by admin | Jun 20, 2011 | Comorbidity
Allergies and Migraine
A recent large study has confirmed findings of previous studies that migraine headaches are more common in people who suffer from allergic rhinitis, and that immunotherapy can decrease the frequency of headache in those patients. Data from the Migraine, Allergy and Rhinitis Study (MARS) was analyzed. Allergy patients with headache received formal headache diagnoses, and received allergy testing with either skin tests, or blood tests of IgE antibodies. Of the 536 allergy patients in the study (60% women), 32.5% had migraine.
The most common allergens found were weeds, trees, grasses, and indoor insects. Patients were divided into those with high atopy and low atopy. (People who have allergies suffer from atopy, the genetic predisposition to develop IgE antibodies to allergens.) The average was 3.39 migraine days per month, and each attack lasted an average of 1.5 days.
What the study found was that the number of people with migraine was not altered by treatment with immunotherapy, but that the frequency and disability from migraine was reduced, but only in migraine sufferers under age 45. The study showed a predicted 52% reduction in the frequency of migraine headache and a 45% reduction of the number of days with migraine-related disability in migraineurs ≤45 years of age that received immunotherapy. The study also found that in the younger group, 45 or younger, low degrees of allergic sensitization were correlated with migraines that were less frequent and less disabling, and that migraines were more frequent in those with high degrees of allergic sensitization.
Allergies and Chronic Headache
Allergies are comorbid with chronic daily headache, which means that they occur more commonly in those with chronic headache. This is true of both chronic migraine, and of new daily persistent headache. (New daily persistent headache is a chronic headache that starts off right from the very beginning as a daily or near-daily headache.) It is not yet clear whether controlling allergies can reverse chronic headaches.
References:
1. Ku M, Silverman B, Prifti N, et al. Prevalence of migraine headaches in patients with allergic rhinitis. Annals of Allergy, Asthma & Immunology. 2006;97(2):226-230.
2. Mortimer MJ, Kay J, Gawkrodger DJ, Jaron A, Barker DC. The prevalence of headache and migraine in atopic children: An epidemiological study in general practice. Headache. 1993;33:427–431.
3. Martin VT, Taylor F, Gebhardt B, et al. Allergy and immunotherapy: are they related to migraine headache? Headache. 2011;51(1):8-20.
4. Eross E, Dodick D, Eross M. The Sinus, Allergy and Migraine Study (SAMS). Headache. 2007;47(2):213-224.
by Christina Peterson, M.D.
updated June 20, 2011
by admin | Jun 20, 2011 | Comorbidity
Are Asthma and Migraine Related?
Asthma has been found to be comorbid with chronic daily headache. (This was chronic migraine without any evidence of medication overuse.) A Norwegian study of over 50,000 people found that headache (both migraine and non-migraine headache) was 1.5 times more likely to occur in asthma sufferers, as well as chronic bronchitis and hay fever. In this study, more women than men had asthma (although more men had chronic bronchitis).
A British study of similar size found that the risk of developing asthma in a migraineur was 1.3 times higher than in a non-migraine sufferer.
Asthma can also serve as a migraine trigger, although asthma does not cause migraine. (Migraine does not cause asthma, either.) The association of asthma and migraine is well established, but the cause of that association is not known.
Just as in migraine, it’s important to identify what your asthma triggers are, and avoid them when possible. Obviously, it is not possible to avoid all pollen exposure. However, you can minimize exposure to dust (and dust mites), and to cigarette smoke.
References:
- Mortimer MJ, Kay J, Gawkrodger DJ, Jaron A, Barker DC. The prevalence of headache and migraine in atopic children: An epidemiological study in general practice. Headache. 1993;35:427-431.
- Wilkinson IA, Halliday JA, Henry RL, Hankin RG, Hensley MJ. Headache and asthma. J Paediatr Child Health. 1994;30:253-256.
- Davey G, Sedgwick P, Maier W, Visick G, Strachan DP, Anderson HR. Association between migraine and asthma: Matched case-control study. Br J Gen Pract. 2002;52:723-727.
- Özge A, Özge C, Oztürk C, et al The relationship between migraine and atopic disorders-the contribution of pulmonary function tests and immunological screening. Cephalalgia. 2006;26:172-179.
