Category: Headaches

Middle-aged women who had migraine headaches with aura (sensory disturbances, such as with vision, balance or speech) had a higher prevalence of brain lesions when they were older, compared to individuals without similar types of headaches, according to a new study.

Migraine is a common neurovascular disorder that affects approximately 11 percent of adults and is more common in women than men. Approximately one-third of individuals with migraine experience neurological aura symptoms before headache onset (migraine with aura). Migraine is considered to be an episodic condition with no long-term consequences. However, recent studies suggest that migraine attacks may be associated with brain lesions identified on magnetic resonance imaging (MRI), particularly in the cerebellum, according to background information in the article.

Ann I. Scher, Ph.D., of Uniformed Services University, Bethesda, Md., and colleagues examined the relationship of midlife migraine symptoms and late-life infarct (tissue death)-like lesions evident on MRI. The study included 4,689 men and women in Reykjavik, Iceland (born between 1907-1935; 57 percent women) who were followed-up since 1967, examined, and interviewed about migraine symptoms in midlife (average age, 51 years; range, 33-65 years).

Between 2002 and 2006, more than 26 years later, brain MRIs were performed. Participants reporting headaches once or more per month were asked about migraine symptoms and were classified as having migraine without aura, migraine with aura, or nonmigraine headache. A comprehensive cardiovascular risk assessment was performed at examinations. Infarct-like lesions were present on MRI in 39.3 percent of men and 24.6 percent of women.

After adjusting for age, sex, and follow-up time, participants with midlife migraine with aura were at increased risk for total infarct-like lesions. Lesions in the cerebellum, but not in other locations of the brain, were more prevalent in women with migraine with aura compared with women without headache (23 percent vs. 15 percent); there was no difference in prevalence for men (19 percent vs. 21 percent).

The relationship between migraine with aura and cerebellar infarcts was only significant in women, but was not statistically different by the age at which headache symptoms were assessed. Migraine without aura and nonmigraine headache were not associated with an increased risk of lesions. The clinical significance of the infarct-like lesions, such as whether the individuals with them had any symptoms, was not assessed.

"In summary, this study suggests that a remote history of migraine with aura is associated with brain lesions commonly found in older populations. Results persisted after controlling for cardiovascular risk factors and history of cardiovascular disease, thus suggesting that the mechanism linking the migraine aura with these lesions is independent of the usual risk factors for ischemic vascular disease and may be specifically related to migraine with aura. Additional longitudinal studies with repeated MRIs are needed to better establish the temporality and dose-response relationship between migraine with aura and brain infarcts. Finally, the clinical implications of the infarct-like lesions identified have not been established and will require investigation," the authors write.

Editorial: Migraine and Cerebral Infarct-like Lesions on MRI

Tobias Kurth, MD, Sc.D., of the University Pierre et Marie Curie, Paris, and Christophe Tzourio, M.D., Ph.D., of the University Pierre et Marie Curie and Harvard School of Public Health, Boston, write in an accompanying editorial that the clinical implications of this study "should be interpreted with caution."

"In the absence of the source and the nature of infarct-like lesions and the absence of clinical symptoms or consequences, it is premature to conclude that migraine has hazardous effects on the brain. In this regard, brain scans among patients with migraine should not be initiated to detect silent brain lesions but to rule out rare secondary forms of migraine among those patients with atypical migraine forms or migraine courses. However, the study raises important questions. New studies examining the association of migraine with structural brain changes and brain function should improve understanding of the associations and perhaps further unveil migraine-specific mechanisms."

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Journal Reference:

1. Ann I. Scher, PhD; Larus S. Gudmundsson, MSc; Sigurdur Sigurdsson, MSc; Anna Ghambaryan, MD; Thor Aspelund, PhD; Guðny Eiriksdottir, MSc; Mark A. van Buchem, MD, PhD; Vilmundur Gudnason, MD, PhD; Lenore J. Launer, PhD. Migraine Headache in Middle Age and Late-Life Brain Infarcts. JAMA, 2009;301(24):2563-2570 [link]

Researchers are calling for space headache to be established as a new secondary disorder after carrying out a study of 17 astronauts, published in the June issue of Cephalalgia.

Their study jettisons the theory that astronauts’ headaches are normally caused by space motion sickness, after showing that more than three-quarters of those studied had no connection.

