Headache-related cognitive distortions questionnaire

Background. - Cognitive distortions are systematic errors in thinking and can be observed in the relationship of headache patients with their own disease and treatment. Objective. - To construct and validate an instrument to evaluate headache-related cognitive distortions in those with primary headache disorders; and to investigate the psychometric properties of this new instrument. Methods. - One hundred thirty-six (136) migraine outpatients from three Brazilian specialized headache hospital services completed the Headache-related Cognitive Distortions Inventory (HCDQ) and validated measures of psychological symptoms, pain catastrophizing, mood disorders, quality of life and headache-related disability. Results. - All hypothesized study measures’ correlations were statistically significant, supporting construct validity. HCDQ scores were positively correlated with headache frequency, headache intensity, psychological symptoms, depression, anxiety, and pain catastrophizing; and negatively correlated with 7 of 8 quality of life domains and time the patient was in treatment. Cronbach’s alpha demonstrated excellent internal consistency for the 17-item total scale (alpha=.92). Along with headache intensity and depression, HCDQ Pain subscale accounted for 46% of variance in the prediction of headache-related disability. Conclusions. - HCDQ is a valid and reliable measure of migraine patients´ cognitive distortions about their headaches and headache treatment.

Enhanced mindfulness-based stress reduction in episodic migraine-effects on sleep quality, anxiety, stress, and depression: a secondary analysis of a randomized clinical trial

ABSTRACT

Patients with migraine suffer from high morbidity related to the repeated headache attacks, characteristic of the disorder, poor sleep, and a high prevalence of comorbid psychosocial disorders. Current pharmacological therapies do not address these aspects of migraine, but nonpharmacological treatments such as mindfulness-based stress reduction (MBSR) have been shown to improve both pain and psychological well-being. In this secondary analysis, we examined the change over time in sleep quality and psychosocial outcomes from the magnetic resonance imaging outcomes for mindfulness meditation clinical trial and assessed how these mediated treatment response (50% reduction in headache frequency postintervention). We also examined the relationship between baseline values and treatment response. The trial (primary outcomes previously reported) included 98 patients with episodic migraine randomized to either enhanced MBSR (MBSR+) or stress management for headache. They completed psychosocial questionnaires and headache diaries at baseline (preintervention), midintervention (10 weeks after baseline), and postintervention (20 weeks after baseline). There was a significant improvement in sleep quality from baseline to postintervention (P = 0.0025) in both groups. There were no significant changes from baseline or between groups in anxiety, depression, and stress. There was also no significant association between baseline scores and treatment response. Mediation analysis showed a significant indirect effect of 6% for sleep: In other words, small improvements in sleep may have contributed to the efficacy of MBSR+.Trial registration: NCT02133209.

Suicide Attempts in US Veterans with Chronic Headache Disorders: A 10-Year Retrospective Cohort Study

Objectives

A large-scale retrospective analysis of veterans with chronic pain was conducted to examine (1) the annual incidence of suicide attempts (SA) in veterans with chronic headache and other chronic pain conditions, and (2) the risk of SA in men and women with chronic headache and chronic headache concurrent with traumatic brain injury (TBI) as compared to non-headache chronic pain.

Methods

This retrospective study (N=3,247,621) analyzed National Veterans Affair Health Administrative data of patients diagnosed with chronic head, neck, back and other chronic pain from 2000 to 2010. Multivariable Poisson regression was used to explore the relative risks of SA in veterans with chronic headache and chronic headache concurrent with TBI as stratified by sex.

Results

Veterans with chronic headaches had the highest annual incidence of SA (329 to 491 per 100,000) each year among all identified types of chronic pain conditions. Compared to other non-headache chronic pain, chronic headache is associated with increased risk of SA [men RR (1.48), CI (1.37,1.59); women RR (1.64), CI (1.28,2.09)], after adjusting for demographic factors, TBI, and psychiatric comorbidities. The risk increased further when chronic headache is comorbid with TBI [men RR (2.82), CI (2.60, 3.05); women RR (2.16, CI (1.67-2.78)].

Conclusion

Veterans with chronic headache have a higher risk of SA than those with other chronic pain and women with chronic headache are at a higher risk than men with chronic headache. Chronic headache concurrent with TBI further heightened this risk, especially in men. Our data underscore the importance of identifying specific types of chronic pain in veterans with comorbid TBI and sex disparity associated with SA when targeting suicide prevention measures.

Associations between adverse childhood experiences and migraine among teenage mothers in Peru

OBJECTIVE

The objective of this study was to evaluate the association between (1) different types of ACEs and migraine, and (2) the number of ACEs and migraine among adolescent mothers in Lima, Peru.

METHODS

Our cross-sectional study included 787 adolescent mothers (14- to 18-years of age) in Peru. In-person interviews were conducted postpartum, in hospital, within 2-days of delivery. Nine types of ACEs were assessed, including exposure to three categories of abuse, two categories of neglect, and four categories of household dysfunction. Multivariable logistic regression procedures were used to estimate odds ratios (ORs) and 95% confidence intervals (95% CI) for the association between ACEs and migraine while adjusting for putative confounders.

RESULTS

Approximately 75% of adolescent mothers reported having experienced at least one type of ACE. Adolescent mothers who reported any childhood abuse had 1.49-fold increased odds of migraine (aOR = 1.49; 95% CI 1.03-2.18) compared to those with no history of childhood abuse. Adolescent mothers who reported experiencing household dysfunction had 1.56-fold increase odds of migraine (aOR = 1.56; 95% CI 1.09-2.24). Compared to participants who reported no ACE, those who experienced four or more ACEs had 3.09-fold (aOR = 3.09; 95% CI 1.80-5.40) increased odds of migraine (ptrend < 0.001).

CONCLUSION

Exposure to ACEs is highly prevalent in adolescent-aged mothers postpartum and is associated with increased odds of migraine. These findings support the importance of screening for ACEs and migraine among adolescent mothers; and the need for providing culturally appropriate, trauma-informed headache care.

