Category: Headaches

 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.

The amount of time teenagers spend in front of TV screens and monitors has been associated with physical complaints. A large study of more than 30,000 Nordic teenagers published in the open access journal BMC Public Health has shown that TV viewing, computer use and computer gaming (screen time) were consistently associated with back pain and recurrent headaches.

Torbjørn Torsheim, from the University of Bergen, Norway, worked with an international team of researchers to study the association between 'screen time' and head- or back-ache. He said, "A rising prevalence of physical complaints such as back pain, neck and shoulder pain, and headache has been reported for adolescent populations. Parallel to this, adolescents are spending an increasing amount of time on screen-based activities, such as TV, computer games, or other types of computer based entertainment."

The researchers found that there was little interaction between specific types of screen-based activity and particular physical complaints, with the exception of headache in girls, which seemed to be particularly associated with computer use and TV viewing but not gaming. Torsheim and his colleagues suggest this indicates that physical complaints are not related to the type of screen-based activity, but to the duration and ergonomic aspects of such activity.

Speaking about the findings, Torsheim said, "The consistent but relatively weak magnitude of associations is in line with the interpretation that screen time is a contributing factor, but not a primary causal factor, in headache and backache in the general population of Nordic school-aged teenagers."

---

Journal Reference:

1. Torbjørn Torsheim, Lilly Eriksson, Christina W Schnohr, Fredrik Hansen, Thoroddur Bjarnason and Raili Välimaa. Screen-based activities and physical complaints among adolescents from the Nordic countries. BMC Public Health, 2010; (in press) [link]

A single dose of 900-1000 mg aspirin can substantially reduce migraine headache pain within two hours, for more than half of people who take it. It also reduces any associated nausea, vomiting, and sensitivity to light or sound (photophobia or phonophobia). Formulations of aspirin 900 mg together with 10 mg of the antiemetic metoclopramide are better than placebo at reducing symptoms of nausea and vomiting.

These were the findings of a Cochrane Systematic Review using data from 13 studies with 4,222 participants.

Migraine affects about 18% women and 6% of men in western populations, mostly affecting people 30 to 50 years old. The common symptom, whatever type of migraine someone has, is a severe headache, typically once or twice a month, lasting between four and 72 hours.

The headache is often pounding, on one side of the head, frequently with nausea, and sometimes with vomiting. Given the numbers of people affected, and the extent of the pain caused, migraine has considerable social and economic impact.

What sufferers want is for the pain to go away completely and quickly, and not return — though for many the headache does return within 24 hours of the first attack. Despite being common and debilitating, many sufferers choose to use only medicines available without prescription from pharmacies (over the counter, OTC medicines), or use OTC medicines to supplement prescription medicines, but good reviews of the evidence have been lacking. In the review published this week, Cochrane Researchers compared the differences in response rates for people taking aspirin alone or aspirin plus an antiemetic with those of people taking placebo or another active agent.

Researchers found that severe or moderate migraine headache pain can be reduced from moderate or severe to no pain in 25% of people (one in four) within two hours by taking a single dose of 900-1000 mg aspirin alone compared to placebo, with pain reduced to no worse than mild pain in 52% (one in two). While aspirin alone reduced some of the associated symptoms of nausea, vomiting, photophobia and phonophobia, aspirin plus metoclopramide was particularly good a reducing nausea and vomiting, though it produced no greater frequency of pain relief.

Researchers also found that a combination of aspirin and metoclopramide had a similar effect to 50 mg of the headache treatment sumatriptan (a serotonin agonist), but that a 100 mg dose of sumatriptan was slightly better at delivering a pain free response within two hours of taking the medication.

In terms of adverse effects, short-term use of the different drugs produced mostly mild and transient adverse effects. These occurred more commonly when taking aspirin than when taking a placebo, and more commonly when taking 100 mg sumatriptan than when taking aspirin plus metoclopramide.

"Aspirin plus metoclopramide will be a reasonable therapy for acute migraine attacks, but for many it will be insufficiently effective," said the study leader Andrew Moore, who works in Pain Relief and the Department of Anaesthetics at the John Radcliffe Hospital, Oxford, UK.

"We are presently working on reviews of other OTC medicines for migraines, to provide consumers with the best available evidence on treatments that don't need a prescription."

