Allodynia in Migraine: Association With Comorbid Pain Conditions

Background.— Cutaneous allodynia (CA) in migraine is a clinical manifestation of central nervous system sensitization. Several chronic pain syndromes and mood disorders are comorbid with migraine. In this study we examine the relationship of migraine‐associated CA with these comorbid conditions. We also evaluate the association of CA with factors such as demographic profiles, migraine characteristics, and smoking status that may have an influence on the relationships of CA to pain and mood. Methods.— Data are from a cross‐sectional multicenter study of comorbid conditions in persons seeking treatment in headache clinics. Diagnosis of migraine was determined by a physician based on the International Classification of Headache Disorders‐II criteria. Participants completed a self‐administered questionnaire ascertaining sociodemographics, migraine‐associated allodynia, physician‐diagnosed comorbid medical and psychiatric disorders, headache‐related disability, current depression, and anxiety. Results.— A total of 1413 migraineurs (mean age = 42 years, 89% women) from 11 different headache treatment centers completed a survey on the prevalence of comorbid conditions. Aura was reported by 38% and chronic headache by 35% of the participants. Sixty percent of the study population reported at least one migraine‐related allodynic symptom, 10% reported ≥4 symptoms. Symptoms of CA were associated with female gender, body mass index, current smoking, presence of aura, chronic headaches, transformed headaches, severe headache‐related disability, and duration of migraine illness from onset. The prevalence of self‐reported physician diagnosis of comorbid pain conditions (irritable bowel syndrome, chronic fatigue syndrome, fibromyalgia) and psychiatric conditions (current depression and anxiety) was also associated with symptoms of CA. Adjusted ordinal regression indicated a significant association between number of pain conditions and severity of CA (based on symptom count). Adjusting for sociodemographics, migraine characteristics, and current depression and anxiety, the likelihood of reporting symptoms of severe allodynia was much higher in those with 3 or more pain conditions (odds ratio = 3.03, 95% confidence interval: 1.78‐5.17), and 2 pain conditions (odds ratio = 2.67, 95% confidence interval: 1.78‐4.01) when compared with those with no comorbid pain condition. Conclusion.— Symptoms of CA in migraine were associated with current anxiety, depression, and several chronic pain conditions. A graded relationship was observed between number of allodynic symptoms and the number of pain conditions, even after adjusting for confounding factors. This study also presents the novel association of CA symptoms with younger age of migraine onset, and with cigarette smoking, in addition to confirming several previously reported findings.     

Headache disorders in the millennium cohort: epidemiology and relations with combat deployment

(Headache 2011;51:1098‐1111) Objective.— Characterize migraine and other headache disorders within a large population‐based US military cohort, with an emphasis on the temporal association between military deployment and exposure to combat. Background.— Little research has been published on the prevalence of headache disorders in the US military population, especially in relation to overseas deployments and exposure to combat. A higher than expected prevalence of migraine has previously been reported among deployed US soldiers in Iraq, suggesting an association. Headache disorders, including migraine, could have important effects on the performance of service members. Methods.— A total of 77,047 US active‐duty, Reserve, and National Guard members completed a baseline questionnaire between July 2001 to June 2003 for the Millennium Cohort Study. Headache disorders were assessed using the following survey‐based measures: self‐reported history of provider‐diagnosed migraine, recurrent severe headache within the past year, and recent headaches/bothered a lot within the past 4 weeks. Follow‐up surveys were completed on average 3 years after baseline (mean = 2.7 years; range = 11.4 months to 4.5 years). Results.— The overall male and female prevalence of self‐reported headache conditions at baseline were: provider‐diagnosed migraine, 6.9% and 20.9%, respectively; recurrent severe headache, 9.4% and 22.3%, respectively; and bothered a lot by headaches, 3.4% and 10.4%, respectively. Combat deployers had significantly higher odds of any new‐onset headache disorders than non‐deployers (adjusted odds ratios = 1.72 for men, 1.84 for women; 95% confidence intervals, 1.55‐1.90 for men, 1.55‐2.18 for women), while deployers without combat exposure did not. Conclusions.— Deployed personnel with reported combat exposure appear to represent a higher risk group for new‐onset headache disorders. The identification of populations at higher risk of development of headache provides support for targeted interventions.     