Enhanced mindfulness-based stress reduction in episodic migraine: a randomized clinical trial with magnetic resonance imaging outcomes

We aimed to evaluate the efficacy of an enhanced mindfulness-based stress reduction (MBSR+) vs stress management for headache (SMH). We performed a randomized, assessor-blind, clinical trial of 98 adults with episodic migraine recruited at a single academic center comparing MBSR+ (n = 50) with SMH (n = 48). MBSR+ and SMH were delivered weekly by group for 8 weeks, then biweekly for another 8 weeks. The primary clinical outcome was reduction in headache days from baseline to 20 weeks. Magnetic resonance imaging (MRI) outcomes included activity of left dorsolateral prefrontal cortex (DLPFC) and cognitive task network during cognitive challenge, resting state connectivity of right dorsal anterior insula to DLPFC and cognitive task network, and gray matter volume of DLPFC, dorsal anterior insula, and anterior midcingulate. Secondary outcomes were headache-related disability, pain severity, response to treatment, migraine days, and MRI whole-brain analyses. Reduction in headache days from baseline to 20 weeks was greater for MBSR+ (7.8 [95% CI, 6.9-8.8] to 4.6 [95% CI, 3.7-5.6]) than for SMH (7.7 [95% CI 6.7-8.7] to 6.0 [95% CI, 4.9-7.0]) (P = 0.04). Fifty-two percent of the MBSR+ group showed a response to treatment (50% reduction in headache days) compared with 23% in the SMH group (P = 0.004). Reduction in headache-related disability was greater for MBSR+ (59.6 [95% CI, 57.9-61.3] to 54.6 [95% CI, 52.9-56.4]) than SMH (59.6 [95% CI, 57.7-61.5] to 57.5 [95% CI, 55.5-59.4]) (P = 0.02). There were no differences in clinical outcomes at 52 weeks or MRI outcomes at 20 weeks, although changes related to cognitive networks with MBSR+ were observed. Enhanced mindfulness-based stress reduction is an effective treatment option for episodic migraine.

Migraine Age of Onset and Association With Ischemic Stroke in Late Life: 20 Years Follow-Up in ARIC

BACKGROUND AND PURPOSE

To evaluate the association between cumulative exposure to migraine and incidence of ischemic stroke in the Atherosclerosis Risk in Communities (ARIC) study.

METHODS

In this ongoing, prospective longitudinal community-based cohort, participants were interviewed to ascertain migraine history at the third visit (1993-1995), followed for ischemic stroke incidence over 20 years. We performed a post hoc analysis to evaluate the association between the age of migraine onset and ischemic stroke.

RESULTS

We identified 447 migraineurs with aura (MA) and 1128 migraineurs without aura (MO) among 11,592 black and white participants. There was an association between the age of MA onset ≥50 years old (average duration = 4.75 years) and ischemic stroke when compared to no headache group (multivariable adjusted HR = 2.17, 95% CI [1.39-3.39], P < .001). MA onset <50 years old (average duration = 28.17 years) was not associated with stroke (multivariable adjusted HR = 1.31, 95% CI [0.86-2.02], P = .212). These results were consistent with our logistic regression model. MO was not associated with increased stroke regardless of the age of onset. The absolute risk for stroke in migraine with aura is 37/447 (8.27%) and migraine without aura is 48/1128 (4.25%).

CONCLUSION

As compared to the no headache participants, increased stroke risk in late life was observed in participants with late onset of MA. In this cohort, longer cumulative exposure to migraine with visual aura, as would be expected with early onset of migraine, was not associated with increased risk of ischemic stroke in late life. This study underscores the importance of the age of onset of MA in assessing stroke risk in older migraineurs.

Modulation of salience network intranetwork resting state functional connectivity in women with chronic migraine

Objective To investigate the intranetwork resting state fMRI connectivity within the Salience Network of chronic migraine with and without medication overuse headache. Methods We compared 351 pairs of intranetwork connectivity in chronic migraine (n = 13) and chronic migraine with medication overuse headache (n = 16) compared to matched controls, and between each chronic migraine subgroup. Results Compared to controls, 17 pairs of intranetwork connections in chronic migraine and 27 pairs in chronic migraine with medication overuse headache were decreased. When comparing chronic migraine with medication overuse headache versus chronic migraine, connectivity between bilateral extended amygdala, and between paracingulate to right ventral tegmental area/substantia nigra were decreased in chronic migraine (chronic migraine < chronic migraine with medication overuse headache). Connectivity between left dorsolateral prefrontal cortex to bilateral ventral striatum/pallidum, to bilateral dorsal anterior cingulate cortex; left anterior prefrontal cortex to contralateral orbitofrontal insula; and left ventral striatum/pallidum to ipsilateral supplementary motor area (SMA)/preSMA were decreased in chronic migraine with medication overuse headache (chronic migraine with medication overuse headache < chronic migraine). Conclusion Both chronic migraine subgroups had shared intranetwork connectivity abnormality, however, each subgroup had unique pattern of disruption within the salience network. The results suggest that the aberrant assignment of salience to external and internal stimuli plays an important role in chronic migraine and chronic migraine with medication overuse headache interictally, mostly involving mesolimbic pathways (especially bilateral extended amygdala) in chronic migraine, and prefrontal-subcortical limbic pathways in chronic migraine with medication overuse headache.

Association Between Migraine and Suicidal Behaviors: A Nationwide Study in the USA

BACKGROUND

Recent studies show migraineurs are at an increased risk of developing suicidal behaviors, even after controlling for comorbid depression. However, previous research has not examined the impact of psychiatric mood disorders on suicidal behaviors in migraineurs within a nationally representative sample.

OBJECTIVE

A cross-sectional study was used to investigate the association between migraine and suicidal behaviors and determine whether psychiatric comorbidities modify this association in a nationwide inpatient cohort.

METHODS

We analyzed the Nationwide Inpatient Sample of hospitalizations compiled from USA billing data. Migraine, suicidal behaviors, and psychiatric disorders were identified based on the International Classification of Diseases, 9^th Revision, Clinical Modification diagnosis codes from hospitalization discharges (2007-2012). Weighted national estimates were used to estimate odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

156,172,826 hospitalizations were included, of which 1.4% had a migraine diagnosis and 1.6% had a diagnosis of suicidal behavior. Migraineurs had a 2.07-fold increased odds of suicidal behaviors (95%CI: 1.96-2.19) compared with non-migraineurs. We repeated analyses after stratifying by depression, anxiety, or posttraumatic stress disorder (PTSD). Among hospitalizations with depression, migraine was associated with a 20% reduced odds of suicidal behaviors (95%CI: 0.76-0.85). Among hospitalizations without depression, migraine was associated with 2.35-fold increased odds of suicidal behaviors (95%CI: 2.20-2.51). In stratified analyses, we noted that among hospitalizations with anxiety, migraineurs had slightly increased odds of suicidal behaviors (OR: 1.07, 95%CI: 1.02-1.13). Among hospitalizations without anxiety, migraine was associated with a 2.06-fold increased odds of suicidal behaviors (95%CI: 1.94-2.20). Similarly, in analyses stratified by PTSD, migraine was not associated with an increased risk of suicidal behaviors (OR: 1.00, 95%CI: 0.94-1.07) among those with PTSD. However, the odds of suicidal behaviors were increased among hospitalizations without PTSD (OR: 1.95, 95%CI: 1.84-2.08).

CONCLUSION

Chronic conditions that do not affect the current hospitalization may not have been reported. The presence of psychiatric diagnoses influences associations of suicidal behaviors with migraine in a national inpatient sample. Migraineurs with diagnosed comorbid psychiatric disorders may be receiving care that mitigates their risk for suicidal behaviors.