---

Journal Reference:

1. Sheena Derry, R Andrew Moore, Henry J McQuay, Maura Moore. Aspirin with or without an antiemetic for acute migraine in adults. Cochrane Database of Systematic Reviews Protocols, 2009; DOI: 10.1002/14651858.CD008041

People with no health insurance are less likely than the privately insured to receive proper treatment for their migraines, according to a study published in the April 13, 2010, print issue of Neurology®, the medical journal of the American Academy of Neurology.

Migraines, often characterized by excruciating headache and nausea, can cause significant distress. They can cause people affected by them to lose an average of four to six days of work each year. Study authors say migraine sufferers who lack private health insurance are twice as likely to get inadequate treatment for their condition as their insured counterparts. Migraine patients insured through Medicaid are one and a half times as likely to receive substandard treatment.

"The tragedy is that we know how to treat this disabling condition. But because they are uninsured or inadequately insured, millions of Americans suffer needlessly," said study author Rachel Nardin, MD, of Harvard Medical School and a member of the American Academy of Neurology. "Optimizing migraine care requires improvement in our health care systems as well as educating physicians to prescribe the best available drug and behavioral treatments."

Neurologists usually recommend one of two types of drugs when a moderate-to-severe migraine strikes: "triptans" (such as sumatriptan) or dihydroergotamine. For the majority of people with migraine whose headaches are frequent or severe, neurologists also recommend a daily dose of one of several preventive medications. The researchers used these recommendations from the American Academy of Neurology to define standard migraine treatment.

For the study, the researchers analyzed data from two federal surveys, the National Hospital Ambulatory Medical Care Survey and the National Ambulatory Medical Care Survey, which provide a nationally representative sample of all US visits to doctors' offices, hospital clinics and emergency rooms. They analyzed the 6,814 visits for migraine between 1997 and 2007.

The study found that people with no insurance were twice as likely to receive substandard migraine care as people with private health insurance. Medicaid enrollees were 50 percent more likely to receive substandard treatment, suggesting that "access to some forms of insurance is not the same as access to adequate care," according to Nardin.

The uninsured and those on Medicaid were more likely to receive their migraine care in an emergency department than in a doctor's office, which explained some, though not all, of their substandard care. People were one-fifth as likely to receive standard acute treatment to stop a migraine and 10 percent as likely to receive standard treatment to prevent migraine in emergency rooms than in doctor's offices.

"This was a nationally representative sample of people, so our results give a comprehensive picture of migraine care in the entire US," Nardin said. "With approximately 15 percent of the US population currently uninsured and migraine affecting 12 percent of the population, we estimate that 5.5 million Americans are at risk of substandard treatment of their migraines and of suffering and disability that could be avoided."

---

Journal Reference:

1. Andrew Wilper, Steffie Woolhandler, David Himmelstein, and Rachel Nardin. Impact of insurance status on migraine care in the United States: A population-based study. Neurology, 2010; 74: 1178-1183 

When people feel the onset of a migraine headache, they may head to a dark, quiet room to rest. This instinct may be sound: A new study suggests that even without the headache, migraine sufferers may process visual cues better in an environment with few visual distractions.

In a study published in the April issue of Investigative Ophthalmology & Visual Science, researchers from Scotland's Glasgow Caledonian University asked migraine sufferers to pick out a small disk of light amid visual noise, an effect similar to the black-and-white snow on an off-air television. Without the visual noise, people prone to migraine could identify the light disk about as well as the control group. When the noise was added, migraine sufferers ("migraineurs") performed significantly worse.

"Our visual environment is generally very busy and full of objects, many of which are important at some times but not at others. Normally, we can attend effortlessly to those items of interest and often do not even notice others," said lead researcher Doreen Wagner, Diplom-Ingenieur (FH) of Optometry, PhD student in Vision Science. "Migraineurs may be at a disadvantage when searching for details, especially in cluttered environments."

About a third of migraine sufferers experience neurological disturbances before a headache begins. These auras are frequently visual and can appear as shimmering lights or zig-zag patterns that move across the field of vision. The study showed that migraine sufferers with auras were the most adversely affected by the addition of visual noise.

Wagner said a current theory about migraines is that nerve cells in the brain of migraineurs are excitable and when exposed to certain triggers, the increased excitability may cause whole clusters of nerve cells to become overactive, similar to a spasm, and bring on the headache. In this study, "We believe that the noise on the display overexcites the nerve cells in the brain of the migraineurs. This in turn makes it harder for a migraineur to see the disk."

Although Wagner noted that further research should examine the connections between the severity and frequency of the attacks and visual problems, she said the results may have practical applications for migraine sufferers today.

