Eliova Zukerman

Hypothalamic involvement in chronic migraine

OBJECTIVES Chronic migraine (CM), previously called transformed migraine, is a frequent headache disorder that affects 2%-3% of the general population. Analgesic overuse, insomnia, depression, and anxiety are disorders that are often comorbid with CM. Hypothalamic dysfunction has been implicated in its pathogenesis, but it has never been studied in patients with CM. The aim was to analyze hypothalamic involvement in CM by measurement of melatonin, prolactin, growth hormone, and cortisol nocturnal secretion. METHODS A total of 338 blood samples (13/patient) from 17 patients with CM and nine age and sex matched healthy volunteers were taken. Melatonin, prolactin, growth hormone, and cortisol concentrations were determined every hour for 12 hours. The presence of comorbid disorders was also evaluated. RESULTS An abnormal pattern of hypothalamic hormonal secretion was found in CM. This included: (1) a decreased nocturnal prolactin peak, (2) increased cortisol concentrations, (3) a delayed nocturnal melatonin peak in patients with CM, and (4) lower melatonin concentrations in patients with CM with insomnia. Growth hormone secretion did not differ from controls. CONCLUSION These results support hypothalamic involvement in CM, shown by a chronobiologic dysregulation, and a possible hyperdopaminergic state in patients with CM. Insomnia might be an important variable in the study findings.

A nationwide population-based study of migraine in Brazil

The aim of this study was to estimate the 1-year prevalence of migraine and the degree of the association of migraine with some sociodemographic characteristics of a representative sample of the adult population of Brazil. This was a cross-sectional, population-based study. Telephone interviews were conducted on 3848 people, aged 18–79 years, randomly selected from the 27 States of Brazil. The estimated 1-year gender- and age-adjusted prevalence of migraine was 15.2%. Migraine was 2.2 times more prevalent in women, 1.5 times more in subjects with > 11 years of education, 1.59 times more in subjects with income of < 5 Brazilian Minimum Wages per month, and 1.43 times more in those who do not do any physical exercise. The overall prevalence of migraine in Brazil is 15.2%. Migraine is significantly more prevalent in women, subjects with higher education, with lower income, and those who do not exercise regularly, independently of their body mass index.

Cerebrospinal fluid glutamate levels in chronic migraine.

Both preclinical and clinical data link glutamate to the migraine pathophisiology. Altered plasma, platelets and cerebrospinal (CSF) glutamate levels have been reported in migraine patients. Chronic migraine is comorbid with several conditions. It has been recently shown chronic migraine comorbidity with fibromyalgia. The objective of this study was to study cerebrospinal fluid glutamate levels in chronic migraine patients with and without fibromyalgia. We studied 20 chronic migraine patients, with and without fibromyalgia, compared to age-sex matched controls. CSF glutamate levels were measured by HPLC. CSF glutamate demonstrated significantly higher levels in patients with fibromyalgia compared to those without fibromyalgia. Patients overall had higher CSF glutamate levels than controls. Mean pain score correlated with glutamate levels in chornic migraine patients. Tender points, the hallmark of fibromyalgia, can be considered as pressure allodynia, and is probably mediated by central sensitization, with increase in CSF glutamate levels. We postulate chronic migraine patients with fibromyalgia, in addition to have more disabling headaches, suffer from a more severe central sensitization process. This subtype of patients may respond to medications modulating glutamate receptors. Headache intensity correlate with glutamate levels in chronic migraine patients.

Chronic daily headache in Brazil: a nationwide population‐based study

The objectives of this study were to estimate the 1-year prevalence of chronic daily headache (CDH) and the degree of the association of CDH with some sociodemographic characteristics of the adult population of Brazil. This was a cross-sectional, population-based study. We conducted telephone interviews with 3848 people, aged 18-79 years, randomly selected from the 27 States of Brazil. The degree of the association was calculated through prevalence ratios, adjusted with Poisson regression by gender, age and some sociodemographic factors. The estimated 1-year gender- and age-adjusted prevalence of CDH was 6.9±. CDH was 2.4 times more prevalent in women, 1.72 times more in unemployed, 1.63 times more in subjects with high household income and two times greater in those who did not exercise. The overall prevalence of CDH in Brazil is high. CDH is significantly more prevalent in women, the unemployed, subjects with higher income, and in those who do not exercise.