Ethnic Differences in the Effects of Naloxone on Sustained Evoked Pain: A Preliminary Study

Ethnic differences in pain response have been well documented, with non-Hispanic Black (NHB) participants reporting enhanced clinical pain and greater laboratory-evoked pain sensitivity to a variety of quantitative sensory testing (QST) methods compared to non-Hispanic Whites (NHW). One potential mechanism that may contribute to these disparities is differential functioning of endogenous pain-regulatory systems. To evaluate endogenous opioid (EO) mechanisms in pain responses, we examined group differences in response to tonic capsaicin pain following double-blinded crossover administration of saline and the opioid antagonist, naloxone. Ten percent topical capsaicin cream and a thermode were applied to the dorsum of the non-dominant hand, maintaining a constant temperature of 40°C for 90 min. Naloxone (0.1 mg/kg) or saline placebo was administered at the 25 min mark and post-drug pain intensity ratings were obtained every 5 min thereafter. As an index of EO function, blockade effects were derived for each participant, reflecting the difference between mean post-drug pain intensity ratings under the saline versus naloxone conditions, with higher positive scores reflecting greater EO inhibition of pain. Thirty-nine healthy, young individuals (19 non-Hispanic Black [NHB], 20 non-Hispanic White [NHW]) participated. Group difference in EO function were identified, with NHB participants displaying lower EO function scores (mean=-10.8, SD=10.1) as compared to NHW participants (mean=-0.89, SD=11.5; p=0.038). NHB participants experienced significant paradoxical analgesia with naloxone. Thirty five percent of the NHW participants showed a positive blockade effect indicating EO analgesia (i.e., an increase in pain with naloxone), while only 10% of the NHB participants exhibited evidence of EO analgesia. These findings suggest differential functioning of the endogenous opioid pain regulatory system between NHB and NHW participants. Future research is warranted to examine whether these differences contribute to the disparities observed in clinical pain between groups.

Migraine and the risk of post-traumatic stress disorder among a cohort of pregnant women

Background

Individually both migraine and post-traumatic stress disorder (PTSD) prevalence estimates are higher among women. However, there is limited data on the association of migraine and PTSD in women during pregnancy.

Methods

We examined the association between migraine and PTSD among women attending prenatal clinics in Peru. Migraine was characterized using the International Classification of Headache Disorders (ICHD)-III beta criteria. PTSD was assessed using the PTSD Checklist-Civilian Version (PCL-C). Multivariable logistic regression analyses were performed to estimate odds ratios (OR) and 95% confidence intervals (CI) after adjusting for confounders.

Results

Of the 2922 pregnant women included, 33.5% fulfilled criteria for any migraine (migraine 12.5%; probable migraine 21.0%) and 37.4% fulfilled PTSD criteria. Even when controlling for depression, women with any migraine had almost a 2-fold increased odds of PTSD (OR: 1.97; 95% CI: 1.64–2.37) as compared to women without migraine. Specifically, women with migraine alone (i.e. excluding probable migraine) had a 2.85-fold increased odds of PTSD (95% CI: 2.18–3.74), and women with probable migraine alone had a 1.61-fold increased odds of PTSD (95% CI: 1.30–1.99) as compared to those without migraine, even after controlling for depression. In those women with both migraine and comorbid depression, the odds of PTSD in all migraine categories were even further increased as compared to those women without migraine.

Conclusion

In a cohort of pregnant women, irrespective of the presence or absence of depression, the odds of PTSD is increased in those with migraine. Our findings suggest the importance of screening for PTSD, specifically in pregnant women with migraine.

Electronic supplementary material

The online version of this article (doi:10.1186/s10194-017-0775-5) contains supplementary material, which is available to authorized users.

Modulation of intrinsic resting-state fMRI networks in women with chronic migraine

OBJECTIVE

To evaluate the intrinsic resting functional connectivity of the default mode network (DMN), salience network (SN), and central executive network (CEN) network in women with chronic migraine (CM), and whether clinical features are associated with such abnormalities.

METHODS

We analyzed resting-state connectivity in 29 women with CM as compared to age- and sex-matched controls. Relationships between clinical characteristics and changes in targeted networks connectivity were evaluated using a multivariate linear regression model.

RESULTS

All 3 major intrinsic brain networks were less coherent in CM (DMN: p = 0.030, SN: p = 0.007, CEN: p = 0.002) as compared to controls. When stratified based on medication overuse headache (MOH) status, CM without MOH (DMN: p = 0.029, SN: p = 0.023, CEN: p = 0.003) and CM with MOH (DMN: p = 0.016, SN: p = 0.016, CEN: p = 0.015) were also less coherent as compared to controls. There was no difference in CM with MOH as compared to CM without MOH (DMN: p = 0.382, SN: p = 0.408, CEN: p = 0.419). The frequency of moderate and severe headache days was associated with decreased connectivity in SN (p = 0.003) and CEN (p = 0.015), while cutaneous allodynia was associated with increased connectivity in SN (p = 0.011).

CONCLUSIONS

Our results demonstrated decreased overall resting-state functional connectivity of the 3 major intrinsic brain networks in women with CM, and these patterns were associated with frequency of moderate to severe headache and cutaneous allodynia.

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.

Pain catastrophizing may moderate the association between pain and secondary hyperalgesia

Catastrophizing, a persistent negative mental set characterized by helplessness, rumination, and magnification of pain sensations, has a potent effect on pain report and clinical outcomes. Previous studies have documented an association between cognitive factors and central sensitization. The current analysis sought to test the potential modulating effect of pain catastrophizing on the association between capsaicin pain and the region of secondary hyperalgesia. Thirty-eight healthy individuals (50% women, mean age = 25.7, SD = 5.3) completed the Pain Catastrophizing Scale (PCS), then underwent topical application of 10% capsaicin, which was covered by a thermode maintained at 40°C for 90-min. Following removal of the capsaicin, the region of secondary hyperalgesia was determined. Hayes' PROCESS macro was employed to examine catastrophizing's potential moderating effect, which did not reveal a significant association between capsaicin pain ratings and the region of secondary hyperalgesia (β = 15.1, p = .06). Though PCS was not associated with area of secondary hyperalgesia (β = 23.9, p = .29), a significant interaction was present between PCS and capsaicin pain ratings (β = 3.7, p = .0004). Specifically, those endorsing higher catastrophizing levels and higher pain ratings experienced the greatest areas of secondary hyperalgesia. The Johnson-Neyman technique was used to determine the regional effect of the moderation, which indicated that when PCS scores were ≥10.6, capsaicin pain significantly moderated the association between pain and area of secondary hyperalgesia. These results suggest that catastrophizing plays an important role in the area of secondary hyperalgesia, and potentially central sensitization, warranting further testing in future research.

Migraine and Adiponectin: Is There a Connection?

