by admin | Jun 11, 2011 | Comorbidity
Patent Foramen Ovale and Migraine
Patent foramen ovale is a form of heart defect—sometimes called a “hole in the heart.” The foramen ovale permits fetal circulation to bypass the lungs in yet-to-be-born babies, and closes at the time of birth to permit blood flow to the lungs. Occasionally, the foramen ovale does not close all the way after birth, and is thus patent, or open. The size of the opening varies in a PFO (patent foramen ovale), and those that are more open can cause more difficulty.
A patent foramen ovale can predispose you to stroke. Patent foramen ovale is also more common in people who have migraine with aura, about twice as common as in the general population. People with PFO also have a higher rate of migraine with aura.
Why are PFO and migraine with aura connected? One theory is that if there is shunting of blood from the right side of the heart to the left because of a PFO, less blood goes through the lungs to be filtered. This results in a higher level of migraine triggers in venous blood, although it is not clear if those are activated platelets (which contain serotonin) or other chemical triggers. It is not clear, however, if this is the cause, or if the association is non-causative, such as coexistence of the two conditions because both were inherited. In larger PFOs, and a related condition called ASD (anteroseptal defect), there is autosomal dominant inheritance.
About 25-27% of the general population has a patent foramen ovale. The rate is higher in migraine with aura.
Should PFO Be Treated?
Whether PFO in migraine should be treated with closure is not clear. There are several devices that can be inserted via cardiac catheter to close the hole. Several studies have suggested that closure might result in a reduction of migraine attacks. However, there have been flaws in the way these studies were done. Until further studies determine that the benefits of closure outweigh the risks, closure of patent foramen ovale is not recommended.
references:
1. Wilmshurst P, Nightingale S. Relationship between migraine and cardiac and pulmonary right- to-left shunts. Clinical Science 2001;100:215-220.
2. Wilmshurst P, Pearson M, Nightingale S. Re-evaluation of the relationship between migraine and persistent foramen ovale and other right-to-left shunts. Clinical Science 2005;108:365-367.
3. Post MC, Thijs V, Herroelen L, Budts WIHL. Closure of a patent foramen ovale is associated with a decrease in prevalence of migraine. Neurology 2004;62:1439-1440.
4. Schwerzmann W, Wiher S, Nedeltchev K, et. al. Percutaneous closure of patent foramen ovale reduces the frequency of migraine attacks. Neurology 2004;62:1399-1401.
5. Wammes‐van der Heijden EA, Tijssen CC, Egberts ACG. Right‐to‐left shunt and migraine: the strength of the relationship. Cephalalgia. 2006;26(2):208-213.
6. Tobis J. Management of patients with refractory migraine and PFO: Is MIST I Relevant? Catheterization and Cardiovascular Interventions. 2008;72(1):60-64.
7. Taylor FR, Tepper SJ, Stillman MJ. Recent Studies on PFO and Migraine: Is There a Future for Closure? Headache: The Journal of Head and Face Pain. 2008;48(7):1083-1086.
by Christina Peterson, M.D.
updated June 11, 2011
by admin | Jun 1, 2011 | Comorbidity
Obesity and Headache
Obesity has been called the most common disease in America, although technically I believe dental decay holds that distinction.
A BMI (Body Mass Index) of 30 or more places an individual at risk for new onset of chronic daily headaches, which is a condition called New Daily Persistent Headache. A BMI of 25 to 30 is considered “overweight.” A BMI of 30 to 35 is called class I obesity, 35-40 is class II obesity, and BMI over 40 is class III obesity. Most of the studies that determined a correlation between obesity and migraine also did so at a BMI of 30 or greater, although the most risk was seen for class II obese women of reproductive age. Neither the prevalence of migraine nor the risk of severe headache were increased in older women or men with total obesity or abdominal obesity.
The Cause and Effect of Obesity—Are Chronic Headaches Included?
From the decade of the 1960s to the decade of the 1970s, medical epidemiologists, the folks who study statistics about diseases, found that the number of people with headaches, and especially migraines, was increasing. But they didn’t know why. Now, it may partly be due to increased stress in our lives. And it may partly be that migraines are being diagnosed more. However, the increasing waistlines of the US may also be contributing to an increase in headache severity. There may a correlation between migraine and both total body obesity and abdominal obesity.