PTSD, Combat Injury, and Headache in Veterans Returning From Iraq/Afghanistan

Objective.— To examine the relationship between posttraumatic stress disorder, combat injury, and headache in Operation Iraqi Freedom and Operation Enduring Freedom veterans at the VA San Diego Healthcare System. Background.— Previous investigations suggest that a relationship between posttraumatic stress disorder and primary headache disorders exists and could be complicated by the contribution of physical injury, especially one that results in loss of consciousness. These associations have not been systematically examined in Operation Iraqi Freedom and Operation Enduring Freedom veterans. Methods.— In this observational cross‐sectional study, a battery of self‐report, standardized questionnaires was completed by 308 newly registered veterans between March and October 2006. The Davidson Trauma Scale was used to determine the degree of posttraumatic stress disorder symptoms and combat‐related physical injury was assessed by self‐report. The presence of headache was based on a symptom checklist measure and self‐reported doctor diagnoses. Logistic regression analysis was performed to predict presence of headache and determine odds ratios and 95% confidence intervals associated with demographic, military, in‐theatre, and mental health characteristics. Results.— About 40% of the veterans met the criteria for posttraumatic stress disorder; 40% self‐reported current headache, 10% reported a physician diagnosis of migraine, 12% a physician diagnosis of tension‐type headache, and 6% reported both types of headache. Results from the logistic regression model indicated that combat‐related physical injury (odds ratio: 2.25; 95% confidence interval: 1.17‐4.33) and posttraumatic stress disorder (odds ratio: 4.13; 95% confidence interval: 2.44‐6.99) were independent predictors of self‐reported headache. Additional analyses found that veterans with both tension and migraine headache had higher rates of posttraumatic stress disorder (chi‐square [d.f. = 3] = 15.89; P = .001) whereas veterans with migraine headache alone had higher rates of combat‐related physical injury (chi‐square [d.f. = 9] = 22.00; P = .009). Conclusion.— Posttraumatic stress disorder and combat‐related physical injury were related to higher rates of self‐reported headache in newly returning veterans. Our finding that posttraumatic stress disorder and injury during combat are differentially related to migraine and tension‐type headache, point to a complex relationship between physical and psychological trauma and headache. These findings have implications for a comprehensive approach to interventions for headache and the physical and psychological sequelae of trauma.     

Ethnic differences in antihypertensive medication use in the elderly

BACKGROUND: Determining the optimal treatment for hypertension in very old patients requires better understanding of interethnic differences in patterns and predictors of antihypertensive drug use in this population. OBJECTIVE: To investigate interethnic variations in antihypertensive drug use in a tri-ethnic sample of community-dwelling adults aged > or =77 years. METHODS: We performed a cross-sectional study of non-Hispanic white, black, and Hispanic adults > or =77 years old residing in Galveston County, TX. In-home interviews in 1997 and 1998 assessed blood pressures and antihypertensive medication use in 281 subjects who reported having hypertension or who had a systolic blood pressure > or =140 mm Hg and/or diastolic blood pressure > or =90 mm Hg. RESULTS: Of the population evaluated, 62.9% of non-Hispanic whites, 60.2% of blacks, and 45.2% of Hispanics with hypertension were on antihypertensive medications (p < 0.027 across the ethnic groups). After adjusting for age, gender, years of education, household income, Medicaid insurance, number of physician visits, and cognitive function, Hispanic ethnicity, unlike black ethnicity, continued to be significantly associated with lower use of antihypertensive drugs compared with non-Hispanic whites (OR 0.41; 95% CI 0.19 to 0.90). Characteristics associated with the lower use of antihypertensive drugs included older age and low income in whites, poor cognition and infrequent physician visits in blacks, and lack of Medicaid insurance in Hispanics. CONCLUSIONS: In the elderly, Hispanic ethnicity, unlike black ethnicity, is significantly associated with lower use of antihypertensive drug therapy compared with non-Hispanic white ethnicity, adjusting for relevant sociodemographic and health factors.     