- Low NC, Merikangas KR. The comorbidity of migraine. CNS Spectr. 2003;8:433-444.
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Aamodt AH, Stovner LJ, Langhammer A, Hagen K, Zwart J-A. Is headache related to asthma, hay fever, and chronic bronchitis? The Head-HUNT Study. Headache. 2007;47(2):204-212.
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Becker C, Brobert GP, Almqvist PM, et al. The risk of newly diagnosed asthma in migraineurs with or without previous triptan prescriptions. Headache. 2008;48(4):606-610.
by Christina Peterson, M.D.
updated June 20, 2011
by admin | Jun 19, 2011 | Comorbidity
Migraine Sufferers Have an Increased Risk of Cardiovascular Disease
For several years, there has been increasing evidence of an increased risk of heart disease and stroke in migraine sufferers. The risk is clearly increased in migraine with aura. Whether or not there is an increased risk in migraine without aura has been less clear. Several large studies have now been done, and we have more information about this.
In the Womens Health Initiative study, 2006, women with migraine with aura were found to have about twice the risk of cardiovascular disease as were women without migraine, or women with migraine without aura.
Also reported in 2006 was a study of men with migraine. Over 20,000 men, 1449 with migraine, were followed for 15.7 years. Information regarding aura was not available. Migraineurs in this study were younger than controls, and more likely to have high blood pressure or a cholesterol of 240 or more. They were also less likely to smoke or use alcohol.
Men with migraine in this study had a higher risk for major cardiovascular disease than men without migraine.
Cardiovascular disease (CVD) means heart disease, including heart attack (myocardial infarction), stroke, or other types of vascular problems due to arterial atherosclerosis.
Recent Studies of Migraine and Cardiovascular Disease
Reykjavik Study
The Reykjavik Study, reported in 2010, looked at a large number of people with one or more migraines a month, and followed them for 26 years. They found that both men and women with migraine with aura were at increased risk of CVD, regardless of whether or not they had classic cardiovascular risk factors (smoking, high blood pressure, high cholesterol, or diabetes.)
In this study, the excess ten-year risk of all-cause mortality at age 50 was 1.2% for men and 0.6% for women. The risk associated with migraine was less that the risk associated with hypertension, smoking, or diabetes. The study authors stated, “The absolute risk is low, and the focus should be on conventional risk factors, such as hypertension, smoking, and adverse lipid profile, for reducing the risk of cardiovascular disease, regardless of migraine status.”
GEM Study
The Genetic Epidemiology of Migraine Study, conducted in The Netherlands, looked at 863 migraine sufferers, 111 with migraine with aura only, 396 with migraine without aura only, and 81 with both migraine types. The average age was 42, and 53% were women.
This study found that the risk for cardiovascular disease over a ten year time span was < 1% in about ⅓ of all study participants. However, it was twice as high in migraine with aura and for non-migraine headaches. The risk elevation was higher for women than for men with migraine with aura.
All migraine sufferers had an increased risk of CVD compared to those with non-migraine headaches, but for migraine with aura, the risk was double compared to those with non-migraine headaches. The diagnosis of high blood pressure was more likely in all migraineurs. A maternal history of early heart attack (myocardial infarction) was associated with all migraine sufferers, while a paternal history of early MI was found in men with all migraine types.
Women who have migraine with aura were more likely to have had gestational hypertension. Female migraine with aura sufferers were also more likely to use oral contraceptives.
The authors of this study commented “Migraineurs, particularly with aura, have a higher cardiovascular risk profile than individuals without migraine.” They went on to comment:
“Further research is warranted to determine why migraineurs have these risk factors more frequently than nonmigraineurs and the nature of the additional mechanism that predisposes these individuals to early-onset cardiovascular disease.”
Other Studies
In a paper by Dr. Marcel Bigal, Dr. Tobias Kurth, and their colleagues, the authors have pointed out that the association of migraine with aura and cardiovascular disease could be due to several things. One possibility is that some of the migraine with aura patients were incorrectly diagnosed with TIA (transient ischemic attack) instead of migraine aura. The studies done have been large enough, however, that this is unlikely to be affecting the overall results. It is also unlikely that migraine medications are causative.