Idiopathic intracranial hypertension with and without papilloedema in a consecutive series of patients with chronic migraine

Chronic migraine (CM) has been associated with idiopathic intracranial hypertension without papilloedema (IIHWOP), a significant percentage of these cases occurring in obese patients with intractable headache. A prospective study from February 2005 to June 2006 was made of 62 CM patients who fulfilled International Headache Society diagnostic criteria and had cerebral magnetic resonance venography (MRV) and lumbar puncture (LP) done. Two patients were excluded, six (10%) with elevated cerebrospinal fluid (CSF) open pressure (OP), five with body mass index (BMI) > 25. None of the patients had papilloedema or abnormal MRV. BMI and CSF OP were significantly correlated (r = 0.476, P < 0.001, Pearsons correlation test). Obesity (defined as BMI > 30) was a predictor of increase in intracranial pressure (defined as OP > 200 mmH2O) (f = 17.26, 95% confidence interval 6.0, 8.6; P < 0.001). From our study we strongly recommend that not only intractable CM patients with high BMI, but also first diagnosed patients with BMI > 30 should be systematically evaluated by a LP to rule out IIHWOP.

Fatigue in chronic migraine patients

Fatigue is a common symptom frequently reported in many disorders including headaches, but little is known about its nature. The objective was to determine the prevalence of fatigue in chronic migraine (CM) patients, to define its subtypes and its relationship with other conditions comorbid with CM. Sixty-three CM patients were analysed. The Fatigue Severity Scale (FSS), the Chalder fatigue scale and the CDC diagnostic criteria for chronic fatigue syndrome (CFS) were used. Fifty-three (84.1%) patients had FSS scores greater than 27. Forty-two (66.7%) patients met the CDC criteria for CFS. Thirty-two patients (50.8%) met the modified CDC criteria (without headache). Beck depression scores correlated with FSS, mental and physical fatigue scores. Trait anxiety scores also correlated with fatigue scales. Women had higher FSS scores than men, P < 0.05. Physical fatigue was associated with fibromyalgia, P < 0.05. Fatigue as a symptom and CFS as a disorder are both common in CM patients. Therapeutic interventions include a graded aerobic exercise program, cognitive behavioural therapy and antidepressants. Identification of fatigue and its subtypes in headache disorders and recognition of headaches in CFS patients has implications for the pathophysiology, diagnosis and treatment of these disorders.

Primary headaches in obese patients

BACKGROUND AND OBJECTIVE Obesity is a major public health problem worldwide. Little is known about the prevalence and impact of headache disorders in obese patients. The objective of this study was to assess the prevalence of primary headaches in obese patients and controls. METHOD Seventy-four consecutive obese patients from the obesity surgery service were studied, and compared to controls with body mass index less than 25. RESULTS Fifty-six patients (75%) had a headache diagnosis, 49 migraine (66%), 7 tension-type headache (9%), 36 (48%) had incapacitating headaches. CONCLUSION Primary headaches are more common and incapacitating in obese patients than controls, migraine is the most important diagnosis in this population. Headaches should be properly diagnosed and treated in obese patients.

Cephalalgiaphobia: a possible specific phobia of illness.

Psychiatric comorbidity, mainly anxiety and depression, are common in chronic migraine (CM). Phobias are reported by half of CM patients. Phobic avoidance associated with fear of headache or migraine attack has never been adequately described. We describe 12 migraine patients with particular phobic-avoidant behaviours related to their headache attacks, which we classified as a specific illness phobia, coined as cephalalgiaphobia. All patients were women, mean age 42, and all had a migraine diagnosis (11 CM, all overused acute medications). Patients had either a phobia of a headache attack during a pain-free state or a phobia of pain worsening during mild headache episodes. Patients overused acute medication as phobic avoidance. It is a significant problem, associated with distress and impairment, interfering with medical care. Cephalalgiaphobia is a possible specific phobia of illness, possibly linked to progression of migraine to CM and to acute medication overuse headache.

Depression in chronic migraine: Severity and clinical features

INTRODUCTION Chronic migraine (CM) is a common medical condition affecting 2.4% of the general population. Depression is one of the most frequent comorbid disorders in CM. METHOD Seventy patients diagnosed with chronic migraine were studied. All patients evaluated filled out the Beck Depression Inventory (BDI). Depression severity was divided into none or minimal depression, mild, moderate, and severe. RESULTS BDI ranged from 4 to 55, mean 21 +/- 10.7. Moderate or severe depression, were present in 58.7% of the patients. Some degree of depression appeared in 85.8% of patients. The BDI scores correlated with pain intensity (p = 0.02). Severe depression was more frequent in patients with comorbid fibromyalgia and in patients reporting fatigue. CONCLUSION The BDI is an easy tool to access depression in CM patients. Suicide risk assessment is needed in CM patients. Patients with fibromyalgia and fatigue are at even higher risk for severe depression.

Glutamate Levels in Cerebrospinal Fluid and Triptans Overuse in Chronic Migraine

Objective.—Chronic migraine (CM) is a common disorder, affecting 2% to 3% of the general population. Glutamate is implicated in cortical spreading depression, trigeminovascular activation, central sensitization, and may be linked to migraine chronification. Triptans brought a novel option for the acute migraine treatment. As the development of central sensitization impacts upon the effectiveness of triptan therapy, we hypothesized that glutamate might be related to triptan response mechanisms.