The Association Between Periodontal Disease and Chronic Migraine: A Systematic Review

Migraine is a neurologic illness that produces intense throbbing pain on one side of the head and affects roughly 1 billion people worldwide. Recent research indicates a relationship between periodontitis and chronic migraines. This study aimed to review the association between chronic migraines and periodontitis through a systematic literature review. Four research databases (Google Scholar, PubMed, ProQuest, and SpringerLink) were searched according to PRISMA guidelines to retrieve the studies included in this review. A search strategy was developed to answer the study question with appropriate inclusion and exclusion criteria. Out of 34 published studies, 8 studies were included in this review. Three of the studies were cross-sectional, 3 were case-control, and 2 were clinical report and medical hypothesis papers. Seven of the 8 included studies showed that there is an association between periodontal disease and chronic migraine. The elevated blood levels of some biomarkers such as leptins, ProCalcitonin (proCT), calcitonin gene-related peptides (CGRPs), Pentraxin 3 (PTX3), and Soluble Tumor Necrosis Factor-like Weak Inducer Of Apoptosis (sTWEAK) play a significant role in this association. The limitations include a small sample size, the influence of anti-inflammatory drugs, and a self-reported headache measure that is subject to misclassification bias. This systematic review reveals a supposed correlation between periodontal disease and chronic migraine, as evidenced by various biomarkers and inflammatory mediators. This suggests that periodontal disease could potentially contribute to the development of chronic migraine. However, to further assess the potential benefits of periodontal treatment in patients with chronic migraine, additional longitudinal studies with larger sample sizes and interventional studies are needed.

On the impairment of executive control of attention in chronic tinnitus: Evidence from the attention network test

Subjective, chronic tinnitus is a condition that is common in most populations. Whereas many individuals tend to habituate to tinnitus over time, for some their attention seems pathologically drawn towards the sensation. For this subgroup of individuals with severe tinnitus, dysfunctional executive attention has been suggested to be implicated in the failure to habituate. However, since most previous studies have used attention tests with low validity and specificity in this assessment, there is a need for further corroborating studies. In the present study, the Attention Network Test was used to compare mainly the efficiency of executive attention between a group of individuals with chronic tinnitus (TG; n = 33) and a healthy control group (CG; n = 37). The results showed that individuals with chronic tinnitus, compared to the CG, did not present with a specific impairment in executive control of attention, nor in any of the other two attention domains. These findings are discussed in relation to the sampling characteristics in this study, which might have led to the sample being more homogenous and high functioning than samples in tinnitus studies generally. Overall, this study suggests that tinnitus and executive control of attention impairment might not be directly related, and that the latter might not necessarily be associated with the maintenance of the condition.

Pain chronification and the important role of non-disease-specific symptoms in patients with systemic sclerosis

Background

Pain is a frequent, yet inadequately explored challenge in patients with systemic sclerosis (SSc). This study aimed to conduct an extensive pain assessment, examining pain chronification and its association with disease manifestations.

Methods

Consecutive SSc patients attending their annual assessment were included. SSc-specific features were addressed as defined by the European Scleroderma Trials and Research (EUSTAR) guidelines. Pain analysis included intensity, localization, treatment, chronification grade according to the Mainz Pain Staging System (MPSS), general well-being using the Marburg questionnaire on habitual health findings (MFHW) and symptoms of anxiety and depression using the Hospital Anxiety and Depression Scale (HADS).

Results

One hundred forty-seven SSc patients completed a pain questionnaire, and 118/147 patients reporting pain were included in the analysis. Median pain intensity was 4/10 on a numeric rating scale (NRS). The most frequent major pain localizations were hand and lower back. Low back pain as the main pain manifestation was significantly more frequent in patients with very early SSc (p = 0.01); those patients also showed worse HADS and MFHW scores. Regarding pain chronification, 34.8% were in stage I according to the MPSS, 45.2% in stage II and 20.0% in stage III. There was no significant correlation between chronification grade and disease severity, but advanced chronification was significantly more frequent in patients with low back pain (p = 0.024). It was also significantly associated with pathological HADS scores (p < 0.0001) and linked with decreased well-being and higher use of analgesics.