“Our research shows that space flights may trigger headaches without other space motion sickness symptoms in otherwise super healthy subjects” says lead researcher Dr Alla Vein from Professor Michel Ferrari’s Headache Research team at the Department of Neurology, Leiden University Medical Center, The Netherlands.

“We propose to classify space headache as a separate entity among the secondary headaches attributed to disorders of homeostasis, which is the maintenance of a constant internal environment within the body.”  

The research team asked one female and 16 male astronauts, ranging from 28 to 58 years of age, to provide anonymous feedback on headaches experienced during four specific time frames – launch, the stay at the space station, activities outside the space station and landing.    

All the astronauts had undergone rigorous medical examinations before they went into space. Nine has taken part in short-duration missions averaging just under 11 days and eight had taken part in long-duration missions averaging just under 202 days.

Key findings included:

• 12 of the 17 astronauts (71 per cent) reported 21 headache episodes during the space missions – nine during launch, nine during the stay at the space station, one during activities outside the space station and two during landing. None of the astronauts had a history of recurrent headache on earth.
• Five astronauts reported headaches during one of the time frames, six during two time frames and one during four time frames.
• Headache severity ranged from mild to severe, with 29 per cent reporting mild intensity, 65 per cent reporting moderate intensity and six per cent reporting severe intensity.
• Only two of the headaches, during launch, matched the international criteria for migraine and the remainder were tension-type or non-specific headaches.
• In 77 per cent of the episodes the astronauts described their headache as “exploding” and, or, “heavy feeling”.
• Launch headaches lasted for an average of 5.6 hours and space station headaches for an average of 1.6 hours.
• When each headache was assessed, 76 per cent demonstrated no association with the main symptoms of space motion sickness, such as nausea, vomiting or vertigo.

“Although headaches in space are not generally considered to be a major issue, our study demonstrated that disabling headaches frequently occur during space missions in astronauts who do not normally suffer from headaches on earth” says Dr Vein.

“Previous research has shown that astronauts can be reluctant to reveal all the physical complaints they experience in space, so the actual incidence could be even higher than our study suggests.”

The authors state that there are a number of reasons why space travel could cause headaches including the physical effects of microgravity.

“Our research shows that space headache is a common and often isolated disabling complaint during space flight” concludes Dr Vein.

“As such we feel that it should be classified as a new secondary headache.”

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Journal Reference:

1. Vein et al. Space headache: a new secondary headache. Cephalalgia, 2009; 29 (6): 683 DOI: 10.1111/j.1468-2982.2008.01775.x

A pain condition common in people with migraines also has a high prevalence in patients with cluster headache, according to a study conducted by researchers at the Jefferson Headache Center at Jefferson Hospital for Neuroscience.

Approximately half of a group of patients with cluster headaches experienced cutaneous allodynia, a condition that causes patients to have pain as a response to normally inconspicuous sensations, according to Michael Marmura, M.D., assistant professor of Neurology at Jefferson Medical College of Thomas Jefferson University.

The study, which was published in the Journal of Headache and Pain, included 41 patients with either chronic or episodic cluster headaches. The researchers tested for allodynia by brushing a gauze pad over the forehead, neck and forearms. Patients then reported if the gauze was painful or unpleasant, or not.

Twenty of the patients experienced allodynia, with the most common site of pain being the forehead. There were no significant differences between patients who experienced allodynia and patients who did not. The majority of patients were using preventive medications, which is a limitation of the study.

According to Dr. Marmura, allodynia has typically been described in migraines, but this is the largest study to date showing that allodynia occurs in cluster headache.

"It was surprising to find that allodynia was so common in patients with cluster headaches," Dr. Marmura said. "This could have important treatment implications, and suggests that there may be overlap in mechanisms for pain between migraines and cluster headaches."

Patients living with migraine have strong reason for new optimism concerning a positive future. Two review articles and an accompanying editorial, "The Future of Migraine: Beyond Just Another Pill," in the current issue of Mayo Clinic Proceedings, are the basis for an ironic premise.

"Migraine is a potentially chronic, progressive disease that substantially affects patients, families, workplaces, and society," according to the editorial written by Roger Cady, M.D., of the Headache Care Center in Springfield, Mo. "Ironically, this is the springboard for renewed optimism of a more positive future for patients living with migraine."

