Category: Headaches

Psychological migraine treatment gives sufferers a confidence boost in their ability to self-manage their symptoms.

For severe migraine sufferers, psychological treatments build on the benefits of drug therapy, according to a new study by Elizabeth Seng and Dr. Kenneth Holroyd from Ohio University in the US. Their comparison of the effects of various treatment combinations for severe migraine — drug therapy with or without behavioral management — shows that those patients receiving the behavioral management program alongside drug therapy are significantly more confident in their ability to use behavioral skills to effectively self-manage migraines. And surprisingly, the increase in confidence in self-management abilities is greatest among those who feel that they have very little control over their condition before treatment starts. Seng's and Holroyd's findings are published online in Springer's journal Annals of Behavioral Medicine.

Seng and Holroyd analyzed data for 176 participants in the US Treatment of Severe Migraine Trial. Treatment programs included acute drug therapy for all, with either β-blockers or placebo — each with or without behavioral migraine management. The behavioral migraine management program consisted of demonstrations of migraine management skills during four monthly clinic visits, which were then applied between sessions by participants through workbooks, audiotape lessons, and guided home practice.

Their analyses showed that the addition of behavioral migraine management to drug therapy dramatically increased participants' confidence in their ability to effectively self-manage migraine, compared to migraine drug therapy alone. Behavioral management also increased participants' belief that migraines can be influenced by one's own behavior and decreased the belief that migraines are primarily influenced by chance or fate.

The authors conclude: "Our exploratory analyses offer an optimistic message: brief psychological interventions for migraine management can effectively increase sufferers' confidence in self-management and can be long-lasting." Psychological interventions enhanced drug therapy, enabling participants to take a more active role in their treatment by using behavioral skills to manage migraines.

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Journal Reference:

1. Elizabeth K. Seng, Kenneth A. Holroyd. Dynamics of Changes in Self-Efficacy and Locus of Control Expectancies in the Behavioral and Drug Treatment of Severe Migraine. Annals of Behavioral Medicine, 2010; DOI: 10.1007/s12160-010-9223-3

A world-wide collaboration of researchers has identified the first-ever genetic risk factor associated with common types of migraine. The researchers, who looked at the genetic data of more than 50,000 people, have produced new insights into the triggers for migraines attacks and they hope their research will open the door for novel therapeutics to prevent migraine attacks.

The team found that patients with a particular DNA variant on Chromosome 8 between two genes — PGCP and MTDH/AEG-1 — have a significantly greater risk for developing migraine. The team also discovered a potential explanation for this link. It appears that the associated DNA variant regulates levels of glutamate — a chemical, known as a neurotransmitter, which transports messages between nerve cells in the brain. The results suggest that an accumulation of glutamate in nerve cell junctions (synapses) in the brain may play a key role in the initiation of migraine attacks. Prevention of the build up of glutamate at the synapse may provide a promising target for novel therapeutics to ease the burden of the disease.

Migraine affects approximately one in six women and one in twelve men, and has been estimated to be the most expensive brain disorder to society in the EU and US. A US report measures its economic costs as similar to those of diabetes and WHO lists it as one of the top 20 diseases with years lived with disability (YLDs).

Although researchers have in the past described genetic mutations giving rise to rare and extreme forms of migraine, this is the first time a team has identified a genetic variant giving rise to the common form of the condition.

"This is the first time we have been able to peer into the genomes of many thousands of people and find genetic clues to understand common migraine," said Dr Aarno Palotie, chair of the International Headache Genetics Consortium at the Wellcome Trust Sanger Institute, which spearheaded the study.

"Studies of this kind are possible only through large-scale international collaboration — bringing together the wealth of data with the right expertise and resources — so that we could pick out this genetic variant. This discovery opens new doors to understand common human diseases."

The researchers carried out what is known as a genome-wide association study (GWAS) to zoom in on genome variants that could increase susceptibility to migraine. The team compared the genomes of more than 3000 people from Finland, Germany and The Netherlands with migraine with the genomes of more than 10,000 non-migraineurs, recruited from pre-existing studies, to spot differences that might account for one group's increased susceptibility to migraine. To confirm their link, the team compared the genomes of a second group of more than 3000 patients with more than 40,000 apparently healthy people.

The statistical analysis revealed that a DNA variation found between the PGCP and MTDH/AEG-1 genes on chromosome 8 appears to be associated with increased susceptibility to common migraine. The variant appears to alter the activity of MTDH/AEG-1 in cells, which regulates the activity of the EAAT2 gene: the EAAT2 protein is responsible for clearing glutamate from brain synapses in the brain. EAAT2 has previously been linked with other neurological diseases, including epilepsy, schizophrenia and various mood and anxiety disorders.

