teaching Hospitals Research Ethics Board protocol number ANAE-287-15). The recruitment started in February 2017.

CONCLUSIONS

This trial will provide evidence for the efficacy of ALA in fibromyalgia.

TRIAL REGISTRATION

International Standard Randomized Controlled Trial Number (ISRCTN): 58259979; www.isrctn.com/ISRCTN58259979 (Archived by WebCite at http://www.webcitation.org/6og9JdiyZ).

The importance of lactic acid in migraines and fibromyalgia

BACKGROUND

Lactic acid is a byproduct of both muscle metabolism and the central nervous system. Changes in metabolism are related to various physiological and pathological conditions. The aim of this study was to determine the relationship between migraine and fibromyalgia with the levels of lactic acid in the blood.

METHODS

We study of 93 patients was divided into five groups: 1) patients with fibromyalgia (n=20); 2) episodic migraine (n=20); 3) chronic migraine (n=20); 4) fibromyalgia and episodic migraine (n= 13); and 5) fibromyalgia and chronic migraine (n=20), and 20 healthy subjects (control group). Blood levels of lactic acid were measured at four different time points: at rest, during aerobic exercise, during anaerobic physical activity and while resting after anaerobic exercise.

RESULTS

Lactic acid increased in all groups during anaerobic physical activity without predominance for either group. During aerobic physical activity, all groups increased lactic acid levels, but the increase was more expressive in the chronic migraine group and the chronic migraine with fibromyalgia group without statistical significance.

CONCLUSIONS

We did not found abnormalities involving the metabolism of lactic acid in episodic and chronic migraine with or without fibromyalgia.

Frequency of Migraine Headaches in Patients With Fibromyalgia

OBJECTIVE

The purpose of this study was to evaluate the frequency of migraine headache in a large cohort of patients with fibromyalgia using a brief migraine headache-screening tool.

BACKGROUND

Several studies report a high prevalence of fibromyalgia among patients with migraine headaches, but there is a dearth of research evaluating the frequency of migraine headaches in patients with fibromyalgia, despite clinical observations suggesting that migraine headaches are common in patients with fibromyalgia.

DESIGN AND METHODS

This was a cross-sectional survey study. Patients (N = 3717) with a previous diagnosis of fibromyalgia who were members of the Mayo Clinic Fibromyalgia Registry were contacted by electronic survey and asked to complete a brief demographic and medical history questionnaire and the validated ID-Migraine screener.

RESULTS

A total of 1730 patients (46.5%) completed the electronic survey. The majority of participants were white (97.2%), female (92.5%), with a mean age of 56.2 (±13.1) years. Of the respondents, 966 (55.8%) met criteria for migraine headaches. Hypertension (309 [32.3%] vs. 294 [40.1%], P = .004), asthma (312 [32.5%] vs. 189 [25.9%], P = .011), irritable bowel syndrome (520 [54.6%] vs. 348 [47.6], P = .017), chronic fatigue syndrome (486 [50.7%] vs. 271 [37.1], P < .0001), depression (634 [66.5%] vs. 413 [56.7%], P = .0002), anxiety (415 [43.5%] vs. 252 [34.7%], P = .0011), and post-traumatic stress disorder (172 [18.0%] vs. 96 [13.2%], P = .006) were all significantly more common in those who met criteria for migraine headaches than those who did not.

CONCLUSION

The results of this study suggest that migraine headaches are common in patients with fibromyalgia. Clinicians who care for either population must be aware that these conditions commonly overlap and can significantly increase a patient's cumulative disease burden.

Headache and migraine: a leading cause of absenteeism

Migraine and tension-type headache, the two dominant primary headache disorders, are among the most common causes of lost work time. The population impact of both disorders is similar, but the demographics and individual impact differ. Approximately 18% of females and 6% of males have migraine in the general population. Prevalence is highest around age 40, when individuals are at the peak of their work abilities. Headaches cause substantial individual impact on work productivity and employer and societal burden from direct medical costs, lost work time, and underemployment, and, in more severe persistent headache, unemployment. The lost work time costs greatly exceed medical care costs. Chronic daily headache (15 or more headache days per month) represents a widely accepted stage of pain progression that occurs in 2-4% of the population. Treatment of headaches can be acute or preventive. The goals of acute treatment are timely alleviation of pain and associated symptoms without recurrence, the restoring of ability to function, minimizing the use of back-up and rescue medications with minimal adverse events, and providing the best cost-effective management. Migraine-preventive medications are used to decrease future attack frequency, severity, and duration, improving responsiveness to acute treatments, and improving overall function and decreasing disability. Preventing analgesic overuse that leads to chronic daily headache is another goal of using preventive treatment. Preventive medications should be considered in migraine patients reporting either 3-6 or more headache days per month, depending on how headaches impair function.