Traditionally, Dr. Cady explains, migraine has been considered a pain disorder involving separate or even sporadic episodes. Now, the condition is defined as an all-encompassing and progressive disease that negatively affects all aspects of an individual's life. Migraine can erode quality of life during what should be a person's most productive years, according to Dr. Cady. Because migraine patients' quality of life has not improved at a pace with medical advances, research is addressing the overall severity and potential progressive nature of migraine, especially migraine episodes as a forerunner of chronic migraine.

According to the three articles, these new insights and understandings are requiring professionals to explore well beyond traditional migraine management. "Understanding migraine as a potentially chronic disease mandates a collaborative health care model with patients and health care professionals working in a partnership toward common therapeutic goals," writes Dr. Cady, specifically intervention and prevention. Physicians and patients must be encouraged to be partners, he says, and evaluation must go far beyond the physician just asking, "How are your migraines?" The models must include an invitation to comprehend and address all migraine-related health issues facing patients, Dr. Cady writes. In addition, understanding the evolutionary "stages" of migraine from sporadic to persistent offers an opportunity to develop new therapies that individualize and personalize care.

In the future, successful management of migraine will ideally be measured not by stopping an attack but by overall disease management and prevention, according to the researchers.

This new understanding of migraine as a chronic disease offers many challenges and rewards, according to Dr. Cady. "Today, the focus of care is rapidly changing from the event of the migraine to the patient with migraine," he notes. These changes present great promise for patients and health care professionals alike, representing assurances of a better future for patients with migraine, concludes Dr. Cady.

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Journal References:

1. Roger K. Cady. The Future of Migraine: Beyond Just Another Pill. Mayo Clinic Proceedings, 2009; 84 (5): 397 DOI: 10.4065/84.5.397
2. Dawn C. Buse, Marcia F. T. Rupnow, Richard B. Lipton. Assessing and Managing All Aspects of Migraine: Migraine Attacks, Migraine-Related Functional Impairment, Common Comorbidities, and Quality of Life. Mayo Clinic Proceedings, 2009; 84 (5): 422 DOI: 10.4065/84.5.422
3. Wayne N. Burton, Stephen H. Landy, Kristen E. Downs, M. Chris Runken. The Impact of Migraine and the Effect of Migraine Treatment on Workplace Productivity in the United States and Suggestions for Future Research. Mayo Clinic Proceedings, 2009; 84 (5): 436 DOI: 10.4065/84.5.436

A new UCSF study examining the mechanism of a novel therapy that uses magnetic pulses to treat chronic migraine sufferers showed the treatment to be a promising alternative to medication.

The therapy is called transcranial magnetic stimulation, or TMS. Study findings were presented April 29, 2009 during the annual American Academy of Neurology scientific meeting in Seattle.

In a previous randomized controlled clinical study by Ohio State University Medical Center, TMS was used to treat patients who suffer from migraine with aura, a condition in which a variety of mostly visual sensations come before or accompany the pain of a migraine attack. The study showed that TMS treatment was superior to the placebo given to the control group. Patients were pain-free at follow-up intervals of 2, 24 and 48 hours.

In the new study, conducted in rats, UCSF researchers focused on understanding the mechanism of action of TMS therapy — how the treatment interacted with the brain to produce the pain-free outcomes of patients in the previous study.

The UCSF research identified potential opportunities to enhance treatment strategies in patients. One example, the study team noted, was that factors such as time and peak intensity of stimulation may be important components in the brain's response to TMS.

"The data demonstrate a biological rationale for the use of TMS to treat migraine aura," said Peter Goadsby, MD, PhD, lead investigator of the study, professor and director of the UCSF Headache Center. "We found that cortical spreading depression, known as CSD and the animal correlate of migraine aura, was susceptible to TMS therapy, with the wave of neuronal excitation blocked on over 50 percent of occasions."

The study findings showed that migraine aura responds to magnetic stimulation because TMS therapy blocks the wave of neuronal excitation, which is a biological system through which neurons become stimulated to fire. TMS creates a focused magnetic pulse that passes noninvasively through the skull, inducing an electric current to disrupt the abnormal brain waves believed to be associated with migraine, including CSD. CSD in humans precedes migraine with aura.

The American Academy of Neurology estimates that over 30 million Americans suffer from migraine, a syndrome characterized by recurrent, often excruciating headaches. The National Headache Foundation estimates that migraine causes 157 million lost workdays each year due to pain and associated migraine symptoms, resulting in a $13 billion burden to American employers.