"It might be helpful to avoid such 'noisy' environments which may impair their performance, scenes overloaded with visual distracters, for example computer screens and learning tools which have a lot of visual information on them." she said.

---

Journal Reference:

1. D. Wagner, V. Manahilov, G. Loffler, G. E. Gordon, G. N. Dutton. Visual Noise Selectively Degrades Vision in Migraine. Investigative Ophthalmology & Visual Science, 2009; 51 (4): 2294 DOI: 10.1167/iovs.09-4318

Chronic migraine sufferers tend to be in poorer general health, less well off, and more depressed than those with episodic migraine, reveals research published ahead of print in the Journal of Neurology Neurosurgery and Psychiatry.

The findings are based on almost 12,000 adults with episodic — a severe headache on up to 14 days of the month — or chronic migraine — headache on 15 or more days of the month.

All participants were already part of the American Migraine Prevalence and Prevention (AMPP) study, a long term US population based study of 24,000 headache sufferers, which has included regular surveys since 2004.

The research team analysed data collected in the 2005 survey on socioeconomic circumstances and other health problems.

The results showed that those with chronic migraine had significantly lower levels of household income, were less likely to be working full time, and were almost twice as likely to have a job related disability than their peers with episodic migraine.

They were twice as likely to be depressed, anxious, and experiencing chronic pain. And they were significantly more likely to have other serious health problems.

These included asthma, bronchitis, and chronic obstructive pulmonary disease (COPD), high blood pressure, diabetes, high cholesterol and obesity. They were also around 40% more likely to have heart disease and angina and 70% more likely to have had a stroke.

The authors point out that chronic migraine "can be an especially disabling and burdensome condition."

Previous research indicates that chronic migraineurs have a relatively high level of sick leave, reduced productivity, and poorer quality of family life than episodic migraineurs.

It also suggests that few are diagnosed correctly and that only around one in three are treated appropriately.

The differences unearthed between the two groups in the present study might reflect differences in biological risk factors and provide valuable clues as to how episodic migraine progresses to chronic migraine, suggest the authors.

Migraine headache affects many people and a number of different preventative strategies should be considered, states an article in CMAJ (Canadian Medical Association Journal). The article, a primer for physicians, outlines various treatments and approaches for migraine headaches.

Migraine headache is a common, disabling condition. When migraine headaches become frequent, therapy can be challenging. Preventative therapy for migraines remains one of the more difficult aspects, as while there are valid randomized controlled trials to aid decision making, no drug is completely effective, and most have side effects.

Medications used for migraine can be divided into two broad categories: symptomatic or acute medications to treat individual migraine attacks, or preventative medications which are used to reduce headache frequency. Symptomatic migraine therapy alone, although helpful for many patients, is not adequate treatment for all. Patients with frequent migraine attacks may still have pain despite treating symptoms, and when symptomatic medications are used too often, they can increase headache frequency and may lead to medication overuse headache.

Physicians need to educate patients about migraine triggers and lifestyle factors. Common headache triggers include caffeine withdrawal, alcohol, sunlight, menstruation and changes in barometric pressure. Lifestyle factors such as stress, erratic sleep and work schedules, skipping meals, and obesity are associated with increased migraine attacks.

Overuse of symptomatic headache medications is considered by headache specialists to make migraine therapy less effective, and stopping medication overuse is recommended to improve the chance of success when initiating physician prescribed therapy.

When preventative therapy is initiated, 1 of 3 outcomes can be anticipated. Patients may show improvement, with 50% or more a reduction in headache frequency which can be assessed using a headache diary. People may develop side effects such as nausea or weight gain, or the drug may be ineffective in some individuals.

An adequate trial of medication takes 8 to 12 weeks, and more than one medication may need to be tried. There is little evidence about how long successful migraine treatment should be continued but recent studies suggest that most patients relapse to some extent after stopping medication.

---

Journal Reference:

1. Tamara Pringsheim , W. Jeptha Davenport, Werner J. Becker. Prophylaxis of migraine headache. Canadian Medical Association Journal, 2010; DOI: 10.1503/cmaj.081657

A preliminary study suggests the same type of botulinum injection used for cosmetic purposes may be associated with reduced frequency of migraine headaches that are described as crushing, vicelike or eye-popping (ocular), but not pain that is experienced as a buildup of pressure inside the head, according to a report in the February issue of Archives of Dermatology.