Poster 4: Ethnic differences in arthritis, depression, and activities of daily living

Objective: To investigate ethnic differences in depression and functional limitations in the general population and among persons with arthritis. Design: Cross-sectional survey using the 1996 National Health and Retirement Survey (HRS). Setting: Households in the contiguous United States. Participants: 7899 persons (age range, 54-65y) selected by multistage area probability sample. Interventions: Not applicable. Main Outcome Measures: The main predictive measure was ethnicity, reported as non-Hispanic white, black, or Hispanic. Outcome variables included self-reported arthritis, depression, and functional limitations. Arthritis was determined by symptom (s) complaints or physician diagnosis. Depression was diagnosed using the World Health Organization’s Composite International Diagnostic Interview. Functional limitations was defined by 1 or more activity of daily living (ADL) limitations. Results: Arthritis was reported by 49% of whites, 54% of blacks, and 46% of Hispanics. Depression rates were 8.1% overall, with 7.8% whites, 8.8% blacks, and 10.7% Hispanics reporting depression. Among persons with arthritis, functional limitations were reported by 18% whites, 34% blacks, and 37% Hispanics. For all persons with arthritis, depressed persons report ADL limitations more frequently than nondepressed persons (Hispanics: 63% vs 33%, blacks: 54% vs 30%, whites: 39% vs 16%). Minorities with arthritis are more likely to be depressed than whites with arthritis (Hispanics: 14%, OR=1.40, 95% CI, .99-1.96; blacks: 13%, OR=1.24, 95% CI, 0.96-1.96 [white referent]). Conclusions: The HRS data demonstrated higher rates of arthritis and depression among minority groups as compared with their white counterparts. Furthermore, in subjects with arthritis, depression was associated with higher rates of ADL limitations and minorities were more functionally limited than whites. Factors that might have contributed to this latter association include socioeconomic status, chronic comorbid medical conditions, education, and medical accessibility.     

Ethnic differences in herb and vitamin/mineral use in the elderly

BACKGROUND: Little information exists on herb and vitamin-mineral supplement use in very old people and whether use varies by ethnicity. OBJECTIVE: To examine the prevalence and predictors of herb and vitamin-mineral supplement use in a tri-ethnic sample of adults aged > or = 77 years. METHODS: In-home interviews in 1997-1998 assessed medications use and sociodemographic and health factors in community-dwelling elderly non-Hispanic white (n = 125), black (n = 112), and Hispanic (n = 128) adults. RESULTS: Of the 365 subjects (71.5% > or = 80 y old, 52.6% female), 172 reported using at least one of the preparations (vitamin-mineral supplements 132, herbs alone 21, both herbs and vitamin-mineral supplements 19). Herbal use varied by ethnicity: 12.8% in non-Hispanic whites, 16.1% in blacks, and 4.7% in Hispanics. The most commonly used herbs were garlic, Ginkgo biloba, saw palmetto, and vinegar. Use of vitamin-mineral supplements, alone or combined with herbs, also varied by ethnicity: 54.4% in non-Hispanic whites, 31.3% in blacks, and 37.5% in Hispanics. In the fully adjusted multivariate model with white ethnicity as reference, the odds ratio of vitamin-mineral supplements use for blacks was 0.37 (95% CI 0.21 to 0.65) and for Hispanics was 0.56 (95% CI 0.30 to 1.03). In bivariate analyses, female gender, black ethnicity, being born in the US, and having coronary artery disease were significantly associated with herbal use (p < 0.05); however, in the fully adjusted multivariate model, only the female gender remained significantly associated with herbal use (OR 2.14; 95% CI 1.00 to 4.59). CONCLUSIONS: Use of herbs or vitamin-mineral supplements is common in very old people and varies by ethnicity.     

Extracephalic tenderness and pressure pain threshold in children with headache

Background Sensitisation of the pain detection system has been suggested to be involved in the pathogenesis of recurrent headache. In adults, increased sensitivity to pain has been found in patients with chronic tension type headache. Children with migraine or with unspecific headache report non‐headache pains and interictal pericranial muscular tenderness more often than headache‐free children. Objective To study if children with different types of headache report non‐headache pain more often than children with no headache and if extracephalic muscular tenderness is different in children with headache in comparison to headache‐free children. To find out if interval to the headache episode has influence on the extracranial muscular tenderness. Design A population‐based sample of 13‐year‐old children with migraine (n = 48), episodic tension type headache (61) or no headache (59) were interviewed for the occurrence and characteristics of headache and fulfilled a questionnaire on non‐headache pain. A structured manual palpation test on muscular tenderness and a pain threshold measurement were done on seven cephalic and three extracephalic points. Results Children with migraine reported other pains, especially stomach pain and limb pain more often than children with episodic tension type or no headache. There were no significant differences in the extracephalic muscular tenderness or in the pressure pain thresholds between the three groups. Conclusions Children with migraine experience more non‐headache pains than children with episodic tension type headache and with no headache. However, neither children with migraine nor children with episodic tension type headache show increased interictal extracephalic muscular sensitivity for palpation.     