Further research is needed, the UCSF team said, but the findings give neurologists a potential new treatment option for migraine sufferers unable to tolerate medication, which can cause stomach bleeding and other painful side effects.

Additional study investigators were Philip R. Holland, PhD, UCSF; Carol T. Schembri and Joe P. Fredrick, Neuralieve, Sunnyvale, Calif.

The research was funded by Neuralieve, Inc., of Sunnyvale, Calif., which provided the TMS technology for the study. Goadsby has served as an advisor to Neuralieve for which he received an honorarium.

Many patients who suffer from migraines avoid taking aerobic exercise because they are afraid that the physical activity may bring on a serious migraine attack. Researchers at the Sahlgrenska Academy, University of Gothenburg, Sweden, have now developed an exercise programme that can improve fitness among migraine sufferers without aggravating this painful condition.

Patients who suffer from migraines are often advised to take exercise, but to date no studies have been conducted to show that exercise actually helps guard against migraine attacks. No exercise programme has so far been scientifically proven to be safe for migraine patients.

"We know that everyone benefits from a little exercise, but if you're convinced that a session at the gym will end up with you being confined to bed with a thumping headache and nausea then it's hardly surprising that people give it a miss," says Jane Carlsson, Professor in Physiotherapy at the Sahlgrenska Academy.

In the study, which is being published in the latest issue of the scientific journal Headache, some twenty migraine sufferers were asked to follow a special exercise programme three times a week for three months. The programme involved using an exercise bike under the guidance of a physiotherapist.

"We could see that those who participated in the study were much fitter after the training period, since their ability to absorb oxygen increased considerably," says physiotherapist Emma Varkey, one of the researchers behind the study.

Only one of the patients suffered a migraine attack that was directly linked to the training session. "Now that we've been able to show that the risk of increased frequency of attacks in connection with this type of exercise is extremely small, we can study whether exercise can be used to prevent or alleviate migraine attacks. "We have already initiated a new study in which we plan to compare the results against a control group," says Mattias Linde, neurologist at Cephalea Headache Centre and researcher at the Sahlgrenska Academy.

 Migraine Headaches

A migraine is a recurring, thumping headache, which intensifies and causes nausea, vomiting and increased sensitivity to light and noise. Attacks can last for anything from a couple of hours to several days. The cause of migraines is unknown, but the condition is thought to be hereditary.

— While physical exercise has been shown to trigger migraine headaches among sufferers, a new study describes an exercise program that is well tolerated by patients. The findings show that the program decreased the frequency of headaches and improved quality of life. 

The study used a sample of migraine sufferers who were examined before, during and after an aerobic exercise intervention. The program was based on indoor cycling (for continuous aerobic exercise) and was designed to improve maximal oxygen uptake without worsening the patients’ migraines.

After the treatment period, patients’ maximum oxygen uptake increased significantly. There was no worsening of migraine status at any time during the study period and, during the last month of treatment, there was a significant decrease in the number of migraine attacks, the number of days with migraine per month, headache intensity and amount of headache medication used.

Individuals with headache and migraine typically are less physically active than those without headache. Patients with migraine often avoid exercise, resulting in less aerobic endurance and flexibility. Therefore, well designed studies of exercise in patients with migraine are imperative.

“While the optimal amount of exercise for patients with migraine remains unknown, our evaluated program can now be tested further and compared to pharmacological and non-pharmacological treatments to see if exercise can prevent migraine,” says Dr. Emma Varkey, co-author of the study.

The study is published in Headache: The Journal of Head and Face Pain.

New research is unraveling the complex brain mechanisms associated with disabling migraine headaches. The study, published in the March 12th issue of the journal Neuron, reveals that perturbation of the delicate balance between excitation and inhibition may make the brain more vulnerable to migraine attacks.

The brain mechanisms that cause debilitating migraine headaches are not well understood. However, previous neuroimaging studies have suggested that the visual disturbance known as migraine aura is due to a phenomenon called cortical spreading depression (CSD). CSD is a wave of strong neuronal depolarization that slowly progresses across the cerebral cortex, generating a transient increase in electrical signals followed by a long-lasting neural suppression. It has also been suggested that CSD may trigger mechanisms that initiate the migraine headache.