"Although we knew that the EAAT2 gene has a crucial role to play in neurological processes in human and potentially in the development of migraine, until now, no genetic link has been identified to suggest that glutamate accumulation in the brain could play a role in common migraine," says co-senior author of the study Professor Christian Kubisch of University of Ulm, Germany (previously at the University of Cologne where he conducted his research for this study.) "This research opens the door for new studies to look in depth at the biology of the disease and how this alteration in particular may exert its effect."

The authors caution that further study will be needed, both into the DNA variant and its regulatory effect on the genes flanking it, to shed light on the mechanism for the occurrence of migraine attacks, and further research to find additional contributing genetic factors. The authors also suggest that broader population samples should be interrogated.

"Although the patients in the study were all diagnosed with common migraine, they were largely recruited from specialist headache clinics," says and Dr Gisela Terwindt of Leiden University Medical Center, another senior author of the study. "Because they are attending headache clinics they are likely to represent only the more extreme end of those who suffer common migraine. In the future, we should look at associations across the general population, including also people who are less severely affected."

A collaboration between more than 40 centres from around the world, steered by the International Headache Genetics Consortium, produced the findings.

About migraine

The World Health Organization defines migraine as a headache disorder where pain-producing inflammatory chemicals are released around the nerves and blood vessels in the head. Migraine commonly begins in puberty and but tends to affect people aged between 35 to 45 years of age. People with migraines most commonly have an attack approximately once a month, but the frequency can range between once a year and once a week.

A migraine attack in an adult can last anywhere between a few hours to two to three days. The pain is moderate or severe and can either be localised to one side of the brain or pulsing. The migraine attack may be accompanied with nausea and may be produce an intolerance of normal levels of light and sound. Normal levels of physical activity may also increase the severity of the symptoms. Migraine attacks in children are more likely to feature nausea and be shorter in duration.

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Journal Reference:

1. Verneri Anttila, Hreinn Stefansson, Mikko Kallela, Unda Todt, Gisela M Terwindt, M Stella Calafato, Dale R Nyholt, Antigone S Dimas, Tobias Freilinger, Bertram Müller-Myhsok, Ville Artto, Michael Inouye, Kirsi Alakurtti, Mari A Kaunisto, Eija Hämäläinen, Boukje de Vries, Anine H Stam, Claudia M Weller, Axel Heinze, Katja Heinze-Kuhn, Ingrid Goebel, Guntram Borck, Hartmut Göbel, Stacy Steinberg, Christiane Wolf, Asgeir Björnsson, Gretar Gudmundsson, Malene Kirchmann, Anne Hauge, Thomas Werge, Jean Schoenen, Johan G Eriksson, Knut Hagen, Lars Stovner, H-Erich Wichmann, Thomas Meitinger, Michael Alexander, Susanne Moebus, Stefan Schreiber, Yurii S Aulchenko, Monique M B Breteler, Andre G Uitterlinden, Albert Hofman, Cornelia M van Duijn, Päivi Tikka-Kleemola, Salli Vepsäläinen, Susanne Lucae, Federica Tozzi, Pierandrea Muglia, Jeffrey Barrett, Jaakko Kaprio, Markus Färkkilä, Leena Peltonen, Kari Stefansson, John-Anker Zwart, Michel D Ferrari, Jes Olesen, Mark Daly, Maija Wessman, Arn M J M van den Maagdenberg, Martin Dichgans, Christian Kubisch, Emmanouil T Dermitzakis, Rune R Frants, Aarno Palotie. Genome-wide association study of migraine implicates a common susceptibility variant on 8q22.1. Nature Genetics, 2010; DOI: 10.1038/ng.652

Individuals who suffer from migraines with aura (temporary visual or sensory disturbances before or during a migraine headache) are at a higher risk of dying from heart disease or stroke, according to research published online in the British Medical Journal.

This is the first large population-based study showing a link between migraine and overall mortality as well as specific mortality.

The findings support increasing evidence that migraine, particularly with aura, is associated with death from heart disease. The researchers stress, however, that the individual risk for a migraine sufferer remains low.

The authors, led by Larus Gudmundsson from the University of Iceland, assessed the impact of mid-life migraine episodes in 18,725 men and women born between 1907 and 1935 who took part in the Reykjavik Study (set up in 1967 by the Icelandic Heart Association to study heart disease in Iceland). In total the research team explored over 470,000 person-years of data with a follow-up of 26 years.

Gudmundsson and colleagues used questionnaires to assess migraine with and without aura.