Migraine Education Improves Quality of Life in a Primary Care Setting

(Headache 2010;50:600‐612) Objective.— The objective of this study was to evaluate the effectiveness of the Mercy Migraine Management Program (MMMP), an educational program for physicians and patients. The primary outcome was change in headache days from baseline at 3, 6, and 12 months. Secondary outcomes were changes in migraine‐related disability and quality of life, worry about headaches, self‐efficacy for managing migraines, emergency room (ER) visits for headache, and satisfaction with headache care. Background.— Despite progress in the understanding of the pathophysiology of migraine and development of effective therapeutic agents, many practitioners and patients continue to lack the knowledge and skills to effectively manage migraine. Educational efforts have been helpful in improving the quality of care and quality of life for migraine sufferers. However, little work has been performed to evaluate these changes over a longer period of time. Also, there is a paucity of published research evaluating the influence of education about migraine management on cognitive and emotional factors (for example, self‐efficacy for managing headaches, worry about headaches). Methods.— In this open‐label, prospective study, 284 individuals with migraine (92% female, mean age = 41.6) participated in the MMMP, an educational and skills‐based program. Of the 284 who participated in the program, 228 (80%) provided data about their headache frequency, headache‐related disability (as measured by the Headache Impact Test‐6 (HIT‐6), migraine‐specific quality of life (MSQ), worry about headaches, self‐efficacy for managing headaches, ER visits for headaches, and satisfaction with care at 4 time points over 12 months (baseline, 3 months, 6 months, 12 months). Results.— Overall, 46% (106) of subjects reported a 50% or greater reduction in headache frequency. Over 12 months, patients reported fewer headaches and improvement on the HIT‐6 and MSQ (all P < .001). The improvement in headache impact and quality of life was greater among those who had more worry about their headaches at baseline. There were also significant improvements in “worry about headaches,”“self‐efficacy for managing headaches,” and “satisfaction with headache care.” Conclusion.— The findings demonstrate that patients participating in the MMMP reported improvements in their headache frequency as well as the cognitive and emotional aspects of headache management. This program was especially helpful among those with high amounts of worry about their headaches at the beginning of the program. The findings from this study are impetus for further research that will more clearly evaluate the effects of education and skill development on headache characteristics and the emotional and cognitive factors that influence headache.     

Improvement in Headaches With Continuous Positive Airway Pressure for Obstructive Sleep Apnea: A Retrospective Analysis

Objective.— We aimed to identify clinical features in patients with severe headaches that predicted obstructive sleep apnea (OSA) and determine clinical and sleep study characteristics that predicted headache improvement with continuous positive airway pressure (CPAP). Background.— Many patients with headaches complain of sleep symptoms and have OSA. There is often improvement of headaches with CPAP treatment. Methods.— We conducted a retrospective chart review of all patients referred to adult neurology clinic for headaches and sent for polysomnography between January 2008 and December 2009. Follow‐up ranged from 18 to 42 months. Results.— Eighty‐two headache patients (70 females, 12 males) were studied. Mean age was 45 ± 13 years (females 45 ± 13, males 43 ± 11) and mean body mass index was 32 ± 9. Headache types included 17% chronic migraine without aura, 22% episodic migraine without aura, 32% migraine with aura, 21% tension‐type headache, 6% chronic post‐traumatic headache, 11% medication overuse headache, and 7% other types. All patients were receiving standard treatment for their headaches by their neurologist. Fifty‐two patients (63%) had OSA. Increasing age, female gender, and chronic migraine without aura were predictive of OSA. Of the patients with OSA, 33 (63%) used CPAP and 27 (82%) were adherent to CPAP. Headache improvement was reported by 40 patients (49%) due to either standard medical therapy or CPAP. Patients with OSA who were CPAP adherent (21/27) were more likely to have improvement in headaches than patients intolerant of CPAP (2/6), those that did not try CPAP (8/19), and those who did not have OSA (16/30) (P = .045). Of the 33 patients who used CPAP, 13 reported improvement in headaches specifically due to CPAP therapy and 10 additional patients noted benefit in sleep symptoms. The presence of witnessed apneas (P = .045) and male gender (P = .021) predicted improvement in headaches due to CPAP. Conclusions.— Headache patients should be evaluated for the presence of OSA. Treating OSA improves headaches in some patients.     