Migraine is a common disorder, characterized by recurrent episodes of headache and associated symptoms. The full pathophysiology of migraine is incompletely delineated. Current theories suggest that it is a neurovascular disorder involving cortical depression, neurogenic inflammation and vasodilation. Various neuropeptides and cytokines have been implicated in the pathophysiology of migraine including calcitonin gene-related peptide, interleukin (IL)-1, IL-6 and tumour necrosis factor (TNF)-α. There is evidence demonstrating an association between migraine and processes associated with inflammation, atherosclerosis, immunity and insulin sensitivity. Similarly, adiponectin, an adipocytokine secreted by adipose tissue, has protective roles against the development of insulin resistance, dyslipidaemia and atherosclerosis and exhibits anti-inflammatory properties. The anti-inflammatory activities of adiponectin include inhibition of IL-6 and TNF-induced IL-8 formation, as well as induction of the anti-inflammatory cytokines IL-10 and IL-1 receptor antagonist. Adiponectin levels are also inversely correlated with C-reactive protein (CRP), TNF-α and IL-6 levels. Likewise, recent studies have shown a possible correlation between CRP, TNF-α and IL-6 and migraine attacks. In addition, insulin sensitivity is impaired in migraine and obesity is a risk factor for the transformation from episodic to chronic migraine. In this review we discuss the basic science of adiponectin and its potential connection to the pathophysiology of migraine. Future research may focus on how adiponectin levels are potentially altered during migraine attacks, and how that information can be potentially translated into migraine therapy.

Childhood Abuse, Intimate Partner Violence and Risk of Migraine Among Pregnant Women: An Epidemiologic Study

OBJECTIVE

To examine the independent and joint associations of childhood abuse and intimate partner violence with migraine among pregnant women.

BACKGROUND

Childhood abuse and intimate partner violence have each been associated with migraine headaches in previous studies, but these associations have not been explored among pregnant women.

METHODS

A cross-sectional study was conducted among a cohort of 2970 pregnant women attending prenatal clinics in Lima, Peru. History of childhood abuse (ie, physical or sexual abuse) was assessed using the Childhood Physical and Sexual Abuse Questionnaire. Intimate partner violence (IPV) was assessed using the World Health Organization questionnaire. Migraine classification (including migraine and probable migraine) was based on International Classification of Headache Disorders (ICHD)-III beta criteria. Multivariable logistic regression analyses were performed to estimate odd ratios (OR) and 95% confidence intervals (95% CI).

RESULTS

The prevalence of any migraine was 33.5% while approximately 70% of participants reported a history of childhood abuse and 36.7% a history of IPV. Women with a history of any childhood abuse had a 38% increased odds of any migraine compared to women with no history of childhood abuse (OR = 1.38; 95% CI 1.15-1.64). The odds of migraine increased with increasing numbers of experienced childhood abuse events (Ptrend  < .001). Additionally, after adjusting for confounders women with a history of IPV had a 43% increased odds of any migraine as compared to women without intimate partner violence (OR = 1.43; 95%CI 1.02-2.02). Women with a joint positive history of childhood abuse and IPV, as compared with the reference group, had a 88% increased odds of migraine (aOR = 1.88, 95%CI: 1.51-2.35).

CONCLUSION

Childhood abuse and IPV are associated with increased odds of migraine in pregnant women. Our findings highlight the importance of screening for abuse among pregnant migraineurs to help guide treatment strategies.

Association of Migraine Headaches With Suicidal Ideation Among Pregnant Women in Lima, Peru

BACKGROUND

Suicide is a leading cause of maternal death globally, and suicide prevalence rates have been shown to be increased in those with migraine. No previous study has examined the association between migraine and suicidal ideation during pregnancy.

OBJECTIVE

To examine the association between migraine and suicidal ideation among a cohort of pregnant women.

METHODS

A cross-sectional study was conducted among 3372 pregnant women attending prenatal care clinics in Lima, Peru. Suicidal ideation and depression were assessed using the Patient Health Questionnaire-9 (PHQ-9) scale during early pregnancy. Migraine classification (including migraine and probable migraine) was based on International Classification of Headache Disorders-III beta criteria. Multivariable logistic regression analyses were performed to estimate odds ratios (OR) and 95% confidence intervals (95% CI).

RESULTS

Suicidal ideation was more common among those with migraine (25.6%) as compared to those with probable migraine (22.1%, P < .001) or non-migraineurs (12.3%, P < .001). After adjusting for confounders, including depression, those with migraine or probable migraine had a 78% increased odds of suicidal ideation (OR = 1.78; 95% CI: 1.46-2.17), as compared with non-migraineurs. Women with both migraine and depression had a 4.14-fold increased odds of suicidal ideation (OR = 4.14; 95% CI: 3.17-5.42) compared to those with neither condition.

CONCLUSION

Migraine is associated with increased odds of suicidal ideation in pregnant women even when controlling for depression. These findings support the consideration of screening women with comorbid migraine and depression for suicidal behavior during pregnancy.

Adipokines and Migraine: A Systematic Review

BACKGROUND

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

OBJECTIVES

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

METHODS

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

CONCLUSIONS

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

A Randomized Trial of Ketorolac vs. Sumatripan vs. Placebo Nasal Spray (KSPN) for Acute Migraine

OBJECTIVE

To compare the efficacy of ketorolac nasal spray (NS) vs. placebo and sumatriptan NS for the acute treatment of migraine.

METHODS

This was a randomized, double-blind, placebo and active-comparator, crossover study. Adult migraineurs were randomized to ketorolac NS 31.5 mg, sumatriptan NS 20 mg, or placebo to treat three moderate to severe migraine attacks and switched treatments with each attack. Patients seeking headache care at a headache center or in response to community advertisement were recruited. Adult participants with episodic migraine who experienced ≥2 migraine attacks per month were eligible for the Ketorolac vs. Sumatriptan vs. Placebo Nasal Spray migraine study. Participants were randomized to treatment arms by a research pharmacist, in a 1:1:1 ratio using computer-generated lists. The primary outcome was 2-hour pain relief. Secondary outcomes included 2-hour pain freedom and absence of migraine associated symptoms, and 24-hour sustained pain relief and pain freedom.

RESULTS

Of the 72 randomized participants, 54 (75%) treated at least one attack and 49 (68%) completed all three treatments, for a total of 152 treated migraine attacks. Both ketorolac NS (72.5%, P < .001) and sumatriptan NS (69.4%, P = .001) were more effective than placebo (38.3%) for 2-hour pain relief and 2-hour pain freedom (ketorolac: 43.1%, P = .004; sumatriptan: 36.7%, P = .046; placebo: 18.4%). Ketorolac NS, but not sumatriptan NS, was more effective than placebo in 2-hour absence of nausea. Both ketorolac NS and sumatriptan NS were more effective than placebo for 24-hour sustained pain relief (ketorolac: 49%, P < .001; sumatriptan: 31%, P = .01, placebo: 20%). Only ketorolac NS was superior to placebo for 24-hour (ketorolac: 35.3%, P = .003; sumatriptan: 22.4%, P = .18, placebo: 12.2%) sustained pain freedom. Nasal burning and dysgeusia were the most common adverse effects for active treatments.

