Çiçek Wöber-Bingöl

Prospective analysis of factors related to migraine attacks: the PAMINA study.

Migraine is related to numerous factors such as hormones, stress or nutrition, but information about their actual importance is limited. Therefore, we analysed prospectively a wide spectrum of factors related to headache in migraineurs. We examined 327 migraineurs recruited via newspapers who kept a comprehensive diary for 3 months. Statistical analysis comprising 28 325 patient days and 116 dichotomous variables was based on the interval between two successive headache attacks. We calculated univariate Cox regression analyses and included covariables with a P-value of <0.05 in two stepwise multivariate Cox regression analyses, the first accounting for a correlation of the event times within a subject, the second stratified by the number of headache-free intervals. We performed similar analyses for the occurrence of migraine attacks and for the persistence of headache and migraine. Menstruation had the most prominent effect, increasing the hazard of occurrence or persistence of headache and migraine by up to 96%. All other factors changed the hazard by <35%. The two days before menstruation and muscle tension in the neck, psychic tension, tiredness, noise and odours on days before headache onset increased the hazard of headache or migraine, whereas days off, a divorced marriage, relaxation after stress, and consumption of beer decreased the hazard. In addition, three meteorological factors increased and two others decreased the hazard. In conclusion, menstruation is most important in increasing the risk of occurrence and persistence of headache and migraine. Other factors increase the risk less markedly or decrease the risk.

Prospective analysis of factors related to migraine aura--the PAMINA study.

Objectives.— The aim of this study was to examine factors increasing and decreasing the risk of occurrence of migraine aura and of headache and migraine not associated with aura (HoA, MoA) prospectively by means of a daily diary.

Trigger factors of migraine and tension-type headache: experience and knowledge of the patients.

The objective was to examine potential trigger factors of migraine and tension-type headache (TTH) in clinic patients and in subjects from the population and to compare the patients’ personal experience with their theoretical knowledge. A cross-sectional study was carried out in a headache centre. There were 120 subjects comprising 66 patients with migraine and 22 with TTH from a headache outpatient clinic and 32 persons with headache (migraine or TTH) from the population. A semistructured interview covering biographic data, lifestyle, medical history, headache characteristics and 25 potential trigger factors differentiating between the patients’ personal experience and their theoretical knowledge was used. The most common trigger factors experienced by the patients were weather (82.5%), stress (66.7%), menstruation (51.4%) and relaxation after stress (50%). The vast majority of triggers occurred occasionally and not consistently. The patients experienced 8.9±4.3 trigger factors (range 0–20) and they knew 13.2±6.0 (range 1–27). The number of experienced triggers was smallest in the population group (p=0.002), whereas the number of triggers known did not differ in the three study groups. Comparing theoretical knowledge with personal experience showed the largest differences for oral contraceptives (65.0 vs. 14.7%, p<0.001), chocolate (61.7 vs. 14.3%, p>0.001) and cheese (52.5 vs. 8.4%, p<0.001). In conclusion, almost all trigger factors are experienced occasionally and not consistently by the majority of patients. Subjects from the population experience trigger factors less often than clinic patients. The difference between theoretical knowledge and personal experience is largest for oral contraceptives, chocolate and cheese.

Quality of sleep, fatigue and daytime sleepiness in migraine - a controlled study.

The objective of this study was to evaluate whether the quality of sleep and the degree of fatigue and daytime sleepiness are related to migraine. We investigated 489 subjects comprising 97 patients with eight or more, 77 patients with five to seven and 196 patients with one to four migraine days per month, and 119 migraine-free controls with fewer than six headache days per year. The patients were recruited via articles in newspapers not stressing the subject of the study. All participants underwent a semistructured interview and completed the Pittsburgh Sleep Quality Index (PSQI), the Fatigue Severity Scale (FSS), the Epworth Sleepiness Scale (ESS) and the Self-rating Depression Scale and the Self-rating Anxiety Scale. For statistical analysis we used two way MANOVAs, post hoc univariate two-way ANOVAs and Hochbergs GT2 tests as well as three-way mixed design ANOVAs. The PSQI total score was highest in patients with frequent migraine (5.9 ± 4.3) and lowest in controls (4.3 ± 2.5, P = 0.04). Four subscores of the PSQI showed similar statistically significant differences. The FSS and ESS scores did not differ in the four study groups. Analysing depression and anxiety revealed a significant impact on PSQI, FSS and ESS, but did not demonstrate interactions with migraine, thus suggesting that the impact of migraine is similar in patients without and with psychiatric comorbidity. In conclusion, the quality of sleep is decreased in patients with migraine, whereas fatigue and daytime sleepiness do not differ from healthy controls. The decreased quality of sleep in migraineurs is also a consequence of migraine itself and cannot be explained exclusively by comorbidity with depression or anxiety.