Prevalence of Migraine in Patients With Celiac Disease and Inflammatory Bowel Disease

Objective.— To assess the prevalence of headache in clinic and support group patients with celiac disease and inflammatory bowel disease (IBD) compared with a sample of healthy controls. Background.— European studies have demonstrated increased prevalence of headache of patients with celiac disease compared with controls. Methods.— Subjects took a self‐administered survey containing clinical, demographic, and dietary data, as well as questions about headache type and frequency. The ID‐Migraine screening tool and the Headache Impact Test (HIT‐6) were also used. Results.— Five hundred and two subjects who met exclusion criteria were analyzed – 188 with celiac disease, 111 with IBD, 25 with gluten sensitivity (GS), and 178 controls (C). Chronic headaches were reported by 30% of celiac disease, 56% of GS, 23% of IBD, and 14% of control subjects (P < .0001). On multivariate logistic regression, celiac disease (odds ratio [OR] 3.79, 95% confidence interval [CI] 1.78‐8.10), GS (OR 9.53, 95%CI 3.24‐28.09), and IBD (OR 2.66, 95%CI 1.08‐6.54) subjects all had significantly higher prevalence of migraine headaches compared with controls. Female sex (P = .01), depression, and anxiety (P = .0059) were independent predictors of migraine headaches, whereas age >65 was protective (P = .0345). Seventy‐two percent of celiac disease subjects graded their migraine as severe in impact, compared with 30% of IBD, 60% of GS, and 50% of C subjects (P = .0919). There was no correlation between years on gluten‐free diet and migraine severity. Conclusions.— Migraine was more prevalent in celiac disease and IBD subjects than in controls. Future studies should include screening migraine patients for celiac disease and assessing the effects of gluten‐free diet on migraines in celiac disease.     

Childhood Maltreatment and Migraine (Part III). Association With Comorbid Pain Conditions

(Headache 2010;50:42‐51) Objective.— To evaluate in a headache clinic population the relationship of childhood maltreatment on the prevalence of pain conditions comorbid with migraine. Background.— Childhood maltreatment is highly prevalent and has been frequently associated with recurrent headache. The relationship of maltreatment and pain has, however, been a subject of some debate. Methods.— Cross‐sectional data on self‐reported physician‐diagnosed pain conditions were electronically collected from persons with migraine (diagnosed according to International Classification of Headache Disorders‐2), seeking treatment in headache clinics at 11 centers across the US and Canada. These included irritable bowel syndrome (IBS), chronic fatigue syndrome (CFS), fibromyalgia (FM), interstitial cystitis (IC), arthritis, endometriosis, and uterine fibroids. Other information included demographics, migraine characteristics (frequency, headache‐related disability), remote and current depression (The Patient Health Questionnaire‐9), and remote and current anxiety (The Beck Anxiety Inventory). Patients also completed the Childhood Trauma Questionnaire regarding sexual, emotional, and physical abuse, and emotional and physical neglect under the age of 18 years old. Statistical analyses accounted for the survey design and appropriate procedures in SAS such as surveymeans, surveyfreq, and surveylogistic were applied to the weighted data. Results.— A total of 1348 migraineurs (88% women) were included in this study (mean age 41 years). Based on physician diagnosis or validated criteria, 31% had IBS, 16% had CFS, and 10% had FM. Diagnosis of IC was reported by 6.5%, arthritis by 25%, and in women, endometriosis was reported by 15% and uterine fibroids by 14%. At least 1 comorbid pain condition was reported by 61%, 2 conditions by 18%, and 3 or more by 13%. Childhood maltreatment was reported by 58% of the patients. Emotional abuse was associated with increased prevalence of IBS, CFS, arthritis, and physical neglect with arthritis. In women, physical abuse was associated with endometriosis and physical neglect with uterine fibroids. Emotional abuse, and physical abuse and neglect (P < .0001 for all) were also associated with increased total number of comorbid conditions. In ordinal logistic regression models, adjusted for sociodemographics and current depression (prevalence 28%) and anxiety (prevalence 56%), emotional abuse (odds ratios [OR] = 1.69, 95% confidence intervals [CI]: 1.224‐2.33) and physical neglect (OR = 1.73, 95% CI: 1.22‐2.46) were independently associated with an increased number of pain conditions. The cohort of women, similarly, had associations of emotional abuse (OR = 1.94, 95% CI: 1.40‐2.72) and physical neglect (OR = 1.90, 95% CI: 1.34‐2.68) with an increased number of pain comorbidities. Conclusion.— The association of childhood maltreatment and pain was stronger in those reporting multiple pain conditions and multiple maltreatment types. This finding suggests that in migraineurs childhood maltreatment may be a risk factor for development of comorbid pain disorders.     