Migraine headaches affect approximately 28 million Americans, causing pain that is often debilitating, according to background information in the article. Researchers conducting clinical trials on botulinum toxin type A to treat facial lines recognized a correlation between injections and the alleviation of migraine symptoms. "The initial promise of a new prophylactic [preventive] therapy for migraines was met by the challenge of replication of these results," as subsequent studies have failed to demonstrate botulinum was more effective than placebo, the authors write. "Researchers have searched for patient characteristics that may predict a favorable treatment response."

Christine C. Kim, M.D., then of SkinCare Physicians, Chestnut Hill, Mass., and now in private practice in Encino, Calif., and colleagues studied 18 patients (average age 50.9) who had already received or were planning to receive botulinum injections for cosmetic purposes but also reported having migraines. Of those, 10 reported imploding headaches — described by adjectives like crushing and vice-like — or ocular headaches, reported to feel like an eye is popping out or that someone is pushing a finger into an eye. Nine patients had exploding headaches, described as feeling like one's head is going to explode or split, or that pressure is building up. Some patients had more than one type.

Three months after treatment, 13 patients had responded to the treatment with a reduction in migraine pain, including 10 who had imploding or ocular headaches and three who had exploding headaches. All six of the patients who did not respond had exploding headaches.

Among all participants who responded to treatment, migraine frequency was reduced from an average of 6.8 days per month to an average of 0.7 days per month. Patients with exploding headaches experienced an average reduction in migraine frequency of 11.4 to 9.4 days per month, whereas frequency in participants with imploding or ocular headaches reduced from an average of 7.1 days per month to 0.6 days per month.

Botulinum produces muscle paralysis, but this alone does not explain how it may prevent migraine pain, the authors note. Research indicates that it may affect the way pain signals travel through the nervous system, block pain receptors or reduce inflammation.

"These preliminary data are intriguing, and our results provide support for the hypothesis that patients with migraine that is characterized by imploding and ocular headaches are more responsive to botulinum toxin type A than those with migraine characterized by exploding headaches," the authors write. "Our findings invite consideration of using botulinum toxin type A injections to prevent migraine headaches and may promote the role of the dermatologist in the treatment of patients with migraine. However, well-controlled trials need to be conducted to confirm these findings."

This study was supported in part by a grant from Allergan Inc. and National Institutes of Health grants. Co-author Dr. Burstein serves as a consultant to Allergan Inc. and receives honoraria for lectures and grants for clinical and animal research.

---

Journal Reference:

1. Kim et al. Predicting Migraine Responsiveness to Botulinum Toxin Type A Injections. Archives of Dermatology, 2010; 146 (2): 159 DOI: 10.1001/archdermatol.2009.356

Workers and residents exposed to dust and fumes caused by the collapse of the World Trade Center on September 11, 2001 frequently reported headache years later, according to research released February 11 that will be presented at the American Academy of Neurology's 62nd Annual Meeting in Toronto April 10 to April 17, 2010.

"We knew that headaches were common in people living and working near the World Trade Center on and immediately after 9/11, but this is the first study to look at headaches several years after the event," said study author Sara Crystal, MD, with the NYU School of Medicine in New York City.

The study involved 765 people who were enrolled in the Bellevue Hospital World Trade Center Environmental Health Center seven years after the building collapse and who did not have headaches prior to 9/11. Of those, about 55 percent reported having exposure to the initial World Trade Center dust cloud.

Headaches in the four weeks prior to enrollment were reported by 43 percent of those surveyed, suggesting that headache is a common and persistent symptom in those exposed to World Trade Center dust and fumes. People caught in the initial dust cloud were slightly more likely to report headaches than those not caught in the dust cloud, which may indicate that greater exposure may be associated with a greater risk of developing persistent headache. People with headaches were also more likely to experience wheezing, breathlessness with exercise, nasal drip or sinus congestion and reflux disease after 9/11.

"More research needs to be done on the possible longer-term effects of exposure to gasses and dust when the World Trade Center fell," Crystal said. "We also need additional studies to understand the relationship between headaches, other physical symptoms, and mental health issues."

More data will be presented by Crystal at the 62nd AAN Annual Meeting.

The study was supported by the National Institutes of Health.

Migraine sufferers are twice as likely to have heart attacks as people without migraine, according to a new study by researchers at Albert Einstein College of Medicine of Yeshiva University. The study, published in the February 10 online issue of Neurology, found that migraine sufferers also face increased risk for stroke and were more likely to have key risk factors for cardiovascular disease, including diabetes, high blood pressure and high cholesterol.