Overview of diagnosis and management of paediatric headache. Part I: diagnosis

Headache is the most common somatic complaint in children and adolescents. The evaluation should include detailed history of children and adolescents completed by detailed general and neurological examinations. Moreover, the possible role of psychological factors, life events and excessively stressful lifestyle in influencing recurrent headache need to be checked. The choice of laboratory tests rests on the differential diagnosis suggested by the history, the character and temporal pattern of the headache, and the physical and neurological examinations. Subjects who have any signs or symptoms of focal/progressive neurological disturbances should be investigated by neuroimaging techniques. The electroencephalogram and other neurophysiological examinations are of limited value in the routine evaluation of headaches. In a primary headache disorder, headache itself is the illness and headache is not attributed to any other disorder (e.g. migraine, tension-type headache, cluster headache and other trigeminal autonomic cephalgias). In secondary headache disorders, headache is the symptom of identifiable structural, metabolic or other abnormality. Red flags include the first or worst headache ever in the life, recent headache onset, increasing severity or frequency, occipital location, awakening from sleep because of headache, headache occurring exclusively in the morning associated with severe vomiting and headache associated with straining. Thus, the differential diagnosis between primary and secondary headaches rests mainly on clinical criteria. A thorough evaluation of headache in children and adolescents is necessary to make the correct diagnosis and initiate treatment, bearing in mind that children with headache are more likely to experience psychosocial adversity and to grow up with an excess of both headache and other physical and psychiatric symptoms and this creates an important healthcare problem for their future life.

Triggers of migraine and tension-type headache

Identification of trigger factors or precipitants is frequently recommended as a basic strategy in the treatment of migraine and tension-type headache (TTH). Trigger factors increase the probability of headache in the short term. Potential trigger factors have been examined most frequently in migraine and less often in TTH. Many of these factors are related to migraine as well as to TTH, but their prevalence may differ in the two headache types. In this chapter, we will review the findings of retrospective as well as of prospective and controlled studies. Taken together, virtually all aspects of life have been suspected to trigger migraine or TTH, but scientific evidence for many of these triggers is poor. Menstruation has a prominent unfavorable role in migraine and possibly in TTH. There is at least some evidence that environmental factors such as weather, lights, noise and odors, stress and other psychological factors, sleeping problems, fatigue and tiredness may play a role. In addition, intake of alcohol, caffeine withdrawal, skipping meals, and possibly dehydration may trigger migraine and TTH in some patients. Scientific evidence is lacking that any other food or food additive plays a relevant role as a trigger factor of headaches.

Overview of diagnosis and management of paediatric headache. Part II: therapeutic management

A thorough evaluation of headache in children and adolescents is necessary to make the correct diagnosis and initiate treatment. In part 1 of this article (Özge et al. in J Headache Pain, 2010), we reviewed the diagnosis of headache in children and adolescents. In the present part, we will discuss therapeutic management of primary headaches. An appropriate management requires an individually tailored strategy giving due consideration to both non-pharmacological and pharmacological measures. Non-pharmacological treatments include relaxation training, biofeedback training, cognitive-behavioural therapy, different psychotherapeutic approaches or combinations of these treatments. The data supporting the effectiveness of these therapies are less clear-cut in children than in adults, but that is also true for the data supporting medical treatment. Management of migraine and TTH should include strategies relating to daily living activities, family relationships, school, friends and leisure time activities. In the pharmacological treatment age and gender of children, headache diagnosis, comorbidities and side effects of medication must be considered. The goal of symptomatic treatment should be a quick response with return to normal activity and without relapse. The drug should be taken as early as possible and in the appropriate dosage. Supplementary measures such as rest in a quiet, darkened room is recommended. Pharmaco-prophylaxis is only indicated if lifestyle modification and non-pharmacological prophylaxis alone are not effective. Although many prophylactic medications have been tried in paediatric migraine, there are only a few medications that have been studied in controlled trials. Multidisciplinary treatment is an effective strategy for children and adolescents with improvement of multiple outcome variants including frequency and severity of headache and school days missed because of headache. As a growing problem both children and families should be informed about medication overuse and the children’s drug-taking should be checked.