Migraine headaches and suicide attempt

(Headache 2012;52:723‐731) Background.— Previous cross‐sectional studies reported an increased risk of suicide attempt in persons with migraine headache, which was sustained when psychiatric comorbidity was statistically controlled. Objective.— To estimate the risk of suicide attempt in persons with migraine vs controls with no history of severe headache, using prospective data and validated diagnostic assessment. To examine the specificity of the migraine‐suicide attempt risk by comparing it to the risk associated with non‐migraine headache of comparable severity and disability. Methods.— A cohort of persons with migraine (n = 496), non‐migraine severe headaches (n = 151), and controls with no history of severe headache (n = 539) was randomly selected from the general community, assessed in 1997 and reassessed 2 years later. Results.— Persons with migraine had an increased risk of suicide attempt during the 2‐year follow‐up period, compared with controls. Odds ratio, adjusted for sex, psychiatric disorder, and previous history of suicide attempt at baseline was 4.43 (95% confidence interval [CI] 1.93, 10.2). Persons with non‐migraine headache of comparable intensity and disability also had an increased risk of suicide attempt, compared to controls: odds ratio, adjusted for the same covariates, was 6.20 (95% CI 2.40, 16.0). The difference between the 2 estimates was not significant. In the entire sample, headache severity at baseline predicted suicide attempt: a difference of 1 standard deviation (SD) in pain score increased the risk of suicide attempt by 79%, adjusting for sex and psychiatric disorders. Conclusions.— The results suggest the possibility that pain severity might account in part for the increased risk of suicide attempt associated with migraine.     

Meta‐Analysis of the Efficacy and Safety of Naproxen Sodium in the Acute Treatment of Migraine

(Headache 2010;50:808‐818) Objective.— To assess the efficacy and safety of naproxen sodium in the treatment of acute migraine attacks. Background.— Non‐steroidal anti‐inflammatory drugs including naproxen sodium have been used in treating migraine attack. A number of clinical trials of naproxen sodium in migraine have been reported. However, it remains to be established whether naproxen sodium unequivocally offers clinical benefits taken into account the desired outcomes in acute migraine therapy as recommended by the International Headache Society. Methods.— Clinical trials were identified through electronic searches (MEDLINE, EMBASE, EBM review, and the Cochrane Library) up to June 2009 and historical searches of relevant articles. Studies were included in the meta‐analysis if they were (1) double‐blind, randomized, placebo‐controlled trials that evaluated naproxen sodium tablet in moderate or severe migraine attacks in adult patients, and (2) reporting the efficacy in terms of headache relief, pain‐free, relief of migraine‐associated symptoms, sustained headache relief, sustained pain‐free, or headache recurrence. Data extraction and study quality assessment were performed independently by 2 investigators. Disagreements were resolved by a third investigator. Treatment effects and adverse effects were expressed as risk ratio. A random effects model was used when significant heterogeneity existed, otherwise the fixed effects model was performed. Results.— We identified 16 published randomized controlled trials of naproxen in the treatment of migraine. Four trials met the inclusion criteria and were included in the meta‐analysis. Naproxen sodium was more effective than placebo in reducing pain intensity and providing pain‐free within 2 hours in adults with moderate or severe migraine attacks. The pooled risk ratios were 1.58 (95% confidence interval [CI] 1.41‐1.77, P < .00001), and 2.22 (95% CI 1.46‐3.37, P = .0002), respectively, for headache relief at 2 hours and pain‐free at 2 hours. It was also effective in achieving headache relief at 4 hours, relief of migraine‐associated symptoms, sustained headache relief, and sustained pain‐free responses. There was no significant difference in headache recurrence rate between naproxen sodium and placebo. The risk of any adverse event was greater with naproxen sodium than with placebo (pooled risk ratio 1.29, 95% CI 1.04‐1.60, P = .02). The adverse events commonly associated with naproxen sodium were nausea, dizziness, dyspepsia, and abdominal pain. Conclusions.— The available evidence suggests that naproxen sodium is more effective but may cause more adverse events than placebo in the acute treatment of moderate to severe migraine. It is effective in reducing headache intensity, rendering pain‐free at 2 hours and improving migraine‐associated symptoms. However, its effectiveness relative to other active comparators needs to be better defined by appropriate head‐to‐head clinical trials.     