Worldwide epidemiology of fibromyalgia

Studying the epidemiology of fibromyalgia (FM) is very important to understand the impact of this disorder on persons, families and society. The recent modified 2010 classification criteria of the American College of Rheumatology (ACR), without the need of tender points palpation, allows that larger and nationwide surveys may be done, worldwide. This article reviews the prevalence and incidence studies done in the general population, in several countries/continents, the prevalence of FM in special groups/settings, the association of FM with some sociodemographic characteristics of the population, and the comorbidity of FM with others disorders, especially with headaches.

Quality of life and emotional functioning in youth with chronic migraine and juvenile fibromyalgia

SUMMARY

Chronic pain in children is associated with significant negative impact on social, emotional, and school functioning. Previous studies on the impact of pain on children's functioning have primarily used mixed samples of pain conditions or single pain conditions (eg, headache and abdominal pain) with relatively small sample sizes. As a result, the similarities and differences in the impact of pain in subgroups of children with chronic pain have not been closely examined.

OBJECTIVE

To compare pain characteristics, quality of life, and emotional functioning among youth with pediatric chronic migraine (CM) and juvenile fibromyalgia (JFM).

METHODS

We combined data obtained during screening of patients for 2 relatively large intervention studies of youth (age range, 10 to 18 y) with CM (N=153) and JFM (N=151). Measures of pain intensity, quality of life (Pediatric Quality of Life; PedsQL, child and parent-proxy), depressive symptoms (Children's Depression Inventory), and anxiety symptoms (Adolescent Symptom Inventory-4-Anxiety subscale) were completed by youth and their parent. A multivariate analysis of covariance controlling for effects of age and sex was performed to examine differences in quality of life and emotional functioning between the CM and JFM groups.

RESULTS

Youth with JFM had significantly higher anxiety and depressive symptoms, and lower quality of life in all domains. Among children with CM, overall functioning was higher but school functioning was a specific area of concern.

DISCUSSION

Results indicate important differences in subgroups of pediatric pain patients and point to the need for more intensive multidisciplinary intervention for JFM patients.

The prevalence of fibromyalgia and its relation with headache characteristics in episodic migraine

The objective of this study was to assess the prevalence of fibromyalgia (FM) in patients with episodic migraine and to evaluate the relationship between migraine characteristics and FM. One hundred and eighteen consecutive patients (mean age = 38 years, 75% women) fulfilling the International Classification of Headache Disorders-II criteria for migraine with (n = 22) and without (n = 96) aura from an outpatient headache clinic of a university hospital were evaluated. The diagnosis of FM was made based on the 1990 American College of Rheumatology classification criteria. Participants completed some self-administered questionnaires ascertaining sociodemographics, headache severity, frequency and duration, headache-related disability (Headache Impact Test [HIT-6]) and Migraine Disability Assessment Scale, widespread musculoskeletal pain (visual analog scale), depression (Beck depression inventory), anxiety (Beck anxiety inventory), sleep quality (Pittsburgh Sleep Quality Index), fatigue (Multidimensional Assessment of Fatigue), and quality of life (Short Form-36 Health Survey [SF-36]). In patients with FM, the tender point count and the Fibromyalgia Impact Questionnaire were employed. FM was diagnosed in 37 (31.4%) of the patients. FM comorbidity was equally distributed across patients with and without aura. Severity of migraine headache, HIT-6, and anxiety were especially associated with FM comorbidity. Patients suffering from migraine plus FM reported lower scores on all items of the SF-36. This study indicates that the assessment and management of coexisting FM should be taken into account in the assessment and management of migraine, particularly when headache is severe or patients suffer from widespread musculoskeletal pain.

Application of density estimation algorithms in analyzing co-morbidities of migraine

In this study, we will propose a density estimation based data analysis procedure to investigate the co-morbid associations between migraine and the suspected diseases. The primary objective of this study has aimed to develop a novel analysis procedure that can discover insightful knowledge from large medical databases. The entire analysis procedure consists of two stages. During the first stage, a kernel density estimation algorithm named relaxed variable kernel density estimation (RVKDE) is invoked to identify the samples of interest. Then, in the second stage, a density estimation algorithm based on generalized Gaussian components and named G²DE is invoked to provide a summarized description of the distribution. The results obtained by applying the proposed two-staged procedure to analyze co-morbidities of migraine revealed that the proposed procedure could effectively identify a number of clusters of samples with distinctive characteristics. The results further revealed that the distinctive characteristics of the clusters extracted by the proposed procedure were in conformity with the observations reported in recently published articles. Accordingly, it is conceivable that the proposed analysis procedure can be exploited to provide valuable clues of pathogenesis and facilitate development of proper treatment strategies.

