Onset Of Chronic Migraine Research Articles

Time to retire 'New daily persistent headache': Mode of onset of chronic migraine and tension-type headache.

New daily persistent headache is described as an enigmatic condition with daily headache from onset. It has posed challenges diagnostically and therapeutically.Methods: We conducted a study of patients referred to headache services based in Central and North-East London, United Kingdom, meeting the International Classificaiton of Headache Disorders - 3 criteria for New daily persistent headache. Information on demographics, phenotype and treatment responses were collected. The syndrome of the daily headache was also classified according any other ICHD-3-defined syndrome.Results: Of 162 patients, females comprised 68.5% with median age of onset 35 years. The daily headache experienced was chronic migraine in 89.7% and tension-type headache in 8.8%. Thunderclap-onset New daily persistent headache occurred in 14.8%. More than one headache syndrome was experienced in 15.4%, including cough, hypnic, sexual and stabbing headache. All aura types were experienced, most commonly brainstem aura in 39%. Prior headache was reported 53.7%. A persisting sub-form was present in 51.2%, relapsing remitting in 12.3% and 14.0% reported improvement; 19.8% were lost to follow-up. Only 11.1% reported an antecedent trigger. The most common premorbid disorders were psychiatric in 35.7%. A fifth improved on preventative medication, most commonly amitriptyline, propranolol and topiramate.Conclusion: Our cohort of New daily persistent headache is consistent with a mode of onset of migraine and tension-type headache which occurs in predisposed individuals.

White matter changes in chronic and episodic migraine: a diffusion tensor imaging study

BackgroundWhite matter alterations have been observed in patients with migraine. However, no microstructural white matter alterations have been found particularly in episodic or chronic migraine patients, and there is limited research focused on the comparison between these two groups of migraine patients.MethodsFifty-one healthy controls, 55 episodic migraine patients and 57 chronic migraine patients were recruited and underwent brain T1-weighted and diffusion-weighted MRI acquisition. Using Tract-Based Spatial Statistics (TBSS), fractional anisotropy, mean diffusivity, radial diffusivity and axial diffusivity were compared between the different groups. On the one hand, all migraine patients were compared against healthy controls. On the other hand, patients from each migraine group were compared between them and also against healthy controls. Correlation analysis between clinical features (duration of migraine in years, time from onset of chronic migraine in months, where applicable, and headache and migraine frequency, where applicable) and Diffusion Tensor Imaging measures was performed.ResultsFifty healthy controls, 54 episodic migraine and 56 chronic migraine patients were finally included in the analysis. Significant decreased axial diffusivity (p < .05 false discovery rate and by number of contrasts corrected) was found in chronic migraine compared to episodic migraine in 38 white matter regions from the Johns Hopkins University ICBM-DTI-81 White-Matter Atlas. Significant positive correlation was found between time from onset of chronic migraine and mean fractional anisotropy in the bilateral external capsule, and negative correlation between time from onset of chronic migraine and mean radial diffusivity in the bilateral external capsule.ConclusionsThese findings suggest global white matter structural differences between episodic migraine and chronic migraine. Patients with chronic migraine could present axonal integrity impairment in the first months of chronic migraine with respect to episodic migraine patients. White matter changes after the onset of chronic migraine might reflect a set of maladaptive plastic changes.

Epidemiology of migraine in men: Results from the Chronic Migraine Epidemiology and Outcomes (CaMEO) Study.

To assess migraine epidemiology in men by examining gender differences in disease presentation, comorbidities, and prognosis. The Chronic Migraine Epidemiology and Outcomes (CaMEO) Study is a longitudinal survey of US adults with migraine identified by web questionnaire. Data were stratified by gender, collected between September 2012-November 2013, and included sociodemographics, headache features, Migraine Disability Assessment, Migraine Symptom Severity Score, Allodynia Symptom Checklist, and comorbidities. Discrete time hazard models addressed 1-year likelihood of transition from episodic to chronic migraine headache frequency. Of the 16,789 migraine respondents, 4294 were men (25.6%). Compared to women, men were slightly older at onset of their headaches (mean 24.1 vs. 22.3 years) and had fewer headache days/month (4.3 vs. 5.3 days), slightly less severe attacks (Migraine Symptom Severity Score, 21.6 vs. 22.6), reduced frequencies of grade IV Migraine Disability Assessment scores (15.7% vs. 24.1%), allodynia (32.6% vs. 49.7%), chronic migraine (6.5% vs. 9.6%, each p < 0.001), and common comorbidities. Men were less likely to report consulting a doctor for their headaches and receiving a migraine diagnosis if they consulted. Men and women with episodic migraine had similar crude 1-year risk of chronic migraine onset. Controlling for known risk factors (i.e. depression, headache frequency, allodynia), men had greater likelihood of chronic migraine onset at 6, 9, and 12 months (each p < 0.05). Findings confirmed gender differences. Men with migraine generally have less severe attacks and disability and are less likely to receive a diagnosis than women with migraine. Prognostic factors may be better understood for women than men.