CONCLUSIONS

This study supports that ketorolac NS is superior to placebo and that it is non-inferior to sumatriptan NS for the acute abortive treatment of migraine.

The Impact of Post-Traumatic Stress Disorder on the Burden of Migraine: Results From the National Comorbidity Survey-Replication

BACKGROUND

Post-traumatic stress disorder (PTSD) has been linked with migraine in prior studies.

OBJECTIVE

To evaluate the individual and joint burdens of migraine and PTSD in a population-based cohort.

METHODS

The National Comorbidity Survey-Replication (NCS-R) is a general population study conducted in the United States from February 2001-April 2003. PTSD and migraine were assessed, and four groups defined based on their migraine and PTSD status. The four groups included those with no migraine and no PTSD (controls, n=4535), those with migraine and without PTSD (migraine alone, n=236), those with PTSD and without migraine (PTSD alone, n=244), and those with both migraine and PTSD (mig+PTSD, n=68). Logistic and Poisson regression models were used to assess the association between dichotomous/multilevel outcome variables indicating financial, health, and interpersonal burdens and each migraine/PTSD group.

RESULTS

Compared to controls, those with Mig+PTSD were more likely to be in the low poverty index (48% vs 41%, AOR 2.16; CI: 1.10, 4.24) and were less likely to be working for pay or profit in the past week (50% vs 68%, AOR 0.42; CI: 0.24, 0.74) but not those with migraine or PTSD alone. Additionally, the number of days where work quality was cut due to physical or mental health or substance abuse in the past month was greater in all groups compared to controls: (1) migraine alone: mean 2.57 (SEM 0.32) vs mean 1.09 (SEM 0.08) days, ARR=2.39; CI: 2.19, 2.62; (2) PTSD alone: mean 2.43 (SEM 0.33) vs mean 1.09 (SEM 0.08) days, ARR=2.09; CI: 1.91, 2.29; (3) mig+PTSD: mean 8.2 (SEM 0.79) vs 1.09 (SEM 0.08) days, ARR 6.79; CI 6.16, 7.49; and was over 2.5-fold greater in those mig+PTSD than migraine alone (mean 8.0 [SEM 0.79] vs 2.6 days [SEM 0.72], ARR 2.77; CI: 2.45, 3.14). The likelihood of having difficulty getting along or maintaining a social life was also increased in all groups relative to controls: (1) migraine alone: 21% vs 5.4%, AOR 4.20; CI: 2.62, 6.74; (2) PTSD alone: 18% vs 5.4%, AOR 3.40; CI: 2.40, 4.82; (3) Mig+PTSD: 39% vs 5.4%, AOR 9.95; CI: 5.72, 17.32, and was 2-fold greater in those with Mig+PTSD as compared to those with migraine alone (AOR 2.32; CI: 1.15, 4.69).

CONCLUSIONS

These findings support the need for those who treat migraine patients to be aware of the comorbidity with PTSD, as these patients may be particularly prone to adverse financial, health, and interpersonal disease burdens.

Interictal, circulating sphingolipids in women with episodic migraine: A case-control study

OBJECTIVE

To evaluate interictal, circulating sphingolipids in women migraineurs.

METHODS

In the fasting state, serum samples were obtained pain-free from 88 women with episodic migraine (EM; n=52) and from controls (n=36). Sphingolipids were detected and quantified by high-performance liquid chromatography coupled with tandem mass spectrometry using multiple reaction monitoring. Multivariate logistic regression was used to examine the association between serum sphingolipids and EM odds. A recursive partitioning decision tree based on the serum concentrations of 10 sphingolipids was used to determine the presence or absence of EM in a subset of participants.

RESULTS

Total ceramide (EM 6,502.9 ng/mL vs controls 10,518.5 ng/mL; p<0.0001) and dihydroceramide (EM 39.3 ng/mL vs controls 63.1 ng/mL; p<0.0001) levels were decreased in those with EM as compared with controls. Using multivariate logistic regression, each SD increase in total ceramide (odds ratio [OR] 0.07; 95% confidence interval [CI]: 0.02, 0.22; p<0.001) and total dihydroceramide (OR 0.05; 95% CI: 0.01, 0.21; p<0.001) levels was associated with more than 92% reduced odds of migraine. Although crude sphingomyelin levels were not different in EM compared with controls, after adjustments, every SD increase in the sphingomyelin species C18:0 (OR 4.28; 95% CI: 1.87, 9.81; p=0.001) and C18:1 (OR 2.93; 95% CI: 1.55, 5.54; p=0.001) was associated with an increased odds of migraine. Recursive portioning models correctly classified 14 of 14 randomly selected participants as EM or control.

CONCLUSION

These results suggest that sphingolipid metabolism is altered in women with EM and that serum sphingolipid panels may have potential to differentiate EM presence or absence.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that serum sphingolipid panels accurately distinguish women with migraine from women without migraine.

Fasting lipid and lipoproteins concentrations in pregnant women with a history of migraine

BACKGROUND

Migraine is associated with a number of cardiometabolic risk factors including abnormalities in lipid metabolism. However, little is known about these associations among pregnant migraineurs. We conducted the present study to evaluate the extent to which altered lipid profiles are associated with history of migraine among pregnant women.

METHODS

A cohort of 1062 Peruvian women were interviewed at 24-28 weeks of gestation. Migraine status was classified based on the International Classification of Headache Disorders-II diagnostic criteria. Serum lipid concentrations were measured enzymatically using standardized assays. Multivariable logistic regression was used to estimate adjusted odds ratios (AORs) and 95% confidence intervals (CIs) as measures of associations of migraine status with varying concentrations of lipids and lipoproteins during pregnancy.

RESULTS

Approximately 18.5% of the study participants were identified as migraineurs (196 of 1062). Maternal serum total cholesterol, high-density lipoprotein (HDL), low-density lipoprotein (LDL), triglycerides, and total cholesterol : HDL ratio were all statistically significantly elevated among pregnant migraineurs compared with pregnant non-migraineurs. In multivariate adjusted models, pregnant women with migraine had higher odds of elevated total cholesterol, LDL, and total cholesterol : HDL ratio as compared with pregnant women without migraine. For instance, the AOR and 95% CI for successive quartiles of the total cholesterol associated with history of migraine were Q2 (219-247 mg/dL): 1.05 (0.64-1.70), Q3 (248-281 mg/dL): 1.16 (0.72-1.86), and Q4 (≥282 mg/dL): 1.87 (1.20-2.91) with the lowest quartile (<219 mg/dL) as the referent group (P value for trend = .003). Obese women with elevated total cholesterol (≥282 mg/dL) were more likely to be migraineurs (OR = 3.71; 95% CI 1.58-8.71) as compared with non-obese women with lower total cholesterol (<219 mg/dL). Similar elevated odds of migraine were observed for obese women with elevated LDL cholesterol, elevated triglycerides and high total cholesterol : HDL ratio.