Another possibility is that one disease leads to another, and that migraine could lead to stroke or brain lesions because of repeated episodes of cortical spreading depression. We do not yet know for certain if this is the case.
It is also possible that there are shared genetic factors or shared environmental factors that account for the association between migraine with aura and cardiovascular disease. For example, migraine and heart disease risk genes could be on the same chromosome.
It has been found that migraineurs (of all types) had higher glucose levels as a group, as well as an insulin resistance pattern in 65% (as compared to 19% in the control group. Migraine sufferers were also found to have a higher rate of retinal blood vessel narrowing (retinopathy), even after controlling for age and cardiovascular risk factors.
The authors of this study noted, “Most migraine patients have migraine without aura and are at no or little increased risk of CVD. Accordingly, most patients with migraine should be reassured instead of being frightened.”
Most of the same authors also participated in a more recent study involving 9107 migraine subjects and 10,000 controls. This showed an increased rate of MI (myocardial infarction) and claudication (leg pain due to arterial narrowing) in all migraine sufferers, but only found an increased rate of stroke in migraine with aura.
How does cardiovascular disease affect the body in migraine?
Why would migraine itself be a risk factor for cardiovascular disease? There are many reasons, and more than one could be a factor. We know that people with migraine have a higher rate of what are known as “prothrombotic factors,” which are things that make your blood more likely to clot. (These include things like von Willebrand factor, factor V Leiden, endothelin, and others.)
It also appears from these various studies that migraine sufferers may have an increased rate of elevated cholesterol.
Migraine researchers have noted that migraine is a complex disorder, and may not be the same biochemically or genetically in various migraine sufferers. The mechanisms behind cardiovascular disease in migraine are as yet unclear, and may themselves be complex.
What Should You Do As a Migraine Sufferer?
Most migraine sufferers will have a low risk of heart disease or stroke. The risk of cardiovascular disease due to migraine with aura is still less than the risk of cardiovascular disease associated with other risk factors, such as uncontrolled high blood pressure, diabetes, smoking, or elevated cholesterol. While some studies showed no risk in those who had migraine without aura, other studies suggested an intermediate risk for heart disease as compared to those without migraine.
The best thing to do is to control known cardiovascular risk factors. Keep your blood pressure under control. Don’t smoke. If you have elevated cholesterol, work with your doctor to find the best way to control it. Keep your blood sugar well controlled if you are diabetic, and keep your weight under control to lower the risk of developing diabetes.
Future studies will likely tell us more about this connection between migraine and cardiovascular disorders—and what to do about it.
References:
1. Scher AI, Terwindt GM, Picavet HSJ, et al. Cardiovascular risk factors and migraine: the GEM population-based study. Neurology. 2005;64(4):614-620.
2. Schurks M, Rist PM, Bigal ME, et al. Migraine and cardiovascular disease: systematic review and meta-analysis. BMJ. 2009;339(oct27 1):b3914-b3914.
3. Gudmundsson LS, Scher AI, Aspelund T, et al. Migraine with aura and risk of cardiovascular and all cause mortality in men and women: prospective cohort study. BMJ. 2010;341(aug24 1):c3966-c3966.
4. Bigal ME, Kurth T, Hu H, Santanello N, Lipton RB. Migraine and cardiovascular disease. Neurology. 2009;72(21):1864 -1871.
5. Kurth T, Schurks M, Logroscino G, Gaziano JM, Buring JE. Migraine, vascular risk, and cardiovascular events in women: prospective cohort study. BMJ. 2008;337(aug07 1):a636-a636.
6. Kurth T, Gaziano JM, Cook NR, et al. Migraine and Risk of Cardiovascular Disease in Men. Arch Intern Med. 2007;167(8):795-801.
7. Kurth T, Gaziano JM, Cook NR, et al. Migraine and Risk of Cardiovascular Disease in Women. JAMA: The Journal of the American Medical Association. 2006;296(3):283 -291.
8. Bigal ME, Kurth T, Santanello N, et al. Migraine and cardiovascular disease. Neurology. 2010;74(8):628 -635.
By Christina Peterson
updated 6-19-11
by admin | Jun 17, 2011 | Comorbidity
Fibromyalgia
Fibromyalgia is a chronic pain syndrome which manifests as chronic widespread pain. The pain is in the muscles and soft tissues, not in the joints. Specific tender points must be present for more than three months before the diagnosis is made.