The results concluded that men and women who suffered from migraine with aura were at an increased risk of dying from all causes, as well as heart disease and stroke, while those with migraine without aura were not at increased risk.

Furthermore, the study says that women who experience migraine with aura are also at a higher risk of dying from causes other than cardiovascular disease or cancer. "However, it remains to be seen which diseases drive the risk increase seen for women with migraine," say the researchers.

The researchers conclude that the individual risk faced by migraine sufferers is low, and efforts to reduce heart disease deaths should focus on conventional risk factors such as high blood pressure, smoking and high cholesterol, regardless of migraine status.

They call for more research on the association between migraine and death from cardiovascular disease and all other causes. "Finally, studies are needed to determine if reducing the frequency of attacks with migraine preventive treatment might reduce the risk of cardiovascular disease," they add.

A second paper, also published online in the British Medical Journal, finds that female sufferers of migraines with aura are also at a higher risk of haemorrhagic stroke (where bleeding occurs in the brain). These account for around 20% of all strokes. However, lead author, Dr Tobias Kurth, Director of Research at INSERM, argues that the risk remains low and further research is required to confirm these findings.

Dr Klaus Berger from the University of Muenster in Germany has written an editorial to accompany the first study and questions whether doctors should inform patients about the risks associated with migraine with aura. Berger argues that "for many people the information will cause an unwarranted amount of anxiety, although others may use the opportunity to modify their lifestyle and risk factors accordingly" and that "clinicians must carefully weigh the decision whether or not to discuss the risks related to this condition."

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Journal References:

1. L. S. Gudmundsson, A. I. Scher, T. Aspelund, J. H. Eliasson, M. Johannsson, G. Thorgeirsson, L. Launer, V. Gudnason. Migraine with aura and risk of cardiovascular and all cause mortality in men and women: prospective cohort study. BMJ, 2010; 341 (aug24 1): c3966 DOI: 10.1136/bmj.c3966
2. T. Kurth, C. S. Kase, M. Schurks, C. Tzourio, J. E. Buring. Migraine and risk of haemorrhagic stroke in women: prospective cohort study. BMJ, 2010; 341 (aug24 1): c3659 DOI: 10.1136/bmj.c3659
3. K. Berger, S. Evers. Migraine with aura and the risk of increased mortality. BMJ, 2010; 341 (aug24 1): c4410 DOI: 10.1136/bmj.c4410

Teens who are overweight, get little exercise or who smoke may be more likely to have frequent headaches and migraines than teens with none of these factors, according to a study published in the August 18, 2010, online issue of Neurology®, the medical journal of the American Academy of Neurology.

Teens with all three of the negative lifestyle factors were 3.4 times more likely to have frequent headaches than those with none of the negative lifestyle factors. Of those with all three negative lifestyle factors, 55 percent had frequent headaches, compared to 25 percent of those with no negative lifestyle factors. Those with two negative factors were 1.8 times more likely to have frequent headaches.

Overweight teens were 40 percent more likely to have frequent headaches than those with no negative factors. Teens who smoked were 50 percent more likely to have frequent headaches, and teens who exercised less than twice a week were 20 percent more likely to have frequent headaches than those who exercised at least twice a week and had no other negative factors.

"These lifestyle factors have rarely been studied in teens," said Andrew D. Hershey, MD, PhD, of the University of Cincinnati College of Medicine and a member of the American Academy of Neurology, who wrote an editorial accompanying the study. "This study is a vital step toward a better understanding of lifestyle factors and potential preventive measures that can be taken."

As part of the Nord-Trøndelag Health Study, 5,847 students age 13 to 18 in Nord-Trøndelag county in Norway were interviewed by nurses about headaches and their weight and height measurements were taken. They also completed a questionnaire about physical activity and smoking. Out of the group, 36 percent of girls and 21 percent of boys reported having recurrent headaches within the last year.

A total of 16 percent of the students were overweight, 19 percent were smokers, and 31 percent exercised less than twice a week.

Study author John-Anker Zwart, MD, PhD, of the University of Oslo said the study suggests that the treatment and prevention of headaches in teens may need to include management of healthy habits such as regular exercise, healthy food choices and stopping smoking.

The Nord-Trøndelag Health Study is a collaboration of HUNT Research Centre, the Norwegian University of Science and Technology, Norwegian Institute of Public Health and the Nord-Trøndelag County Council.

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Journal Reference:

1. Andrew D. Hershey, Richard B. Lipton. Lifestyles of the young and migrainous. Neurology, 2010; DOI: 10.1212/WNL.0b013e3181eee4ff

Researchers at the University of Granada — in collaboration with the Clinical Hospital San Cecilio and the University Rey Juan Carlos — have shown that the psychological and physiological state of patients with tension headache improves within 24 hours after receiving a 30-minute massage.