"Migraine has been viewed as a painful condition that affects quality of life, but not as a threat to people's overall health," said lead investigator Richard B. Lipton, M.D., senior author of the study and professor and vice chair in The Saul R. Korey Department of Neurology at Einstein. He also directs the Headache Center at Montefiore Medical Center, the University Hospital and Academic Medical Center for Einstein.

Dr. Lipton added, "Our study suggests that migraine is not an isolated disorder and that, when caring for people with migraine, we should also be attentive to detecting and treating their cardiovascular risk factors."

More than 29 million Americans suffer from migraine, according to the National Headache Foundation. There are two major forms, migraine without aura and migraine with aura. Both forms involve pulsing or throbbing pain, pain on one side of the head, nausea or vomiting, or sensitivity to light or sound. Migraine with aura has additional neurological symptoms including flashing lights, zig-zag lines, or a graying out of vision. Migraine is most common between the ages of 25 and 55; women are affected three times more frequently than men.

Previous population studies found that migraine with aura is associated with heart disease and stroke, particularly in health care professionals over the age of 45. The Einstein study showed that both migraine with aura and migraine without aura are risk factors for heart disease and stroke in a broadly representative sample of the U.S. population, including people from all walks of life between the ages of 18 and 80.

In the study, the researchers analyzed data on 6,102 people with migraine and 5,243 people without migraine. Participants completed questionnaires that asked about general health; headache frequency, severity and symptoms; and a broad range of medically diagnosed cardiovascular symptoms and events. Data was collected as part of The American Migraine Prevalence and Prevention Study, a longitudinal, population-based study of U.S. headache sufferers.

Results showed that migraine sufferers were about twice as likely to have had a heart attack compared with people without migraine (4.1 percent of people with migraine compared with 1.9 percent of those without migraine). The heart-attack risk was higher for those whose migraine is accompanied by aura: a three-fold greater risk compared with people who didn't suffer migraine.

The data also shows that people with migraine were about 50 percent more likely than controls to have diabetes, hypertension, and elevated cholesterol, all well-known cardiovascular risk factors. The study found that these risk factors may contribute — but do not fully explain — the increased risk of heart attack and stroke in persons with migraine. This finding, according to an editorial accompanying the study, suggests a possible mechanism linking migraine headaches and cardiovascular events: the functioning of the inner layer of blood vessels, known as the endothelium, might be compromised in vessels both inside and outside the brains of migraine sufferers.

"Migraine sufferers should not be alarmed by our findings," said Dr. Lipton. "While we found an increased risk for cardiovascular problems, the percentage of people actually affected remains small. Overall, for example, only 4.1 percent of migraine sufferers had heart attacks. And while the risk of stroke was 60 percent higher for migraine sufferers than for the rest of the population, the percentage of migraine sufferers experiencing strokes was still quite low — 2 percent."

The main message of the study, said Dr. Lipton, is that migraine patients and their doctors should be particularly attentive to identifying and managing cardiovascular risk factors, such as high blood pressure, high cholesterol, obesity, and diabetes.

"We hope these findings will motivate migraine sufferers to exercise regularly, to avoid smoking and to address their other health problems," said Dawn Buse, Ph.D., assistant professor in The Saul R. Korey Department of Neurology and co-author of the study. "It is important to view migraine as more than a series of individual attacks. We need to think about migraine as a chronic disorder with episodic attacks — and between those attacks, migraine sufferers have an enduring predisposition to cardiovascular events. In that sense, migraine has a lot in common with conditions like asthma, where sufferers seem fine between attacks, but there is more going on beneath the surface."

In follow-up studies, Dr. Lipton and his colleagues aim to assess the importance of headache frequency and severity, aura frequency, and other factors influencing cardiovascular risk. They also hope to assess whether effective migraine treatment reduces that risk.

The first author of the study is Marcelo E. Bigal, M.D., Ph.D., a scientist with Merck Research Laboratories and an associate clinical professor in The Saul R. Korey Department of Neurology at Einstein. His co-authors include Matthew S. Robbins, M.D., at Einstein; Tobias Kurth, M.D., Ph.D. at Harvard Medical School; and Nancy Santanello, M.D. and Wendy Golden, M.S., at Merck, Inc.

The American Migraine Prevalence and Prevention Study was funded through a research grant to the National Headache Foundation from Ortho-McNeil Neurologics, Inc., Titusville, NJ. Additional data collection was supported by Merck & Co., Inc.