Conclusions

Our study implies that also non-disease-specific symptoms such as low back pain need to be considered in SSc patients, especially in early disease. Since low back pain seems to be associated with higher grades of pain chronification and psychological problems, our study underlines the importance of preventing pain chronification in order to enhance the quality of life.

[Targeted treatment of posttraumatic disorders-what can confrontation therapy achieve?]

Confrontation with aversive trauma symptoms is a key element in the treatment of stress-associated disorders, especially posttraumatic stress disorder. It is aimed at working through and reattributing aversive memories and situations. Various techniques enable confrontation in sensu (i.e. imagined) and in vivo (in reality). Confrontation techniques are highly effective; however, since there is a risk of temporarily enhanced, possibly previously suppressed traumatic memories, confrontation must be carefully prepared and revised.

Searching for Predictors of Migraine Chronification: a Pilot Study of 1911A>G Polymorphism of TRPV1 Gene in Episodic Versus Chronic Migraine

Transient receptor potential vanilloid type 1 (TRPV1) receptors activated by heat and capsaicin are expressed in trigeminal nociceptive neurons and implicated in the generation of migraine pain. Genetic studies suggested that single-nucleotide polymorphism (SNP) 1911A>G (rs8065080), leading to amino acid substitution Ile585Val, in the TRPV1 gene affects functional activity of TRPV1 receptors and is involved in different pain conditions. However, this polymorphism has not been tested in migraine patients. The objective of this pilot study was to investigate genetic factors of migraine susceptibility. We evaluated frequency distribution of AA, AG, and GG variants of SNP 1911A>G in the TRPV1 gene in patients with episodic and chronic migraine compared with healthy individuals. The study included 46 patients diagnosed with migraine (27 episodic and 19 chronic) and 50 healthy individuals as a control group. DNA from peripheral blood was used to test TRPV1 SNP using allele-specific PCR combined with gel electrophoresis. The genotype frequency distribution in episodic migraine was comparable with that in controls (AA 33%, AG 56%, GG 11% and AA 34%, AG 46%, GG 20%, respectively). On the contrary, in chronic migraine, the distribution differed significantly (p < 0.05) (AA 68%, AG 32%, GG 0%). This are first indications for a distinctive genotype frequency distribution of TRPV1 1911A>G in chronic migraine patients compared with episodic migraine patients and controls. Our data confirm a different predisposition to chronic pain in migraine and give a prerequisite for a new look at the nature of chronification of migraine, proposing that the absence of GG genotype may be considered as possible risk biomarker of episodic migraine evolution to chronic form.

Compare and contrast: pediatric cancer versus adult malignancies

Cancer is a leading cause of death in both adults and children, but in terms of absolute numbers, pediatric cancer is a relatively rare disease. The rarity of pediatric cancer is consistent with our current understanding of how adult malignancies form, emphasizing the view of cancer as a genetic disease caused by the accumulation and selection of unrepaired mutations over time. However, considering those children who develop cancer merely as stochastically "unlucky" does not fully explain the underlying aetiology, which is distinct from that observed in adults. Here, we discuss the differences in cancer genetics, distribution, and microenvironment between adult and pediatric cancers and argue that pediatric tumours need to be seen as a distinct subset with their own distinct therapeutic challenges. While in adults, the benefit of any treatment should outweigh mostly short-term complications, potential long-term effects have a much stronger impact in children. In addition, clinical trials must cope with low participant numbers when evaluating novel treatment strategies, which need to address the specific requirements of children.

[Current aspects of pain management during and after dermatologic surgery]

The project "Pain-free Hospital" was the first attempt to improve the level of postoperative care by standardizing pain therapy standards (concepts) in the individual surgical disciplines. Dermatosurgery is no exception. In addition to drug therapy, it is also important to consider biopsychosocial aspects of the symptom pain, as this is the only way to prevent chronification of acute pain in the further course of a disease. Drug therapy should not only be adapted to the classic WHO system (only considering pain intensity), but should also address aspects of pain quality. In this article, we discuss these aspects in more detail and present our treatment concept for dermatosurgery.