Anxiety and depression are associated with migraine and pain in general: an investigation of the interrelationships

There is a well-established comorbidity between migraine and anxiety and depression (A/D). Here, we investigate whether this relationship is specific for migraine and A/D or whether other types of pain are also consistently associated with A/D. In addition, we test whether there is a consistent association between migraine and other types of pain when comorbidity with A/D is controlled for. Data on A/D, migraine, and 6 nonheadache pain locations (back, neck, orofacial area, abdomen, joints, and chest) were analyzed in 2,981 participants from the Netherlands Study of Depression and Anxiety (NESDA). It was tested whether the prevalence of pain in each individual location, as well as the total number of pain locations, depended on A/D and migraine status. A/D was consistently associated with pain in all measured locations. Migraine was also associated with pain in all anatomical sites, but these associations weakened substantially after correction for A/D severity, suggesting that a considerable part of the comorbidity of migraine and other types of pain may be explained by A/D. These findings emphasize the importance of accounting for A/D in studies of pain comorbidity. This will contribute to a better understanding of the mechanisms underlying A/D and pain.

PERSPECTIVE

Anxiety and depression are consistently associated with pain, regardless of anatomical site. These disorders may be important factors in the co-occurrence of different pain disorders. Awareness of this comorbidity and a better understanding of the underlying mechanisms may facilitate adequate treatment of both types of conditions.

Prevalence, clinical features and potential therapies for fibromyalgia in primary headaches

Fibromyalgia (FM) syndrome is predominantly related to generation and persistence of central sensitization, which is an aggravating factor for chronic headaches. This review aims to examine the last 11 years of studies on FM and primary headache comorbidity, focusing on prevalence, clinical features and treatments. Chronic forms of migraine and tension-type headache show a high frequency of FM comorbidity. The symptoms characterizing headache patients presenting with FM comorbidity are high headache frequency, poor sleep quality, pericranial tenderness, anxiety and reduction of physical performances. The effects of headache-preventive drugs on factors favoring FM comorbidity were poorly evaluated. Nonpharmacological approaches such as transcranial magnetic stimulation may be an option for treatment of chronic migraine associated with FM.

Comorbidity in perimenstrual migraine

Comorbidity may be defined as the association of two or more diseases in individuals at a frequency greater than that expected statistically by chance. Studying the co-occurrence of two disorders requires a careful statistical analysis before any clear conclusion on causality is reached. Many studies have looked for an association between migraine and many diseases, reporting several sometimes controversial comorbidities in migraine subjects. Although migraine is more common in women than in men, very few studies have analyzed the comorbidity of perimenstrual migraine, a migraine sub-type characterized by attacks of migraine without aura related to menstruation. We review the studies on migraine comorbidities, particularly migraine without aura in women.

Clinical features of headache patients with fibromyalgia comorbidity

Our previous study assessed the prevalence of fibromyalgia (FM) syndrome in migraine and tension-type headache. We aimed to update our previous results, considering a larger cohort of primary headache patients who came for the first time at our tertiary headache ambulatory. A consecutive sample of 1,123 patients was screened. Frequency of FM in the main groups and types of primary headaches; discriminating factor for FM comorbidity derived from headache frequency and duration, age, anxiety, depression, headache disability, allodynia, pericranial tenderness, fatigue, quality of life and sleep, and probability of FM membership in groups; and types of primary headaches were assessed. FM was present in 174 among a total of 889 included patients. It prevailed in the tension-type headache main group (35%, p < 0.0001) and chronic tension-type headache subtype (44.3%, p < 0.0001). Headache frequency, anxiety, pericranial tenderness, poor sleep quality, and physical disability were the best discriminating variables for FM comorbidity, with 81.2% sensitivity. Patients presenting with chronic migraine and chronic tension-type headache had a higher probability of sharing the FM profile (Bonferroni test, p < 0.01). A phenotypic profile where headache frequency concurs with anxiety, sleep disturbance, and pericranial tenderness should be individuated to detect the development of diffuse pain in headache patients.

The prevalence of fibromyalgia in other chronic pain conditions

Central sensitivity syndromes (CSS) include fibromyalgia syndrome (FMS), irritable bowel syndrome, temporomandibular disorder, restless legs syndrome, chronic fatigue syndrome, and other similar chronic painful conditions that are based on central sensitization (CS). CSS are mutually associated. In this paper, prevalence of FMS among other members of CSS has been described. An important recent recognition is an increased prevalence of FMS in other chronic pain conditions with structural pathology, for example, rheumatoid arthritis, systemic lupus, ankylosing spondylitis, osteoarthritis, diabetes mellitus, and inflammatory bowel disease. Diagnosis and proper management of FMS among these diseases are of crucial importance so that unwarranted use of such medications as corticosteroids can be avoided, since FMS often occurs when RA or SLE is relatively mild.