Onabotulinumtoxin A for the management of chronic migraine in current clinical practice: results of a survey of sixty-three Italian headache centers

BackgroundChronic migraine is a complex clinical condition often undertreated. Onabotulinumtoxin A (OBT-A) was approved in Italy in 2013 for symptom relief in patients with chronic migraine who have failed, or do not tolerate, oral prophylactic treatments. However, the impact of OBT-A in clinical practice remains to be defined.MethodsTo investigate the current management of chronic migraine with OBT-A in clinical practice, a web-based survey was conducted among clinicians working in third-level headache centers across Italy. A 26-item questionnaire was designed and developed by a group of 10 Italian headache specialists to address the following issues: treatment paradigm and OBT-A injection intervals, frequency of treatment and retreatment, definition of responders/non-responders, satisfaction with treatment potential impact of early treatment with OBT-A. Ninety-six headache centers were selected and contacted via e-mail. The online survey was anonymous and carried out using a secure website.ResultsOverall, 64 of the 96 centers (66.7%) completed the questionnaire. Most centers (98.4%) had been using OBT-A for >1 year. OBT-A was administered according to the PREEMPT paradigm in most centers (88.9%). While during the first year of prophylaxis with OBT-A most clinicians (93.6%) repeated OBT-A treatment every 3 months, as recommended, in the following years interval duration was variable. Response to OBT-A was defined as a ≥ 50% reduction in the headache days by 58.7% of the clinicians, and as a ≥ 30% reduction by 25.4% of them. Almost 60% of the clinicians considered OBT-A as a long-lasting therapy, while for one-third of them treatment could be discontinued in patients showing a benefit for ≥6 months. According to 80% of the clinicians, early administration of OBT-A after the onset of chronic migraine was associated with better outcomes, and 47.6% felt that OBT-A should be recommended as a first-line option.ConclusionsThis survey indicates that in third-level headache centers in Italy OBT-A is used in good compliance with current recommendations. There is agreement about the definition of response as a reduction in headache days by 30% to 50%. Additional effort is required to define response to OBT-A and to establish optimal treatment duration.

Asthma is a risk factor for new onset chronic migraine: Results from the American migraine prevalence and prevention study.

To test the hypothesis that in persons with episodic migraine (EM), asthma is a risk factor for the onset of chronic migraine (CM). Migraine and asthma are comorbid chronic disorders with episodic attacks thought to involve inflammatory and neurological mechanisms. Herein, we assess the influence of asthma on the clinical course of EM. To be eligible for this observational cohort study, AMPP Study participants had to meet criteria for EM in 2008, complete the validated six-item asthma questionnaire from the European Community Respiratory Health Survey (ECRHS) in 2008, and provide follow-up data in 2009. Using the ECRHS, we defined asthma as a binary variable (present or absent) based on an empirical cut score and developed a Respiratory Symptom Severity Score (RSSS) based on the number of positive responses (no severity = 0 positive responses, low severity = 1-2 positive responses, moderate severity = 3-4 positive responses, high severity = 5-6 positive responses). Chronic migraine was the primary outcome measure and was defined as those with ≥15 headache days per month on the 2009 AMPP Study survey. We used logistic regression in separate models to assess the influence of asthma as a binary variable (Model 1) and RSSS score categories (Model 2 using no respiratory symptoms as the reference) on CM onset after adjusting for sociodemographic factors, headache day frequency, migraine preventive medication use, and medication overuse. The eligible sample for this study included 4446 individuals with EM in 2008 of whom 17% had asthma. This group had a mean age of 50.4 and was 80.8% female. In 2009, new onset CM developed in 2.9% (131/4446) of the 2008 EM cohort, including 5.4% (40/746) of the asthma subgroup and 2.5% (91/3700) of the non-asthma subgroup. In comparison to those without asthma, the adjusted odds for individuals with asthma and EM in 2008 to develop CM in 2009 were greater than two (adjusted odds ratio [aOR] 2.1; 95% CI: 1.4-3.1). Using the RSSS, the aOR for CM onset increased with the number of asthma symptoms, but only those in the high RSSS category showed a statistically significant increase in the odds of chronic migraine onset in comparison with the no RSSS reference group (aOR 3.3; 95% CI 1.7-6.2). Asthma is associated with an increased risk of new onset CM 1 year later among individuals with EM, with the highest risk being among those with the greatest number of respiratory symptoms. The exact mechanisms underlying this association are unknown, but could suggest mast cell degranulation, autonomic dysfunction, or shared genetic or environmental factors.