CONCLUSION

Pregnant migraineurs had elevated odds of dyslipidemia, particularly hypercholesterolemia, elevated LDL, and total cholesterol : HDL ratio as compared with pregnant non-migraineurs. The observed associations were more pronounced among obese migraineurs. Our findings add to the accumulating evidence of adverse cardiometabolic risk profiles among migraineurs and extend these associations to pregnant women.

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

OBJECTIVE/BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Sleep disturbances and quality of life in Sub-Saharan African migraineurs

BACKGROUND

Although in the past decade occidental countries have increasingly recognized the personal and societal burden of migraine, it remains poorly understood in Africa. No study has evaluated the impact of sleep disturbances and the quality of life (QOL) in sub-Saharan Africans with migraine.

METHODS

This was a cross-sectional study evaluating adults, ≥ 18 years of age, attending outpatient clinics in Ethiopia. Standardized questionnaires were utilized to collect demographic, headache, sleep, lifestyle, and QOL characteristics in all participants. Migraine classification was based on International Classification of Headache Disorders (ICHD)-II criteria. The Pittsburgh Sleep Quality Index (PSQI) and the World Health Organization Quality of Life (WHOQOL-BREF) questionnaires were utilized to assess sleep quality and QOL characteristics, respectively. Multivariable logistic regression models were fit to estimate adjusted odds ratio (OR) and 95% confidence intervals (95% CI).

RESULTS

Of 1,060 participants, 145 (14%) met ICHD-II criteria for migraine. Approximately three-fifth of the study participants (60.5%) were found to have poor sleep quality. After adjustments, migraineurs had over a two-fold increased odds (OR = 2.24, 95% CI 1.49-3.38) of overall poor sleep quality (PSQI global score >5) as compared with non-migraineurs. Compared with non-migraineurs, migraineurs were also more likely to experience short sleep duration (≤7 hours) (OR = 2.07, 95% CI 1.43-3.00), long sleep latency (≥30 min) (OR = 1.97, 95% CI 1.36-2.85), daytime dysfunction due to sleepiness (OR = 1.51, 95% CI 1.12-2.02), and poor sleep efficiency (<85%) (OR = 1.93, 95% CI 1.31-2.88). Similar to occidental countries, Ethiopian migraineurs reported a reduced QOL as compared to non-migraineurs. Specifically Ethiopian migraineurs were more likely to experience poor physical (OR = 1.56, 95% CI 1.08-2.25) and psychological health (OR = 1.75, 95% CI 1.20-2.56), as well as poor social relationships (OR = 1.56, 95% CI 1.08-2.25), and living environments (OR = 1.41, 95% CI 0.97-2.05) as compared to those without migraine.

CONCLUSION

Similar to occidental countries, migraine is highly prevalent among Ethiopians and is associated with poor sleep quality and a lower QOL. These findings support the need for physicians and policy makers to take action to improve the quality of headache care and access to treatment in Ethiopia.

Adiponectin and leptin levels in migraineurs in the Atherosclerosis Risk in Communities Study

OBJECTIVE

To evaluate adiponectin and leptin levels in older men and women with migraine.

METHODS

Fasting total and high molecular weight (HMW) adiponectin and leptin levels were evaluated in a case-cohort study of nondiabetic older migraine and nonmigraine control participants from the ongoing, longitudinal, general population, Atherosclerosis Risk in Communities Study at visit 1 (1987-1989). A standardized headache questionnaire was completed at visit 3 (1993-1995). Logistic regression models adjusted for age, sex, race, center, body mass index, and fasting glucose were used to evaluate the association of each adipocytokine with migraine.

RESULTS

Of the 981 participants, the mean age at baseline was 52.8 years (SE 0.3); 131 fulfilled migraine criteria. Crude, mean total adiponectin levels were greater in men and women with migraine (8.1 µg/mL, SE 0.5) as compared to those without migraine (7.0 µg/mL, SE 0.2) (p = 0.031). After adjustments, the odds of migraine were increased by 88% with each SD increase in total adiponectin in men (odds ratio [OR] 1.86; 95% confidence interval [CI] 1.15, 3.01; p = 0.011), but not in women (OR 1.05; 95% CI 0.80, 1.37; p = 0.728; p interaction = 0.029). Similar results were demonstrated for HMW adiponectin. Crude and adjusted leptin levels were not associated with migraine.

CONCLUSIONS

Although crude, total adiponectin levels were higher in older men and women with migraine than controls, after adjustments, the prevalence of migraine was significantly associated with total adiponectin only in older men, suggesting the association may be confounded or absent in older women. Leptin was not associated with migraine in older men or women.

Objectively measured physical activity in obese women with and without migraine

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Obesity and headache: part I--a systematic review of the epidemiology of obesity and headache

Individually, both obesity and headache are conditions associated with a substantial personal and societal impact. Recent data support that obesity is comorbid with headache in general and migraine specifically, as well as with certain secondary headache conditions such as idiopathic intracranial hypertension. In the current manuscript, we first briefly review the epidemiology of obesity and common primary and secondary headache disorders individually. This is followed by a systematic review of the general population data evaluating the association between obesity and headache in general, and then obesity and migraine and tension-type headache disorders. Finally, we briefly discuss the data on the association between obesity and a common secondary headache disorder that is associated with obesity, idiopathic intracranial hypertension. Taken together, these data suggest that it is important for clinicians and patients to be aware of the headache/migraine-obesity association, given that it is potentially modifiable. Hypotheses for mechanisms of the obesity-migraine association and treatment considerations for overweight and obese headache sufferers are discussed in the companion manuscript, as part II of this topic.

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

BACKGROUND

Migraine is a common neurological disorder, ranked among the world's leading causes of years lived with disability by the World Health Organization. The burden of migraine is highest in women of reproductive age.

METHODS

We characterized the prevalence, symptoms, and correlates of migraine and other headaches among 500 women enrolled in a pregnancy cohort study. Migraine diagnoses (eg, definitive migraine and probable migraine) were based on the International Classification of Headache Disorders-II criteria. Headache-related disability, before and during early pregnancy, was determined using the Migraine Disability Assessment questionnaire. Logistic regression models were used to estimate adjusted odds ratios and 95% confidence intervals.

RESULTS

The lifetime prevalence of definitive migraine was 20.0% (95% confidence interval 16.6-23.8%). When probable migraine was included, the lifetime prevalence of any migraine (definitive migraine plus probable migraine) increased to 29.8% (95% confidence interval 25.9-34.0%). An additional 16.6% (95% confidence interval 13.5-20.2%) of women in the cohort were classified as having non-migraine headaches. Over 26% of migraineurs experienced moderate or severe headache-related disability during early pregnancy. Migraine headaches were associated with a family history of headache or migraine (odds ratio = 3.47; 95% confidence interval 2.14-5.63), childhood car sickness (odds ratio = 8.02; 95% confidence interval 4.49-14.35), pre-pregnancy obesity status (odds ratio = 3.83; 95% confidence interval 1.77-8.26), and a high frequency of fatigue (odds ratio = 2.01; 95% confidence interval 1.09-3.70).