Psychological distress of patients suffering from restless legs syndrome: a cross-sectional study

BACKGROUND

Restless legs syndrome (RLS) is a chronic disorder with substantial impact on quality of life similar to that seen in diabetes mellitus or osteoarthritis. Little is known about the psychological characteristics of RLS patients although psychological factors may contribute to unfavourable treatment outcome.

METHODS

In an observational cross-sectional design, we evaluated the psychological features of 166 consecutive RLS patients from three outpatient clinics, by means of the Symptom Checklist 90-R (SCL-90-R) questionnaire. Additionally, the Beck Depression Inventory-II (BDI-II) and the International RLS Severity Scale (IRLS) were measured. Both treated and untreated patients were included, all patients sought treatment.

RESULTS

Untreated patients (n = 69) had elevated but normal scores on the SCL-90-R Global Severity Index (GSI; p = 0.002) and on the sub-scales somatisation (p < 0.001), compulsivity (p = 0.003), depression (p = 0.02), and anxiety (p = 0.004) compared with a German representative sample. In the treated group, particularly in those patients who were dissatisfied with their actual treatment (n = 62), psychological distress was higher than in the untreated group with elevated scores for the GSI (p = 0.03) and the sub-scales compulsivity (p = 0.006), depression (p = 0.012), anxiety (p = 0.031), hostility (p = 0.013), phobic anxiety (p = 0.024), and paranoid ideation (p = 0.012). Augmentation, the most serious side effect of dopaminergic, i.e. first-line treatment of RLS, and loss of efficacy were accompanied with the highest psychological distress, as seen particularly in the normative values of the sub-scales compulsivity and anxiety. Generally, higher RLS severity was correlated with higher psychological impairment (p < 0.001).

CONCLUSION

Severely affected RLS patients show psychological impairment in multiple psychological domains which has to be taken into account in the treatment regimen.

Central sensitization: implications for the diagnosis and treatment of pain

Nociceptor inputs can trigger a prolonged but reversible increase in the excitability and synaptic efficacy of neurons in central nociceptive pathways, the phenomenon of central sensitization. Central sensitization manifests as pain hypersensitivity, particularly dynamic tactile allodynia, secondary punctate or pressure hyperalgesia, aftersensations, and enhanced temporal summation. It can be readily and rapidly elicited in human volunteers by diverse experimental noxious conditioning stimuli to skin, muscles or viscera, and in addition to producing pain hypersensitivity, results in secondary changes in brain activity that can be detected by electrophysiological or imaging techniques. Studies in clinical cohorts reveal changes in pain sensitivity that have been interpreted as revealing an important contribution of central sensitization to the pain phenotype in patients with fibromyalgia, osteoarthritis, musculoskeletal disorders with generalized pain hypersensitivity, headache, temporomandibular joint disorders, dental pain, neuropathic pain, visceral pain hypersensitivity disorders and post-surgical pain. The comorbidity of those pain hypersensitivity syndromes that present in the absence of inflammation or a neural lesion, their similar pattern of clinical presentation and response to centrally acting analgesics, may reflect a commonality of central sensitization to their pathophysiology. An important question that still needs to be determined is whether there are individuals with a higher inherited propensity for developing central sensitization than others, and if so, whether this conveys an increased risk in both developing conditions with pain hypersensitivity, and their chronification. Diagnostic criteria to establish the presence of central sensitization in patients will greatly assist the phenotyping of patients for choosing treatments that produce analgesia by normalizing hyperexcitable central neural activity. We have certainly come a long way since the first discovery of activity-dependent synaptic plasticity in the spinal cord and the revelation that it occurs and produces pain hypersensitivity in patients. Nevertheless, discovering the genetic and environmental contributors to and objective biomarkers of central sensitization will be highly beneficial, as will additional treatment options to prevent or reduce this prevalent and promiscuous form of pain plasticity.

Comorbidities of migraine

Migraine is a common neurological disorder and can be severely disabling during attacks. The highest prevalence occurs between the ages of 25 and 55 years, potentially the most productive period of life. Migraine leads to a burden not only for the individual, but also for the family and society in general. Prior studies have found that migraine occurs together with other illnesses at a greater coincidental rate than is seen in the general population. These occurrences are called “comorbidities,” which means that these disorders are interrelated with migraine. To delineate the comorbidities of migraine is important, because it can help improve treatment strategies and the understanding of the possible pathophysiology of migraine. The comorbid illnesses in patients with migraine include stroke, sub-clinical vascular brain lesions, coronary heart disease, hypertension, patent foramen ovale, psychiatric diseases (depression, anxiety, bipolar disorder, panic disorder, and suicide), restless legs syndrome, epilepsy and asthma. In this paper, we review the existing epidemiological and hospital-based studies, and illustrate the connections between these illnesses and migraine.