Fibromyalgia is a central nervous system disorder. The chronic pain is associated with central sensitization, which can make pain processing in the brain occur more easily.
Depression is vey common in fibromyalgia. Between 50% and 70% of fibromyalgia patients have a history of depression. Major depressive episodes occur in 18-36%. Sleep disorders are almost universal in fibromyalgia. Metabolic syndrome is also more common, occurring in five times as many women with fibromyalgia than those without. Elevations in total cholesterol and LDL have been found to be associated with fibromyalgia in women.
Fibromyalgia and Migraine
Estimates of migraine or chronic headache in fibromyalgia range from 30% to over 50%. An epidemiologic study of headache in fibromyalgia was conducted, and 63% of fibromyalgia patients were found to have migraine. Only 8% met criteria for medication overuse headache.
In a study of 92 consecutive migraine patients who were assessed for fibromyalgia, 22.2% of female migraineurs (and none of the men) were found to have fibromyalgia. Migraine severity and characteristics were similar in both those who had fibromyalgia and those who did not.
A questionnaire-based survey, which asked which of several conditions migraine sufferers had been diagnosed with by a doctor, found that musculoskeletal conditions, including fibromyalgia, were increased in migraine sufferers. Migraine with aura sufferers were more likely to to have comorbid conditions than were those who had migraine without aura. Women with migraine were more likely than men to have comorbid conditions.
What is the fibromyalgia-migraine connection?
Hypothalamic neuroendocrine dysfunction has been proposed as a brain mechanism common to both fibromyalgia and migraine. Both conditions also share the mechanism of central sensitization of pain neurons.
While you may read that the transformation of migraine to chronic migraine results in fibromyalgia, this idea has not been borne out in formal studies. In an epidemiologic study, there was no difference in migraine severity or other migraine characteristics in fibromyalgia sufferers with migraine and migraineurs who did not meet diagnostic criteria for fibromyalgia. Not all fibromyalgia sufferers also have migraine. And not all chronic migraine sufferers also have widespread chronic pain.
Many migraine sufferers have a condition called allodynia (also called cutaneous allodynia) during migraine attacks. Allodynia means that a touch that is normally perceived as just that–pressure or touching–is experienced as painful. Usually allodynia is confined to the head and neck, but can involve other areas of the body as well. Allodynia is generally episodic and does not occur all the time, although it can be frequent in chronic migraine sufferers. Allodynia is not the same thing as fibromyalgia.
In some studies, allodynia has been reported in up to 80% of migraineurs during attacks. A recent study of 1413 migraine sufferers found severe cutaneous allodynia to be more likely in those who had two or three comorbid pain conditions (IBS, chronic fatigue syndrome, or fibromyalgia).
Fibromyalgia, Migraine, and Other Comorbid Conditions
If you have both fibromyalgia and migraine, you are more likely to also have anxiety and depression. Correlations have also been made between fibromyalgia, migraine, and irritable bowel syndrome.
The association between fibromyalgia and tension-type headache is even stronger than the association with migraine.
References:
1. Ifergane G, Buskila D, Simiseshvely N, Zeev K, Cohen H. Prevalence of fibromyalgia syndrome in migraine patients. Cephalalgia. 2006;26(4):451-456.
2. Le H, Tfelt-Hansen P, Russell MB, et al. Co-morbidity of migraine with somatic disease in a large population-based study. Cephalalgia. 2011;31(1):43 -64.
3. Tietjen GE, Brandes JL, Peterlin BL, et al. Childhood maltreatment and migraine (part III). Association with comorbid pain conditions. Headache. 2010;50(1):42-51.
4. Tietjen GE, Brandes JL, Peterlin BL, et al. Allodynia in migraine: association with comorbid pain conditions. Headache. 2009;49(9):1333-1344.
5. Valença MM, Medeiros FL, Martins HA, Massaud RM, Peres MFP. Neuroendocrine dysfunction in fibromyalgia and migraine. Curr Pain Headache Rep. 2009;13(5):358-364.