CONCLUSION

Migraine- and headache-related disability are prevalent conditions among pregnant women. Diagnosing and treating migraine and headaches during pregnancy are essential.

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

Obesity and headache are both associated with a substantial personal and societal impact, and epidemiologic studies have consistently identified a positive association between obesity and headache in general, as well as obesity and migraine specifically (see part I). In the current manuscript, we will discuss the potential mechanisms for the migraine-obesity association, with a focus on the central and peripheral pathophysiological pathways which overlap between migraine and those modulating the drive to feed. We then discuss surgical, behavioral, and pharmacological treatment considerations for overweight and obese migraineurs as well as for those with idiopathic intracranial hypertension. We close by briefly discussing where future research may be headed in light of this data.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Episodic migraine and obesity and the influence of age, race, and sex

OBJECTIVE

To evaluate the episodic migraine (EM)-obesity association and the influence of age, race, and sex on this relationship.

METHODS

We examined the EM-obesity association and the influence of age, race, and sex in 3,862 adult participants of both black and white race interviewed in the National Comorbidity Survey Replication. EM diagnostic criteria were based on the International Classification of Headache Disorders. Body mass index was classified as underweight (<18.5 kg/m(2)), normal (18.5-24.9 kg/m(2)), overweight (25-29.9 kg/m(2)), or obese (≥30 kg/m(2)). Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for EM were estimated using logistic regression. Models were stratified by age (<50/≥50 years), race (white/black), and sex (male/female).

RESULTS

A total of 188 participants fulfilled criteria for EM. In all participants, the adjusted odds of EM were 81% greater in individuals who were obese compared with those of normal weight (OR 1.81; 95% CI: 1.27-2.57; p = 0.001), with a significant trend of increasing odds of EM with increasing obesity status from normal weight to overweight to obese (p = 0.001). In addition, stratified analyses demonstrated that the odds of EM were greater in obese as compared with normal-weight individuals who were 1) younger than 50 years of age (OR 1.86; 95% CI: 1.20-2.89; p for trend = 0.008), 2) white (OR 2.06; 95% CI: 1.41-3.01; p for trend ≤0.001), or 3) female (OR 1.95; 95% CI: 1.38-2.76; p for trend ≤0.001).

CONCLUSION

The odds of EM are increased in those with obesity, with the strongest relationships among those younger than 50 years, white individuals, and women.

Migraine and the social selection vs causation hypotheses: a question larger than either/or?

For decades, the question of social selection vs social causation has been raised by public health researchers and social scientists to explain the association between socioeconomic factors and mood disorders.(1,2) The social selection or "downward drift" theory postulates that the disease itself limits an individual's educational and occupational achievements, leading to a lower socioeconomic status (SES). In contrast, the social causation hypothesis suggests that factors associated with low SES (e.g., stressful life events, poor health care access) increase the likelihood of disease onset or prolonged disease duration.(3,4) Simply stated, the end result of each hypothesis is as follows:

Migraine and white matter hyperintensities: the ARIC MRI study

OBJECTIVE

Migraine is associated with white matter hyperintensities (WMH) cross-sectionally, but its effect on WMH progression is uncertain.

METHODS

Participants in the Atherosclerosis Risk in Communities cohort study (n = 10,924) completed a standardized headache questionnaire between 1993 and 1995. A subset of participants (n = 1,028) received 2 MRIs 8 to 12 years apart: once at the time of headache ascertainment, and again from 2004 to 2006. WMH were quantified using both a visually graded score (0-9) and semiautomated volumetric analysis. Linear and logistic regression models adjusted for age, sex, and other vascular risk factors were constructed.

RESULTS

Individuals who had migraine without aura were cross-sectionally associated with an 87% greater odds of having a WMH score ≥3 than individuals without headache (adjusted odds ratio = 1.87; 95% confidence interval [CI]: 1.04, 3.37). Participants with migraine had an average of 2.65 cm(3) more WMH than those without headache (95% CI: 0.06, 5.24). However, there was no significant difference in WMH progression over the study period between individuals with and without migraine (1.58 cm(3) more progression for individuals with migraine compared to those without; 95% CI: -0.37, 3.53).

CONCLUSION

Migraine is associated with WMH volume cross-sectionally but not with WMH progression over time. This suggests that the association between migraine and WMH is stable in older age and may be primarily attributable to changes occurring earlier in life, although further work is needed to confirm these findings.

Chemical mediators of migraine: preclinical and clinical observations

Migraine is a neurovascular disorder, and although the pathophysiology of migraine has not been fully delineated, much has been learned in the past 50 years. This knowledge has been accompanied by significant advancements in the way migraine is viewed as a disease process and in the development therapeutic options. In this review, we will focus on 4 mediators (nitric oxide, histamine, serotonin, and calcitonin gene-related peptide) which have significantly advanced our understanding of migraine as a disease entity. For each mediator we begin by reviewing the preclinical data linking it to migraine pathophysiology, first focusing on the vascular mechanisms, then the neuronal mechanisms. The preclinical data are then followed by a review of the clinical data which support each mediator's role in migraine and highlights the pharmacological agents which target these mediators for migraine therapy.

Sex matters: evaluating sex and gender in migraine and headache research

Significant sex differences exist in migraine and other headache disorders. Several hypotheses have been proposed to explain these differences, including fluctuations in sex hormones and receptor binding, genetic factors, differences in exposure to environmental stressors, as well as differences in response to stress and pain perception; but how valid are some of these findings and can we improve the quality of research in this field? It is notable that the preponderance of animal pain studies use male subjects to study a predominantly female disorder. Furthermore, with respect to headache and migraine sex differences, limited data have been derived from animal models. Additionally, although sex differences (based on the categorization of male vs female) may be more routinely evaluated in clinical headache research than in the basic science research, greater attention to potential differences across the life cycle of women (ie, premenopausal vs postmenopausal differences) and menstrual cycle is warranted. In this manuscript we define the differences between "sex" and "gender" and highlight the importance of their application and use in headache research. The enhanced recognition and implementation of attention to sex differences throughout the hormonal and life-cycle phase in both human and animal research will only help to strengthen and further our understanding of migraine and may help guide the direction of future headache research.

Use of common migraine treatments in breast-feeding women: a summary of recommendations

BACKGROUND

Breast-feeding has important health and emotional benefits for both mother and infant, and should be encouraged. While there are some data to suggest migraine may improve during breast-feeding, more than half of women experience migraine recurrence with 1 month of delivery. Thus, a thorough knowledge base of the safety and recommended use of common acute and preventive migraine drugs during breast-feeding is vital to clinicians treating migraine sufferers. Choice of treatment should take into account the balance of benefit and risk of medication. For some of the medications commonly used during breast-feeding, there is not good evidence about benefits.