As researchers explained, tension headaches have an increasing incidence in the population. This type of disorder is usually treated with analgesics, that relieve symptoms temporarily. One of the main causes of this type of headache is the presence of trigger points. Recently, new strategies for controlling this disabling pain are being studied.

Physiological improvement

Researcher Cristina Toro Velasco — leader of the study, under Professor Manuel Arroyo Morales supervision — has shown that a 30-minute massage on cervical trigger points improves autonomic nervous system regulation in these patients. Additionally, patients exhibit a better psychological state and "reduce the stress and anxiety associated to such a disturbing disorder."

Similarly, patients report a perceived relief from symptoms within 24 hours after the massage. This might mean that massages may reduce the pain caused by trigger points, which would involve an improvement in the general state of patients.

The results of this pioneer study were published in American Journal of Manipulative Physiological and Therapeutics.

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Journal Reference:

1. Cristina Toro-Velasco, Manuel Arroyo-Morales, César Fernández-de-las-Peñas, Joshua A. Cleland, Francisco J. Barrero-Hernández. Short-Term Effects of Manual Therapy on Heart Rate Variability, Mood State, and Pressure Pain Sensitivity in Patients With Chronic Tension-Type Headache: A Pilot Study. Journal of Manipulative and Physiological Therapeutics, 2009; 32 (7): 527 DOI: 10.1016/j.jmpt.2009.08.011

 Some 19 percent of soldiers returning from Iraq have migraine and migraine is suspected in another 17 percent. While prevalence of migraine among the U.S. military is well documented, little is known about sleep quality in soldiers with chronic headaches including post-traumatic headache and migraine.

A research team from the Madigan Army Medical Center in Tacoma, WA presenting at American Headache Society's 52nd Annual Scientific Meeting in Los Angeles found that although sleep quality is poor in soldiers with post-traumatic headache, treatment including education can improve the condition.

"The research sought to determine if treatment for headache and insomnia could improve sleep quality among our patients with post-traumatic headaches," said Cong Zhi Zhao, MD, lead author of the study. "We found that three months after initial treatment, those with post-traumatic headache reported significantly improved sleep quality and sleep onset than baseline, although their nightmares and interrupted sleep were not significantly changed."

"Post-traumatic headache and migraine is an important cause of disability in our soldiers that affects their field performance and their lives after returning from the battlefield," said David Dodick, M.D., president of the AHS. "Sleep quality is an important factor which is both a result of and a contributing factor to the disability imposed by these disorders, so this work is an important step in understanding the influence of effective headache treatment on sleep quality"

More than 200 scientific papers and posters are being presented during the AHS meeting which is expected to draw some 500 migraine and headache health professionals including doctors, researchers, and specialists.

 Migraine sufferers who experienced abuse and neglect as children have a greater risk of cardiovascular (CV) disease including stroke and myocardial infarction (MI) among others, say scientists presenting data at the American Headache Society's 52nd Annual Scientific Meeting in Los Angeles.

In a multi-center, cross-sectional study of more than 1,300 headache clinic patients diagnosed with migraine, investigators found a linear relationship between the risk of stroke, transient ischemic attack (TIA), MI, or all of these adverse outcomes and the total number of abuse types they experienced as children (physical, emotional or sexual abuse, or physical or emotional neglect.)

Patients in the study completed a self-administered electronic questionnaire which collected information on age, gender, race, highest educational level attained, body mass index, smoking status, history of childhood maltreatment, as well as self-reported physician-diagnosed CV conditions and risk factors such as hypertension, diabetes, obesity, and obstructive sleep apnea. The Childhood Trauma Questionnaire was used to assess physical, sexual, emotional abuse and physical, emotional neglect.

"It is clear from this work that early adverse experiences influence a migraine sufferers' cardiovascular health in adulthood," said Gretchen E. Tietjen, MD, of the University of Toledo College Of Medicine, who led the team from 11 neurology centers in the U.S. and Canada. "Other work has shown a link between childhood maltreatment and migraine and now we know that early abuse puts these adults at a greater risk of cardiovascular and cerebrovascular disease.

"Dr. Tietjen and her teams are pioneers in understanding the relationship between negative childhood experiences and migraine," said David Dodick, M.D., president of the AHS. "Now we need to drill even deeper to understand the relationship between migraine, aura status, childhood maltreatment and CV disease risk."

Researchers looking for the first time at how migraine sufferers experience the stigmatizing effects of their disease show that chronic migraine sufferers experience worse stigma than episodic migraine sufferers and more than those with other neurological diseases including stroke, epilepsy and MS.