Intermediate outcomes by race and ethnicity in peritoneal dialysis patients: results from the 1997 ESRD Core Indicators Project. National ESRD Core Indicators Workgroup.

BACKGROUND: Hispanics are the fastest growing minority group in the United States, and approximately 10% of all end-stage renal disease (ESRD) patients are Hispanic. Few data are available, however, regarding dialysis adequacy and anemia management in Hispanic patients receiving peritoneal dialysis in the U.S. METHODS: Data from the Health Care Financing Administration (HCFA) ESRD Core Indicators Project were used to assess racial and ethnic differences in selected intermediate outcomes for peritoneal dialysis patients. RESULTS: Of the 1219 patients for whom data were available from the 1997 sample, 9% were Hispanic, 24% were non-Hispanic blacks, and 59% were non-Hispanic whites. Hispanics were more likely to have diabetes mellitus as a cause of ESRD compared to blacks or whites, and both Hispanics and blacks were younger than white patients (both p < 0.001). Although whites had higher weekly Kt/V and creatinine clearance values compared to blacks or Hispanics (p < 0.05), blacks had been dialyzing longer (p < 0.01) and were more likely to be anuric compared to the other two groups (p < 0.001). Blacks had significantly lower mean hematocrit values (p < 0.001) and a greater proportion of patients who had a hematocrit level less than 28% (p < 0.05) compared to Hispanics or whites, despite receiving significantly larger weekly mean epoetin alfa doses (p < 0.05) and having significantly higher mean serum ferritin concentrations (p < 0.01). Multivariate logistic regression analysis revealed significant differences by race/ethnicity for experiencing a weekly Kt/V urea < 2.0 and hypertension, but not for other intermediate outcomes examined (weekly creatinine clearance < 60 L/week/1.73 m2, Hct < 30%, and serum albumin < 3.5/3.2 g/dL). CONCLUSION: Hispanics had adequacy values similar to blacks and anemia parameters similar to whites. Additional studies are needed to determine the etiologies of the differences in intermediate outcomes by racial and ethnic groupings in peritoneal dialysis patients.     

Headache Disability Among Adolescents: A Student Population‐Based Study

(Headache 2010;50:210‐218) Objective.— To examine the extent and to identify the relevant predictors of headache disabilities in adolescents. Background.— Headaches are common in adolescents but their impact and related factors have not been extensively studied in adolescent communities. Method.— We recruited and surveyed 3963 students aged 13‐15 from 3 middle schools using self‐administered questionnaires. The questionnaires were used to make 3 assessments: (1) headaches were diagnosed using a validated headache questionnaire; (2) headache disabilities were valuated using the 6‐question Pediatric Migraine Disability Assessment; (3) depression was measured using the Adolescent Depression Inventory. Results.— The student response rate was 93%. In total, 484 students (12.2%) had migraines with or without auras, 444 (11.2%) had probable migraines, and 1092 (27.6%) had tension‐type headaches. The students with migraine had the highest Pediatric Migraine Disability Assessment scores (10.7 ± 20.0); whereas, the students with tension‐type headaches had the lowest scores (2.0 ± 4.4). Logistic regression analyses indicated that there were a number of independent predictors for moderate to severe headache‐related disability (Pediatric Migraine Disability Assessment score ≥31), including a migraine or probable migraine diagnosis, a higher depression score, severe headache intensity, and frequent headaches. Conclusions.— The Pediatric Migraine Disability Assessment provides a simple tool to measure the impact of headaches in adolescents. Adolescents with migraine headaches suffered the greatest level of disability. Higher depression scores were associated with more severe headache‐related disabilities in adolescents, independent of headache frequency and severity.     