Machine-learning-derived classifier predicts absence of persistent pain after breast cancer surgery with high accuracy

Background

Prevention of persistent pain following breast cancer surgery, via early identification of patients at high risk, is a clinical need. Supervised machine-learning was used to identify parameters that predict persistence of significant pain.

Methods

Over 500 demographic, clinical and psychological parameters were acquired up to 6 months after surgery from 1,000 women (aged 28–75 years) who were treated for breast cancer. Pain was assessed using an 11-point numerical rating scale before surgery and at months 1, 6, 12, 24, and 36. The ratings at months 12, 24, and 36 were used to allocate patents to either “persisting pain” or “non-persisting pain” groups. Unsupervised machine learning was applied to map the parameters to these diagnoses.

Results

A symbolic rule-based classifier tool was created that comprised 21 single or aggregated parameters, including demographic features, psychological and pain-related parameters, forming a questionnaire with “yes/no” items (decision rules). If at least 10 of the 21 rules applied, persisting pain was predicted at a cross-validated accuracy of 86% and a negative predictive value of approximately 95%.

Conclusions

The present machine-learned analysis showed that, even with a large set of parameters acquired from a large cohort, early identification of these patients is only partly successful. This indicates that more parameters are needed for accurate prediction of persisting pain. However, with the current parameters it is possible, with a certainty of almost 95%, to exclude the possibility of persistent pain developing in a woman being treated for breast cancer.

Electronic supplementary material

The online version of this article (10.1007/s10549-018-4841-8) contains supplementary material, which is available to authorized users.

Association between periodontitis and chronic migraine: a case-control study

The aim of this investigation was to examine whether chronic periodontitis (CP) is a risk indicator of chronic migraine (CM). We performed a case-control study consisted of 102 cases (patients diagnosed with CM) and 91 controls (non-CM individuals) matched by age and gender. Full-mouth periodontal charts, demographic, medical, clinical, as well as neurological data were obtained. In addition, high sensitive C-reactive protein serum levels were determined from blood samples of both cases (taken during migraine interictal period) and controls. The prevalence of CP was significantly higher in patients with CM compared to those without CM (58.8 vs. 30.8%, p < 0.0001). Logistic regression analysis showed that CP was significantly associated with the presence of CM, independently of well-known chronifying factors of migraine (OR 2.4; 95% CI 1.2-4.7; p = 0.012). Based on our results, CP could be considered as a risk indicator of CM. However, more evidence is necessary to investigate if this relationship is causal or not.

Periodontal disease as a potential factor of migraine chronification

Migraine is a hereditary constitutional base disorder, which is characterized by recurrent episodes of headache pulsatile characteristics associated with photophobia/phonophobia, nausea and/or vomiting. The main complication in migraine is the chronicity of the process, now recognized as a chronic migraine. Although pathogenic mechanisms that may influence the pathophysiology of migraine and its possible chronicity are not fully understood, previous studies have shown in patients with migraine molecular alterations of systemic inflammation, neurogenic inflammation, endothelial dysfunction, innate immunity, dysfunction of matrix proteases and blood-brain barrier. Periodontal disease is an inflammatory lesion caused by bacteria. After the bacterial infection begins, an immune response that will be responsible for individual susceptibility appears. More advanced forms of periodontitis have demonstrated molecular alterations of inflammation, endothelial dysfunction, dysfunction of matrix proteases and innate immunity, similar to those observed in migraine. Furthermore, the main molecular mediators of neurogenic inflammation related to activation of the trigeminovascular system, which are characteristic of migraine, are overexpressed in gingival crevicular fluid and mucosa in patients with periodontal disease. Hypertension, hypercholesterolemia, insulin resistance, stroke or coronary artery disease are comorbidities that periodontal disease and migraine could share. Therefore, several mechanisms and hypotheses could explain the possible association between both diseases. However, epidemiological and molecular studies will be necessary to provide a better understanding of this potential association, which could be implicated in the chronification of migraine.