There is emerging evidence to suggest that there may be a correlation between metabolic syndrome and migraine as well. An increased waist-to-hip ratio is one of the diagnostic criteria for metabolic syndrome. Interestingly, there was also an increased rate of headache in the underweight. The best BMI in order to avoid headache is 20. What has not yet been determined is whether there are shared genetic factors that place a given individual at risk for both migraine and obesity, or whether something about migraine and the neurochemical changes that go on in the brain predispose toward obesity.
Studies on Obesity, Migraine, and Other Headaches
In 2002, Dr. Dawn Marcus noted that pro-inflammatory chemicals called cytokines had been discovered in migraine, and that they had been found to be elevated in obesity. She conducted a small pilot study (61 headache patients) to look for a relationship between obesity and migraine. She found that obesity was related to headache impact on a validated test of pain severity, psychological distress, and quality of life. The test scores were significantly higher in obese patients. Medical geneticists are currently hard at work to see whether there is a genetic link between migraine, obesity, hyperlipidemia (elevated cholesterol and other blood fats), high blood pressure (hypertension), and other chronic conditions.
Research on obesity is moving forward to look at many complex biochemical relationships to learn more. In 2003, a large study was completed looking at the various risk factors for the development of chronic daily headache. Some things we already knew about or suspected, like medication overuse, or not sleeping. But an association with weight was a surprise to headache specialists. This study, conducted by Dr. Ann Scher and colleagues, involved just over 1,100 people who were followed for a year. The obese people were far more likely to develop chronic daily headache (not acute migraine) than the normal group. Chronic daily headache is defined as headaches which occur 15 days a month or more.
Who is Affected by Obesity and Headache?
In a more recent study, Dr. Marcelo Bigal, interviewed over 143,000 people in order to identify nearly 1,100 with chronic daily headache. Sixty-four per cent of the study population was female. Obese individuals, those with a body mass index (BMI) of 30 or more, were about twice as likely to develop chronic daily headache, 7% vs. 3.8% for the normal group. The group who were just in the overweight range, those with a BMI between 25 and 29.9, had a 5% risk of developing chronic daily headache. Obese middle-aged women were at greatest risk. The obese group were also more likely to miss work due to their headaches. When asked if they had missed more than four days of work, 33% of the obese group answered yes, as compared to 27% of the overweight group and 26% of the underweight group.
Can Weight Loss Help Chronic Headache?
We are not yet certain to what extent weight management might reduce the frequency and severity of headaches. Some headache specialists feel that this may be so, while others simply suspect that the same risk factors that contribute to obesity also contribute to headache. Further, if you have chronic headaches, you are less likely to be active or to exercise. A recent study of severely morbidly obese patients who underwent bariatric surgery revealed a 50% reduction in the number of headache days after surgery. Reduction of migraine severity was also seen. However, this was a small study, and given the significant risks associated with bariatric surgery, it cannot be recommended for migraine management alone.
The positive finding Dr. Bigal’s study is that obese chronic daily headache sufferers were just as responsive to treatment as were other patients. In a second study, Dr. Bigal and his colleagues compared the treatment outcomes of 170 migraine patients. They found that after three months of treatment, response rates were about the same in all weight classes. So, the good news is that whether obesity is the chicken or the egg in chronic daily headache, treatment strategies are still effective.
References:
10. Keith SW, Wang C, Fontaine KR, Cowan CD, Allison DB. BMI and headache among women: results from 11 epidemiologic datasets. Obesity (Silver Spring). 2008;16(2):377-383. Available at:
http://www.ncbi.nlm.nih.gov/pubmed/18239647by Christina Peterson, MD
updated June 1, 2011
by admin | May 27, 2011 | Triggers
Stress and Emotional Triggers of Headache
Stress and emotional triggers are common migraine triggers. Stress comes in many varieties, including time stress, emotional stress, and the stress of physical fatigue. Emotions pack a wallop for the migraine sufferer. Anger, depression, anxiety, and crying can trigger a migraine attack. Crying, in fact, can make a migraine quite a bit worse than it already was.
For many migraine sufferers, an attack can occur when the stress is over. This is known as a “let-down” headache. Let-down headaches can have a delayed onset, occurring a day or more after the stress has happened in your life.