Internet-delivered cognitive–behavioural therapy v. conventional guided self-help for bulimia nervosa: long-term evaluation of a randomised controlled trial

BACKGROUND Cognitive-behavioural therapy (CBT)-based guided self-help is recommended as a first step in the treatment of bulimia nervosa. AIMS To evaluate in a randomised controlled trial (Clinicaltrials.gov registration number: NCT00461071) the long-term effectiveness of internet-based guided self-help (INT-GSH) compared with conventional guided bibliotherapy (BIB-GSH) in females with bulimia nervosa. METHOD A total of 155 participants were randomly assigned to INT-GSH or BIB-GSH for 7 months. Outcomes were assessed at baseline, month 4, month 7 and month 18. RESULTS The greatest improvement was reported after 4 months with a continued reduction in eating disorder symptomatology reported at month 7 and 18. After 18 months, 14.6% (n = 7/48) of the participants in the INT-GSH group and 25% (n = 7/28) in the BIB-GSH group were abstinent from binge eating and compensatory measures, 43.8% (n = 21/48) and 39.2% (n = 11/28) respectively were in remission. No differences regarding outcome between the two groups were found. CONCLUSIONS Internet-based guided self-help for bulimia nervosa was not superior compared with bibliotherapy, the gold standard of self-help. Improvements remain stable in the long term.

Migraine and weather: A prospective diary-based analysis

Aims: Weather is mentioned as a trigger factor by migraine patients most frequently. We examined the impact of meteorological factors and the impact of their day-to-day change on the risk of occurrence and persistence of headache and migraine and the correlation of subjective weather perception with objective weather data. Methods: We performed a prospective, diary-based cohort study in 238 patients suffering from migraine with or without aura. Patients had to live within 25 km of the Vienna meteorological station and were required to keep a diary for 90 days. We analysed 11 meteorological parameters and 17 synoptic weather situations. For evaluating the hazard of occurrence and persistence of migraine and headache, we performed a univariate and a stepwise multivariate Cox regression analysis. We calculated correlations between subjective weather perception and meteorological data. Results: In the uni- and multivariate analysis, a ridge of high pressure increased the risk of headache occurrence, lower mean daily wind speed increased the risk of migraine occurrence and a day-to-day change of daily sunshine duration increased the risk of migraine occurrence. A day-to-day change of the daily minimum temperature decreased the risk of migraine persistence. After correction for multiple testing, none of these findings remained statistically significant. Subjective weather perceptions did not correlate with the occurrence or persistence of migraine or headache. Subjective perception of cold and too-cold weather and of too-warm weather correlated with daily minimum, mean and maximum temperature. Conclusion: The influence of weather factors on migraine and headache is small and questionable.

Long‐term results of migraine prophylaxis with flunarizine and beta‐blockers

We followed-up 64 migraine patients after discontinuation of successful interval prophylaxis with flunarizine, propranolol or metoprolol, to investigate how long the therapeutic success would last, if further prophylaxis would be successful again, and what factors would influence the prognosis. We found that 16 out of 64 patients experienced a lasting reduction of migraine frequency, whereas 48 patients did improve initially, but later experienced a relapse. Further prophylaxis was effective in 29, poorly effective in 11, and ineffective in 8 of these patients; in 7 of the 8 non-responders prophylaxis was not changed. Negative prognostic factors were frequent attacks, a history of analgesic abuse and/or analgesic withdrawal therapy and ineffective previous prophylaxis. In conclusion, the therapeutic success decreases dramatically in the majority of patients several months after discontinuation of prophylaxis; further prophylaxis is more effective if the substance class is changed; increased analgesic intake is the most important prognostic factor. As a strategy for migraine prophylaxis we propose sequential changing of interval prophylaxis or -in patients with negative prognostic factors — long-term prophylaxis.