A proposal for the organization of the referral of patients with chronicnon-specific low back pain

Low back pain in general and specifically chronic low back pain forms a major burden for the patient and society. Recently studies demonstrated that up to 65% of patients evolve to chronic pain as opposed to the previously accepted 8%. As low back pain patients present first with their general practitioner, the latter should establish a treatment plan, including the appropriate referrals. There are, however, no clear guidelines as to how to refer low back pain patients. The process of trial and error of different specialties and treatment possibilities often results in a long and costly trajectory. A better understanding of the subtypes of chronic low back pain, the risks for chronification and fast adequate referral may result in higher patient satisfaction and cost reduction. Proposed solutions: We propose a classification system based on the clinical and anatomical characteristics of axial low back pain, separated from radicular pain. It is important to recognize the risks for chronification, such as degenerative and/or herniated disk, a smaller cross-sectional area of the multifidus, erector spinae, and psoas muscles and psychological and social factors, to be able to provide appropriate management. Also stratification of the patients according to the degree of disability may help in defining the correct treatment approach. A one-and-a-half line approach, where a spine physician assistant works under the supervision of the general practitioner to establish the sub-diagnosis, the risk factors for chronicity and to explain the proposed management plan to the patient, may be helpful for an early appropriate treatment selection for the patient with chronic low back pain.

A new model of nerve injury in the rat reveals a role of Regulator of G protein Signaling 4 in tactile hypersensitivity

Tactile hypersensitivity is one of the most debilitating symptoms of neuropathic pain syndromes. Clinical studies have suggested that its presence at early postoperative stages may predict chronic (neuropathic) pain after surgery. Currently available animal models are typically associated with consistent tactile hypersensitivity and are therefore limited to distinguish between mechanisms that underlie tactile hypersensitivity as opposed to mechanisms that protect against it. In this study we have modified the rat model of spared nerve injury, restricting the surgical lesion to a single peripheral branch of the sciatic nerve. This modification reduced the prevalence of tactile hypersensitivity from nearly 100% to approximately 50%. With this model, we here also demonstrated that the Regulator of G protein Signaling 4 (RGS4) was specifically up-regulated in the lumbar dorsal root ganglia and dorsal horn of rats developing tactile hypersensitivity. Intrathecal delivery of the RGS4 inhibitor CCG63802 was found to reverse tactile hypersensitivity for a 1h period. Moreover, tactile hypersensitivity after modified spared nerve injury was most frequently persistent for at least four weeks and associated with higher reactivity of glial cells in the lumbar dorsal horn. Based on these data we suggest that this new animal model of nerve injury represents an asset in understanding divergent neuropathic pain outcomes, so far unravelling a role of RGS4 in tactile hypersensitivity. Whether this model also holds promise in the study of the transition from acute to chronic pain will have to be seen in future investigations.

Advancing the Pain Agenda in the Veteran Population

The Veterans Health Administration (VHA) provides medical care for Veterans after leaving the military. The combination of multiple deployments and battlefield exposures to physical and psychological trauma results in a higher prevalence and complexity of chronic pain in Veterans than in the general public. The VHA and the Department of Defense work together to develop a single standard of stepped pain management appropriate for all settings from moment of injury or disease onset. This article describes the education, academic detailing, and clinical programs and policies that are transforming pain care in the VHA.

Phenotypic features of chronic migraine

BACKGROUND

Chronic migraine is a disabling, under-recognized, and undertreated disorder that increases health burdens. The aim of this study was to evaluate phenotypic features and the relevance of accompanying symptoms of migraine attacks in chronic migraine.

METHOD

This study was conducted as part of an ongoing Turkish Headache Database Study investigating the clinical characteristics and outcomes of headache syndromes in the Turkish population. The electronic database was examined retrospectively, and 835 patients with chronic migraine were included.

RESULTS

Patient group consisted of 710 women and 125 men (85 and 15 %, respectively). Mean patient age was 36.8 ± 13.5 years, median value of migraine onset was 60 months (18-120), median headache frequency was 25 days per month (16-30), median of attack duration was 12 h (4-24), and median of intensity was eight (7-9). Increasing headache days per month were inversely related with the presence of nausea, vomiting, phonophobia, and photophobia. Longer duration of headache (months) and higher visual analog scale (VAS) for headache intensity were associated with all accompanying symptoms. Phonophobia, nausea, photophobia, and vomiting were the most frequent accompanying symptoms (experienced by 80.2, 77.6, 71.2, and 40.9 % of patients, respectively). Osmophobia was also frequent in chronic migraine patients (53.4 %) and was closely associated with other accompanying symptoms. Vertigo and dizziness were observed less frequently, and they were not associated with accompanying symptoms.