Relaxation training, meditation, and counseling can help if stress and emotional triggers are a significant element in causing your headaches.
by Christina Peterson, MD
updated May 27, 2011
by admin | Apr 18, 2011 | Medication
Can painkillers affect how well other migraine medications work?
Migraine patients who used opiate medications first were found to have a less effective triptan response than those who did not use opioid painkillers (also called opiate or narcotic analgesics). This was consistently found in seven different studies of rizatriptan (Maxalt®). The authors of this review concluded, based on these results, that the recommendations to use triptans as first-line treatment rather than using narcotic painkillers are confirmed.
Studies of Opioids and Triptans
The authors reviewed seven studies of rizatriptan that had been done in order to assess the medication for safety and effectiveness prior to submission to the US Food and Drug Administration for approval. (These are called phase 3 studies.) In all seven of these studies, subjects were instructed to wait and treat attacks that were moderate to severe. Altogether, there were over 2000 individuals in these studies who received the active drug, rizatriptan, and not placebo. (In some studies, both rizatriptan and sumatriptan were compared to placebo, but this did not affect the results reported here.)
In addition, the authors reviewed the results of two studies designed to look at the early treatment of migraine. Subjects generally treated a mild migraine with rizatriptan in these studies. Recent prior opiate use was based on medication use reported in the 30 days previous to the study. About 13% of subjects in the moderate-to-severe migraine treatment studies and about 5% of the subjects in the early treatment migraine studies reported recent use of narcotic painkillers. There were fewer study subjects who had recent prior opiate use that achieved pain freedom at the two-hour mark than those who had not used opioids.
In other words, the people that did not use narcotic painkillers were more likely to become pain-free at two hours. This data is retrospective—a look back at the information, and this is never as powerful as what we call a prospective study. But, as the authors of this study comment, this does suggest that a prospective study would be useful to gain further insight into the effect of opiate analgesics on the effectiveness of triptans in the treatment of migraine attacks.
reference:
Ho, T, Rodgers, A, Bigal, M. Impact of recent prior opioid use on rizatriptan efficacy. A post hoc pooled analysis. Headache. 2009;49(3):395-403.
by admin | Apr 14, 2011 | Comorbidity
Sleep Disorders and Headache
Sleep disturbances have been found to be comorbid with chronic daily headache. Sleep disturbances are common in migraine sufferers as well, but have not been studied adequately in large population-based studies. Thus no comment can be made as yet about whether any particular kind of sleep disorder formally relates to migraines, although many migraine sufferers know they can’t skimp on sleep without getting a migraine attack.
It is known that morning headaches can arise from sleep apnea, although morning headaches can certainly have other causes, such as bruxism—the clenching or grinding of teeth. There are many types of sleep disorders in addition to sleep apnea, including simple insomnia, sleep interruption due to depression or anxiety, and others. Deterioration in the quality of sleep can be caused by nocturnal movement disorders, such as periodic limb movements and restless leg syndrome, which is more common in migraine.
Here are four key questions you can ask yourself about the quality of your sleep:
- Is your sleep Restorative?
- Do you have Excessive daytime sleepiness, tiredness or fatigue?
- Do you habitually Snore?
- Is your Total sleep Time sufficient?
(notice how these spell R-E-S-T?)
Why Sleep is Important
Adequate sleep is an important factor in controlling all types of pain, including your headaches. Sleep deprivation is a migraine trigger for many people. If you are concerned about the quality of your sleep, it is a good idea to either keep a sleep diary, or to add space to your headache diary to track your sleep.
References:
1. Rains JC, Poceta JS. Sleep and Headache Disorders: Clinical Recommendations for Headache Management. Headache: The Journal of Head and Face Pain. 2006;46(s3):S147-S148.
2. Rains JC, Poceta JS. Sleep-related headache syndromes. Semin Neurol. 2005;25(1):69-80.
3. Moldofsky H. Sleep and pain. Sleep Med Rev. 2001;5(5):385-396. 4. Rains JC. Chronic Headache and Potentially Modifiable Risk Factors: Screening and Behavioral Management of Sleep Disorders. Headache: The Journal of Head and Face Pain. 2008;48(1):32-39.
by Christina Peterson, MD
updated April 14, 2011
Recent Comments