METHODS

A list of commonly used migraine medications was agreed upon by the 6 authors, who treat migraine and other headaches on a regular basis and are members of the Women's Special Interest Section of the American Headache Society. Each medication was researched by the first author utilizing widely accepted data sources, such as the American Academy of Pediatrics publication "The Transfer of Drugs and Other Chemicals Into Human Milk; Thomas Hale's manual Medications and Mothers Milk; Briggs, Freeman, and Yaffe's reference book Drugs in Pregnancy and Lactation; and the National Library of Medicine's Drugs and Lactation Database (LactMed) - a peer-reviewed and fully referenced database available online.

RESULTS

Many commonly used migraine medications may be compatible with breast-feeding based on expert recommendations. Ibuprofen, diclofenac, and eletriptan are among acute medications with low levels in breast milk, but studies of triptans are limited. Toxicity is a concern with aspirin due to an association with Reye's syndrome; sedation or apnea is a concern with opioids. Finally, preventive medications not recommended include zonisamide, atenolol, and tizanidine.

CONCLUSIONS

Several excellent resources are available for clinicians making treatment decisions in breast-feeding women. Clinicians treating migraine should discuss both acute and preventive treatment options shortly before and within a few months after delivery, keeping in mind the clinical features of the individual patient, and in consultation with their obstetrician and pediatrician. An awareness of the pharmacological data that are currently available and how to access that data may be helpful in making treatment decisions in this population.

Ictal adiponectin levels in episodic migraineurs: a randomized pilot trial

OBJECTIVE

To assess ictal adiponectin (ADP) levels before and after acute abortive treatment in women episodic migraineurs.

METHODS

Peripheral blood specimens were collected from women episodic migraineurs before and after acute abortive treatment with sumatriptan/naproxen sodium vs placebo. Univariate and multivariate models were utilized to examine the relationship between serum total ADP (T-ADP), ADP oligomers (high molecular weight [HMW], middle molecular weight, and low molecular weight [LMW]-ADP), and ADP ratio levels and pain severity. Paired t-tests and random intercept longitudinal models were utilized to assess the mean changes in T-ADP, ADP oligomers, and ratios over time in treatment responders and nonresponders.

RESULTS

Twenty participants (11 responders, 9 nonresponders) have been studied to date. In all participants, increases in the HMW : LMW ADP ratio were associated with an increase in pain severity. For every 1 point increase in the HMW : LMW ratio, pain severity increased by 0.22 (Confidence Interval [CI]: 0.07, 0.37; P = .004). In contrast, for every 0.25 μg/mL increase in LMW-ADP, pain severity decreased by 0.20 (CI: -0.41, -0.002; P = .047). In treatment responders, T-ADP levels were reduced at 30 minutes (12.52 ± 3.4; P = .03), 60 minutes (12.32 ± 3.2; P = .017), and 120 minutes (12.65 ± 3.2; P = .016) after treatment as compared with onset (13.48 ± 3.8). Additionally, in responders, the HMW : LMW ratio level was greater at pain onset (3.70 ± 1.9 μg/mL) as compared with nonresponders (2.29 ± 0.71 μg/mL), P = .050. Responders also showed a decrease in the HMW : LMW ratio at 60 minutes (2.37 ± 1.1; P = .002) and 120 minutes (2.76 ± 1.4; P = .02) after treatment as compared with onset (3.70 ± 1.9). These changes in responders remained significant after adjusting for covariates, including measured body mass index (m-BMI). Although nonresponders showed no significant changes in unadjusted T-ADP or ADP oligomer or ratio levels, the HMW : LMW ratio was increased in nonresponders after adjustments (P = .025).

CONCLUSION

In this pilot study of women episodic migraineurs, the HMW : LMW ADP ratio level was associated with migraine severity and predictive of acute treatment response. ADP and the HMW : LMW ratio of ADP represent potential novel biomarkers and drug targets for episodic migraine.

Migraine and psychiatric comorbidities among sub-saharan african adults

BACKGROUND

Despite being a highly prevalent disorder and substantial cause of disability, migraine is understudied in Africa. Moreover, no previous study has investigated the effects of stress and unipolar psychiatric comorbidities on migraine in a sub-Saharan African cohort.

OBJECTIVE

To evaluate the prevalence of migraine and its association with stress and unipolar psychiatric comorbidities among a cohort of African adults.

METHODS

This was a cross-sectional epidemiologic study evaluating 2151 employed adults in sub-Saharan Africa. A standardized questionnaire was used to identify sociodemographic, headache, and lifestyle characteristics of participants. Migraine classification was based on the International Classification of Headache Disorders-2 diagnostic criteria. Depressive, anxiety, and stress symptoms were ascertained with the Patient Health Questionnaire and the Depression Anxiety Stress Scale, respectively. Multivariable logistic regression models were used to estimate adjusted odds ratio (OR) and 95% confidence intervals (CIs).

RESULTS

A total of 9.8% (n=212) of study participants fulfilled criteria for migraine (9.8%, 95% CI 8.6-11.1) with a higher frequency among women (14.3%, 95% CI 11.9-16.6) than men (6.9%, 95% CI 5.5-8.3). Similar to predominantly Caucasian migraine cohorts, sub-Saharan African migraineurs were more likely to be younger, have a lower education, and more likely to report a poor health status than non-migraineurs. However, in contrast with historical reports in predominantly Caucasian migraine cohorts, sub-Saharan African migraineurs were less likely to report smoking than non-migraineurs. Participants with moderately severe depressive symptoms had over a 3-fold increased odds of migraine (OR=3.36, 95% CI 1.30-8.70) compared with those classified as having minimal or no depressive symptoms, and the odds of migraine increased with increasing severity of depressive symptoms (P trend<0.001). Similarly, those with mild, moderate, and severe anxiety symptoms had increased odds of migraine (OR=2.28, 95% CI 1.24-4.21; OR=1.77, 95% CI 0.93-3.35; and OR=5.39, 95% CI 2.19-13.24, respectively). Finally, those with severe stress had a 3.57-fold increased odds of migraine (OR=3.57, 95% CI 1.35-9.46).

CONCLUSION

Although historically it has been reported that migraine prevalence is greater in Caucasians than African Americans, our study demonstrates a high migraine prevalence among urban-dwelling Ethiopian adults (9.9%) that is comparable with what is typically reported in predominantly Caucasian cohorts. Further, among employed sub-Saharan African adults and similar to predominantly Caucasian populations, migraine is strongly associated with stress and unipolar psychiatric symptoms. The high burden of migraine and its association with stress and unipolar psychiatric symptoms in our study of well-educated and urban-dwelling African adults has important clinical and public health implications pending confirmation in other African populations.