6. de Tommaso M, Sardaro M, Serpino C, et al. Fibromyalgia comorbidity in primary headaches. Cephalalgia. 2009;29(4):453-464.
7. Bradley LA. Pathophysiologic mechanisms of fibromyalgia and its related disorders. J Clin Psychiatry. 2008;69 Suppl 2:6-13.
8. Sarchielli P, Di Filippo M, Nardi K, Calabresi P. Sensitization, glutamate, and the link between migraine and fibromyalgia. Curr Pain Headache Rep. 2007;11(5):343-351.
9. Tietjen GE, Herial NA, Hardgrove J, Utley C, White L. Migraine comorbidity constellations. Headache. 2007;47(6):857-865.
10. Cole JA, Rothman K, Cabral H, Zhang Y, Farraye F. Migraine, fibromyalgia, and depression among people with IBS: a prevalence study. BMC Gastroenterology. 2006;6(1):26.
11. Sakarya ST, Akyol Y, Bedir A, Canturk F. The relationship between serum antioxidant vitamins, magnesium levels, and clinical parameters in patients with primary fibromyalgia syndrome. Clin Rheumatol. 2011.
12. Bigal ME, Kurth T, Hu H, Santanello N, Lipton RB. Migraine and cardiovascular disease. Neurology. 2009;72(21):1864 -1871.
by Christina Peterson, M.D.
updated June 17, 2011
by admin | Jun 12, 2011 | Comorbidity
What is Mitral Valve Prolapse?
Mitral valve prolapse occurs when the leaflets of the valve between the left atrium of the heart and the left ventricle are too large, or the strings (chordae tendinae) that connect them to the heart wall are too long. This causes them to close unevenly and bulge back into the left atrium (the upper chamber of the heart). In most cases, the valve still functions as it should. In a few cases, it may leak blood. This is called mitral regurgitation.
Mitral valve prolapse affects between 3%-10% of the population. About 60% of individuals with MVP have no symptoms. Mitral valve prolapse is also called click-murmur syndrome, Barlow’s syndrome, balloon mitral valve, and floppy valve syndrome.
Mitral valve prolapse, or MVP, is more common in people who have connective tissue disorders such as Marfan’s Syndrome or Ehlers-Danlos Syndrome, in people with Graves Disease, or in polycystic kidney disease. About 40% of people who have MVP also have a condition known as dysautonomia, a disorder of the autonomic nervous system. Dysautonomia can cause a variety of conditions that affect heart rate, blood pressure, and other bodily functions.
Symptoms of MVP
Symptoms of MVP can be brought out by stresses on the body like pregnancy, a viral illness, or major life stresses. MVP symptoms include chest pain, dizziness, palpitations (especially when lying on the left side), fatigue, shortness of breath with exertion or when lying flat, lightheadedness, and chronic low energy. In the infrequent, more severe cases of MVP with mitral regurgitation, symptoms of congestive heart failure can occur, with swollen legs and arrhythmia. Only in the most severe cases is valve replacement surgery necessary. Medical treatment is available for arrhythmia. The majority of people with MVP do not require any treatment.
Mitral Valve Prolapse and Migraine
A 1984 study of 100 migraine patients and 100 controls who all underwent echocardiography and clinical examination found that 11% of the control group and 25% of the migraine group had evidence of mitral valve prolapse. A larger, older study found that 27.8% of migraineurs had MVP. A study of only migraine with aura patients found a 15% rate of definite MVP, and 16% of probable MVP.
Why is there a connection? This is not known for certain. One theory is that blood platelets are damaged by the floppy valve leaflets, releasing serotonin from within the platelet. Serotonin is one of several chemicals in the body that has been implicated in the cause of migraine.
References:
1. Spence JD, Wong DG, Melendez LJ, et al. Increased prevalence of mitral valve
prolapse in patients with migraine. Can Med Assoc J 1984;131:1457–60.
2. Litman GI, Friedman HM. Migraine and the mitral valve prolapse syndrome. Am
Heart J 1978;96:610–4.
3. Amat G, Jean Louis P, Loisy C, et al. Migraine and the mitral valve prolapse
syndrome. Adv Neurol 1982;33:27–9.
by Christina Peterson, M.D.
updated June 12, 2011
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
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