Familial hemiplegic migraine (FHM) is a subtype of severe migraine with aura. Interestingly, recent animal studies have shown that mice carrying the mutation (FHM1) that causes human FHM are more susceptible to CSD. "Investigation of the cortical mechanisms that produce facilitation of CSD in the FHM mouse models may provide unique insights into the unknown mechanisms that lead to CSD susceptibility and initiate migraine attacks in human patients," offers senior study author Dr. Daniela Pietrobon from the Department of Biomedical Sciences at the University of Padova in Italy.

Dr. Pietrobon and colleagues found that calcium influx and subsequent glutamate release at cortical pyramidal cell synapses were increased in mice carrying the FHM mutation. Glutamate is the major excitatory neurotransmitter in the brain. The facilitation of induction and propagation of CSD in the FHM mice was completely eliminated when glutamate release was decreased to control levels. Importantly, in contrast with the enhanced excitatory neurotransmission, inhibitory neurotransmission was not altered in the migraine mice.

"Our findings provide direct evidence that enhanced glutamate release may explain the facilitation of CSD in the FHM mouse model. The differential effect of the FHM mutation at cortical excitatory and inhibitory synapses points to a perturbation of the excitation-inhibition balance and neuronal hyperactivity as the basis for episodic vulnerability to CSD ignition in migraine," explains Dr. Pietrobon.

The researchers include Angelita Tottene, University of Padova and CNR Institute of Neuroscience, Padova, Italy, Leiden University Medical Centre, Leiden, The Netherlands; Rossella Conti, University of Padova and CNR Institute of Neuroscience, Padova, Italy; Leiden University Medical Centre, Leiden, The Netherlands; Alessandra Fabbro, University of Padova and CNR Institute of Neuroscience, Padova, Italy; Dania Vecchia, University of Padova and CNR Institute of Neuroscience, Padova, Italy; Maryna Shapovalova, University of Padova and CNR Institute of Neuroscience, Padova, Italy; Mirko Santello, University of Padova and CNR Institute of Neuroscience, Padova, Italy; Arn M.J.M. van den Maagdenberg, Leiden University Medical Centre, Leiden, The Netherlands; Michel D. Ferrari, Leiden University Medical Centre, Leiden, The Netherlands; and Daniela Pietrobon, University of Padova and CNR Institute of Neuroscience, Padova, Italy.

Women who suffer migraines are at an increased risk of stroke during pregnancy as well as other vascular conditions such as heart disease, high blood pressure and blood clots, concludes a study published on bmj.com today.

Migraine headache occurs in up to 26% of women of childbearing age and around one third of women aged between 35 and 39. Although it is very common in this age group, little is known about the prevalence of migraine during pregnancy.

So in the largest study of its kind, researchers in the United States set out to test the association between migraine and vascular diseases during pregnancy.

Using a national database of over 18 million hospital discharge records, they identified 33,956 pregnancy related discharges with a diagnosis of migraine from 2000 to 2003.

Older women (40 years of age or more) were 2.4 times more likely to have a diagnosis of migraines than women under 20 years of age, and white women were more likely to have a diagnosis of migraines than any other race or ethnicity.

Migraines during pregnancy were linked to a 15-fold increased risk of stroke. Migraines also tripled the risk of blood clots in the veins and doubled the risk of heart disease. Vascular risk factors were also strongly associated with migraines. These included diabetes, high blood pressure and cigarette smoking.

Even when pre-eclampsia (the most influential factor in relation to migraine) was removed from the analysis, there was little change in the results, suggesting that these are independent associations.

The relation between migraine and stroke was the strongest, and this is consistent with a previous analysis in the same sample of women from 2000-1 which found that migraine was associated with a 17-fold increased risk of pregnancy related stroke. However, stroke in pregnancy is very rare (around four cases per 100,000 births), so this relative increase is not as alarming as it might seem, and these results will not apply to every woman with migraine during pregnancy. Nevertheless, for pregnant women admitted to hospital with active migraines, doctors should recognise and help to reduce cardiovascular risk factors and should treat complications of pregnancy such as pre-eclampsia.

The authors suggest that the most logical explanation for these findings lies in the interaction between migraines and the normal physiological changes during pregnancy (such as increased blood volume and heart rate) which put extra stress on the vascular system.

But regardless of the mechanism, active migraine during pregnancy could be viewed as a potential marker of vascular diseases, especially stroke, they say.

Although cause and effect still need to be established, the results of this study lay the groundwork for future studies related to migraine and pregnancy, they conclude.