The research, presented at the American Headache Society's 52nd Annual Scientific Meeting in Los Angeles, was conducted at the Jefferson Headache Clinic at Thomas Jefferson University Hospital in Philadelphia by Jung E. Park, MD and her team.

"Many diseases like HIV, mental illness, and cancer can be highly stigmatizing, resulting in depression, anxiety, decreased quality of life, and disruption of social relationships," said Dr. Park. "Our goal was to understand how stigma attaches to migraine."

The team surveyed 123 outpatients with chronic migraine (CM) and 123 with episodic migraine (EM) ages 18 to 65 using the Stigma Scale for Chronic Illness (SSCI), a recently developed 24-item instrument that allows for the quantitative assessment of stigma in persons with neurological disorders and comparisons across disorders, the Migraine Disability Scale (MIDAS), and the SF-12, a quality of life measure.

"The SSCI was markedly different in EM vs. CM (41.6±14.84 vs. 54.05±20.15, (p<0.001)," Dr. Park noted, "while patients with chronic neurologic diseases; stroke, epilepsy, multiple sclerosis, Alzheimer's, ALS and Parkinson's disease had a mean score of 42.7±19.7." In migraine, stigma correlated with disability as measured by MIDAS, and negatively with the physical and mental components of quality of life, measured by SF-12, although the correlations were not strong. "We were surprised not only by the degree of stigmatization experienced by the individuals with migraine, but also by how little we could explain by disability and quality of life.

"It is as important to understand the impact of migraine on patient quality of life as it is to understand its medical and physiological impact," said David Dodick, M.D., president of the AHS. "Our hope is that work like this will ultimately aid in the development of public health strategies to combat the stigmatizing effects of migraine."

Dr Park agrees, and hopes that by understanding what drives the stigmatizing effect, and perhaps what protects certain individuals from feeling stigmatized we can improve the lives of persons with migraine. To round out the picture we should eventually understand stigmatization not just from the patient's perspective but also the attitudes of the families, employers and acquaintances who stigmatize persons with migraine, rounding out the picture and in order to devise more effective public health strategies.

Children who experience maltreatment such as emotional, physical and sexual abuse are more likely to experience frequent headaches, including chronic migraine, as adults, say scientists presenting data at the American Headache Society's 52nd Annual Scientific Meeting in Los Angeles.

Using data from the Adverse Childhood Experiences (ACE) Study of 17,337 adult members of the Kaiser Health Plan in San Diego, Gretchen E. Tietjen, MD, of the University of Toledo College Of Medicine, and her team found that the number of ACEs showed a graded relationship to the likelihood of experiencing frequent headaches. Her study was supported by the Centers for Disease Control and Prevention.

"We looked at eight ACEs — emotional, physical, or sexual abuse, witnessing domestic violence, growing up with mental illness in the home, having household members who were incarcerated or were abusing drugs, and experiencing parental separation or divorce,." said Dr. Tietjen. "Each ACE increased the chance of frequent headache, and as the number of ACEs increased, so did the risk of frequent headache. This 'dose-response' relationship' suggests that ACEs may contribute to the development and frequency of severe headaches later in life."

"Earlier studies have linked childhood maltreatment to frequent headaches and migraine," said David Dodick, M.D., president of the AHS. "The biological underpinnings of this relationship should be a target of future research and clinicians should be aware of and evaluate for this important relationship in order to facilitate appropriate management strategies"

Reporting at the American Headache Society's 52nd Annual Scientific Meeting in Los Angeles, scientists say new research shows that sleep deprivation leads to changes in the levels of key proteins that facilitate events involved in the underlying pathology of migraine.

Paul L. Dunham, Ph.D. and his team at Missouri State University's Center for Biomedical & Life Sciences sought to understand the mechanisms by which sleep disturbance increases the risk of migraine and may even trigger migraine.

"Previous clinical data support a relationship between sleep quality and migraine," said Dr. Durham, "so we used an established model of sleep deprivation to measure levels of proteins that lower the activation threshold of peripheral and central nerves involved in pain transmission during migraine. We found that REM sleep deprivation caused increased expression of the proteins p38, PKA, and P2X3, which are known to play an important role in initiating and sustaining chronic pain."

"So little is known about the biological mechanisms that underlie how certain factors trigger a migraine attack," said David Dodick, M.D., president of the AHS. "This is important work and this Missouri State team should be applauded for beginning to shed light on an area desperately in need of investigation."

The work was supported by Merck & Co.

More than 200 scientific papers and posters are being presented during the AHS meeting which is expected to draw some 500 migraine and headache health professionals including doctors, researchers, and specialists.