Ineffective acute treatment of episodic migraine is associated with new-onset chronic migraine.

To test the hypothesis that ineffective acute treatment of episodic migraine (EM) is associated with an increased risk for the subsequent onset of chronic migraine (CM). In the American Migraine Prevalence and Prevention Study, respondents with EM in 2006 who completed the Migraine Treatment Optimization Questionnaire (mTOQ-4) and provided outcome data in 2007 were eligible for analyses. The mTOQ-4 is a validated questionnaire that assesses treatment efficacy based on 4 aspects of response to acute treatment. Total mTOQ-4 scores were used to define categories of acute treatment response: very poor, poor, moderate, and maximum treatment efficacy. Logistic regression models were used to examine the dichotomous outcome of transition from EM in 2006 to CM in 2007 as a function of mTOQ-4 category, adjusting for covariates. Among 5,681 eligible study respondents with EM in 2006, 3.1% progressed to CM in 2007. Only 1.9% of the group with maximum treatment efficacy developed CM. Rates of new-onset CM increased in the moderate treatment efficacy (2.7%), poor treatment efficacy (4.4%), and very poor treatment efficacy (6.8%) groups. In the fully adjusted model, the very poor treatment efficacy group had a more than 2-fold increased risk of new-onset CM (odds ratio = 2.55, 95% confidence interval 1.42-4.61) compared to the maximum treatment efficacy group. Inadequate acute treatment efficacy was associated with an increased risk of new-onset CM over the course of 1 year. Improving acute treatment outcomes might prevent new-onset CM, although reverse causality cannot be excluded.

Neck pain disability is related to the frequency of migraine attacks: a cross-sectional study.

Migraine and neck pain can be critical causes of disability. The contribution of neck pain for the overall disability of individuals with migraine remains unknown. To contrast the disability experienced by individuals with episodic and chronic migraine with and without neck pain as captured by the Neck Disability Index. Disability due to neck pain was assessed using the Neck Disability Index in individuals with episodic or chronic migraine seen at a university-based headache center. Neck disability was defined as mild (score ranging from 5 to 14 points), moderate (15-24 points), severe (25-34 points) or complete (35 points or higher). To compare differences between groups, a chi-square test was applied. Log-binomial logistic regression was used to estimate disability as a function of headache status after adjustments for age, time since migraine onset, and headache intensity. Sample consisted of 169 individuals, 104 with episodic migraine and 65 with chronic migraine. Any disability due to neck pain happened in 69% of those with episodic migraine, relative to 92% in chronic migraine (P < .001). Individuals with chronic migraine were at a significantly increased risk to have mild (RR = 2.5; CI 95% 1.1-6.1), moderate (RR = 3.7; CI 95% 1.5-8.8) and severe (RR = 5.1; CI 95%2.1-11.9) cervical disability relative to those with episodic migraine. Relative risks remained significant after adjustments. Time since episodic or chronic migraine onset significantly influenced the model (P = .035), but age and headache intensity did not (P = .27; P = .46). Neck pain significantly adds to the overall disability of individuals with episodic and chronic migraine.