CONCLUSION

Phenotype of chronic migraine may be associated with the course of chronification. Duration of illness and attack intensity were closely related with the presence of accompanying symptoms, although headache frequency was found to be inversely related to the presence of accompanying symptoms. Osmophobia was also a frequent symptom and was closely related with other accompanied symptoms, unlike vertigo and dizziness. Inclusion of osmophobia into the diagnostic criteria might improve accurate diagnosis of chronic migraine.

Parameters of low back pain chronicity among athletes: Associations with physical and mental stress

OBJECTIVE

In the general population, physical and mental stress factors are linked to chronic low back pain (LBP). The aim of the present study was to examine this association among athletes.

DESIGN

Longitudinal study with a six-month interval between measurements.

SETTING

Questionnaires were filled out at home, either in paper-pencil version or online.

PARTICIPANTS

Eighty-two male and 57 female athletes (N = 139, MAge = 32.24) who exercise on a competitive (n = 102) or recreational level (n = 37), with a weekly training volume of at least 3 h.

MAIN OUTCOME MEASURES

At T0, stress parameters were assessed via the Recovery-Stress Questionnaire (RESTQ-Basic-48) and the Screening Scale of the Trier Inventory for the Assessment of Chronic Stress (TICS-SSCS). At T0 and T1, different chronification indicators were measured. Based on these assessments, the sample was split into a chronification and no-chronification group.

RESULTS

ANCOVAs were used to conduct group comparisons with regard to stress levels. The chronification groups showed higher stress values for all chronification indicators. For the variables Physical Complaints and Overall Stress-TICS, the group differences became significant (p < .05).

CONCLUSION

A relationship between stress parameters and LBP chronification was demonstrated among athletes for the first time.

A systematic review based on factors leading to the chronification of pain (part C)

INTRODUCTION

Beyond initial lesions, any form of spinal (re)operation can cause direct potential aggression to the nervous system by contact with neural tissue or by imprinting a morphological change on the neural tissue. The potential consequences of nerve root injury affect both peripheral and axial dermatomal distribution. The hypothesis of a possible neuropathic aspect associated with the back pain component of failed back surgery syndrome (FBSS) therefore appears to be reasonable. Its pathophysiology remains unclear due to the permanent interplay between nociceptive and neuropathic pain components, resulting in the coexistence of physiological and pathological pain at the same anatomical site. This paper is designed to extensively review the fundamental mechanisms leading to chronification of pain and to suggest considering the emerging concept of "neuropathic back pain".

METHODS

Literature searches included an exhaustive review of 643 references and 74 book chapters updated by searching the major electronic databases from 1930 to August 2013.

RESULTS

Inflammatory and neuropathic back pain could be distinguished from pure nociceptive pain as a result of an increased activity and responsiveness of sensitized receptors at the peripheral nervous system and also as a consequence of increased afferent inflow to the central nervous system, moving to a new, more excitable "wind-up" state. This can be clinically translated to an amplified response to a moderate/intense stimulus (primary hyperalgesia) or an aversive sensation provoked by the activation of low-threshold mechanoreceptors through non-noxious stimuli, which defines allodynia. Activated non-neuronal cells including microglia have been found to be cellular intermediaries in mechanical allodynia. Major changes in the spinal cord are the loss of inhibitory mechanisms, resulting in an increased activity of interneurons or projection neurons and a structural reorganization of the central projection pattern. This abnormal excitability of sensory neurons is coupled to changes in the neurotransmitter phenotype, which could induce a resistance to conventional analgesic treatments.

CONCLUSION

A clear understanding of the factors leading to the chronification of back pain should help us to move to the choice of mechanism related pain treatments to improve outcomes in FBSS chronic condition.