Rounding Behavior in the Reporting of Headache Frequency Complicates Headache Chronification Research

To characterize the extent of measurement error arising from rounding in headache frequency reporting (days per month) in a population sample of headache sufferers. When reporting numerical health information, individuals tend to round their estimates. The tendency to round to the nearest 5 days when reporting headache frequency can distort distributions and engender unreliability in frequency estimates in both clinical and research contexts. This secondary analysis of the 2005 American Migraine Prevalence and Prevention study survey characterized the population distribution of 30-day headache frequency among community headache sufferers and determined the extent of numerical rounding ("heaping") in self-reported data. Headache frequency distributions (days per month) were examined using a simplified version of Wang and Heitjan's approach to heaping to estimate the probability that headache sufferers round to a multiple of 5 when providing frequency reports. Multiple imputation was used to estimate a theoretical "true" headache frequency. Of the 24,000 surveys, headache frequency data were available for 15,976 respondents diagnosed with migraine (68.6%), probable migraine (8.3%), or episodic tension-type headache (10.0%); the remainder had other headache types. The mean number of headaches days/month was 3.7 (standard deviation = 5.6). Examination of the distribution of headache frequency reports revealed a disproportionate number of responses centered on multiples of 5 days. The odds that headache frequency was rounded to 5 increased by 24% with each 1-day increase in headache frequency (odds ratio: 1.24, 95% confidence interval: 1.23 to 1.25), indicating that heaping occurs most commonly at higher headache frequencies. Women were more likely to round than men, and rounding decreased with increasing age and increased with symptoms of depression. Because of the coarsening induced by rounding, caution should be used when distinguishing between episodic and chronic headache sufferers using self-reported estimates of headache frequency. Unreliability in frequency estimates is of particular concern among individuals with high-frequency (chronic) headache. Employing shorter recall intervals when assessing headache frequency, preferably using daily diaries, may improve accuracy and allow more precise estimation of chronic migraine onset and remission.

Influence of random measurement error on estimated rates of headache chronification and remission.

To examine the potential influence of random measurement error on estimated rates of chronification and remission. Studies of headache chronification and remission examine the proportion of headache sufferers that move across a boundary of 15 headache days per month between 2 points in time. At least part of that apparent movement may represent measurement error or random variation in headache activity over time. A mathematical simulation was conducted to examine the influence of varying degrees of measurement error on rates of chronic migraine onset and remission. Using data from the American Migraine Prevalence and Prevention Study, we estimated a starting distribution of headache days from 0 to 30 in the migraine population. Assuming various levels of measurement error, we then simulated 2 sets of data for Time 1 and Time 2. The "individuals" in this study were assumed to have no real change in headache frequency from Time 1 to Time 2. The observed variations in headache frequency were those influenced by imputed random variance to resemble typical measurement error or natural variability. Using this simulation approach, we estimated the amount of chronification and remission rates that might be attributed simply to statistical artifacts such as unreliability or regression to the mean. As the degree of measurement error increased, the amounts of illusory chronification and remission increased substantially. For example, if the headache frequency of sufferers randomly varies by only 2 headache days each month due to chance alone, a substantial degree of illusory chronification (0.6% to 1.3%) and illusory remission (10.3% to 23.5%) rates are expected simply due to random variation. Random variation, without real change, has the potential to influence estimated rates of progression and remission in longitudinal migraine studies. The magnitude of random variation needed to fully reproduce observed rates of progression and remission are implausibly large. Recommendations are offered to improve estimation of rates of progression and remission, reducing the influence of random variation.

Depression and risk of transformation of episodic to chronic migraine

The aim of this study was to assess the role of depression as a predictor of new onset of chronic migraine (CM) among persons with episodic migraine (EM). The American Migraine Prevalence and Prevention (AMPP) study followed 24,000 persons with severe headache identified in 2004. Using random-effects logistic regression, we modeled the probability that persons with EM in 2005 or 2006 would develop CM in the subsequent year. Depression was assessed in two ways, using a validated questionnaire (PHQ-9 score ≥15) and based on self-reported medical diagnosis. Analyses were adjusted for multiple covariates including sociodemographics, body mass index, headache pain intensity, headache frequency, migraine symptom severity, cutaneous allodynia, acute medication overuse, anti-depressant use and anxiety. Of 6,657 participants with EM in 2005, 160 (2.4 %) developed CM in 2006. Of 6,852 participants with EM in 2006, 144 (2.2 %) developed CM in 2007. In fully adjusted models, PHQ-9 defined depression was a significant predictor of CM onset [odds ratio (OR) = 1.65, 95 % CI 1.12–2.45]. There was a depression-dose effect; relative to participants with no depression or mild depression, those with moderate (OR = 1.77, 95 % CI 1.25–2.52), moderately severe (OR = 2.35, 95 % CI 1.53–3.62), and severe depression (OR = 2.53, 95 % CI 1.52–4.21) were at increased risk for the onset of CM. Among persons with EM, depression was associated with an increased risk of CM after adjusting for sociodemographic variables and headache characteristics. Depression preceded the onset of CM and risk increased with depression severity suggesting a potentially causal role though reverse causality cannot be excluded.Electronic supplementary materialThe online version of this article (doi:10.1007/s10194-012-0479-9) contains supplementary material, which is available to authorized users.

Clinical trials on onabotulinumtoxinA for the treatment of chronic migraine

Clinical trials on onabotulinumtoxinA for the treatment of chronic migraine

Looking to the Future: Research Designs for Study of Headache Disease Progression

Evidence from clinical observation and population studies suggests that migraine sometimes transforms into chronic migraine. Risk factors for progression include headache frequency, obesity, snoring, stressful life events, and head injury. Other candidate risk factors include depression, anxiety, and lifestyle factors. Progression in a subgroup only raises the possibility that risk factor management or other forms of treatment may prevent migraine progression. Herein, we consider the design of clinical trials for interventions which could prevent the transformation of migraine to chronic migraine. We recommend enrolling individuals at high risk for progression based on baseline high headache frequency, delivering intervention in the context of a double-blind randomized trial and assessing either the onset of chronic migraine or major change in headache frequency as outcomes.

Prognostic Significance of Personality Profiles in Patients With Chronic Migraine

The aim of this study was to assess whether the psychological profile may have prognostic significance in chronic migraine patients. The Minnesota Multiphasic Personality Inventory-2 was used for the psychological assessment of patients with chronic migraine to explore personality traits. Patients with psychiatric disease and medication overuse were excluded. One hundred and two patients completed the study. Migraine-related disability was measured using the Migraine Disability Assessment questionnaire at baseline (T(0)) and again after 2 years (T(1)), during which patients received prophylactic treatment for migraine. At T(1) patients were classified into those exhibiting significant improvement (group 1: scores reduced by at least 50%) and those with unsatisfactory changes in headache-related disability (group 2: scores reduced by less than 50%). At T(1) 49 patients were in group 1 and 53 in group 2; at T(0), group 1 patients had significantly lower Minnesota Multiphasic Personality Inventory-2 scores in the neurotic (hypochondriasis: P < .01; depression: P < .001; hysteria: P < .01) and schizophrenia (P < .05) scales. None of the other variables studied, ie, age, sex, age at migraine onset, number of years from chronic migraine onset, T(0) Migraine Disability Assessment score, T(0) headache frequency, severity and temporal pattern (continuous vs intermittent) differed significantly between the groups. Findings suggest that psychological factors can influence the clinical course of chronic migraine and that psychological evaluation with Minnesota Multiphasic Personality Inventory-2 may be a reliable approach to obtain prognostic data and information for therapy planning in patients with chronic migraine.

What incites new daily persistent headache in children?

This study asked what incites the development of a new daily persistent headache in children. A total of 175 children with chronic daily headache were prospectively identified and observed by the author. Of these patients, 40 (23%) with a new daily persistent headache were identified. These patients had no significant prior headache history. Seventeen patients (43%) had the onset of their symptoms during an infection. Of these patients, over half had positive Epstein-Barr virus serology at the onset of symptoms. Nine patients (23%) manifested minor head injuries at the onset of their symptoms, yet had a normal examination and neuroimaging. Symptom onset was also associated with surgery (four patients) and high-altitude camping (one patient). In five patients, no specific etiologic factor could be identified. Four patients were initially identified as having idiopathic intracranial hypertension, yet their chronic headache persisted despite the normalization of their intracranial pressure. Similar findings were observed in episodic migraine patients who abruptly developed the onset of chronic migraine. In conclusion, the onset of new daily persistent headache in childhood is typically associated with a physiologic stress such as an infection, head trauma, or post-surgery.