A pivotal moment in 50 years of headache history: the first American Migraine Study

Objective.— To describe the magnitude and distribution of the public health problem posed by migraine in the United States by examining migraine prevalence, attack frequency, and attack‐related disability by gender, age, race, household income, geographic region, and urban vs rural residence. Design.— In 1989, a self‐administered questionnaire was sent to a sample of 15,000 households. A designated member of each household initially responded to the questionnaire. Each household member with severe headache was asked to respond to detailed questions about symptoms, frequency, and severity of headaches. Setting.— A sample of households selected from a panel to be representative of the US population in terms of age, gender, household size, and geographic area. Participants.— After a single mailing, 20,468 subjects (63.4% response rate) between 12 and 80 Years of age responded to the survey. Respondents and nonrespondents did not differ by gender, household income, region of the country, or urban vs rural status. Whites and the elderly were more likely to respond. Migraine headache cases were identified on the basis of reported symptoms using established diagnostic criteria. Results.— In total, 17.6% of females and 5.7% of males were found to have 1 or more migraine headaches per year. The prevalence of migraine varied considerably by age and was highest in both men and women between the ages of 35 to 45 years. Migraine prevalence was strongly associated with household income; prevalence in the lowest‐income group (less than $10,000) was more than 60% higher than in the 2 highest‐income groups (greater than or equal to $30,000). The proportion of migraine sufferers who experienced moderate to severe disability was not related to gender, age, income, urban vs rural residence, or region of the country. In contrast, the frequency of headaches was lower in higher‐income groups. Attack frequency was inversely related to disability. Conclusions.— A projection to the US population suggests that 8.7 million females and 2.6 million males suffer from migraine headache with moderate to severe disability. Of these, 3.4 million females and 1.1 million males experience 1 or more attacks per month. Females between ages 30 and 49 years from lower‐income households are at especially high risk of having migraines and are more likely than other groups to use emergency care services for their acute condition.     

Discharge Destination's Effect on Bounce-Back Risk in Black, White, and Hispanic Acute Ischemic Stroke Patients

Kind AJH, Smith MA, Liou J-I, Pandhi N, Frytak JR, Finch MD. Discharge destination's effect on bounce-back risk in black, white, and Hispanic acute ischemic stroke patients.

Objective

To determine whether racial and ethnic effects on bounce-back risk (ie, movement to settings of higher care intensity within 30d of hospital discharge) in acute stroke patients vary depending on initial posthospital discharge destination.

Design

Retrospective analysis of administrative data.

Setting

Four hundred twenty-two hospitals, southern/eastern United States.

Participants

All Medicare beneficiaries 65 years or more with hospitalization for acute ischemic stroke within one of the 422 target hospitals during the years 1999 or 2000 (N=63,679).

Interventions

Not applicable.

Main Outcome Measures

Adjusted predicted probabilities for discharge to and for bouncing back from each initial discharge site (ie, home, home with home health care, skilled nursing facility [SNF], or rehabilitation center) by race (ie, black, white, and Hispanic). Models included sociodemographics, comorbidities, stroke severity, and length of stay.

Results

Blacks and Hispanics were significantly more likely to be discharged to home health care (blacks=21% [95% confidence interval (CI), 19.9-22.8], Hispanic=19% [17.1-21.7] vs whites=16% [15.5-16.8]) and less likely to be discharged to SNFs (blacks=26% [95% CI, 23.6-29.3], Hispanics=28% [25.4-31.6] vs whites=33% [31.8-35.1]) than whites. However, blacks and Hispanics were significantly more likely to bounce back when discharged to SNFs than whites (blacks=26% [95% CI, 24.2-28.6], Hispanics=28% [24-32.6] vs whites=21% [20.3-21.9]). Hispanics had a lower risk of bouncing back when discharged home than either blacks or whites (Hispanics=14% [95% CI, 11.3-17] vs blacks=20% [18.4-22.2], whites=18% [16.8-18.3]). Patients discharged to home health care or rehabilitation centers demonstrated no significant differences in bounce-back risk.

Conclusions

Racial/ethnic bounce-back risk differs depending on initial discharge destination. Additional research is needed to fully understand this variation in effect.     

Headache and Symptoms of Temporomandibular Disorder: An Epidemiological Study

(Headache 2010;50:231‐241) Objectives.— A population‐based cross‐sectional study was conducted to estimate the prevalence of migraine, episodic tension‐type headaches (ETTH), and chronic daily headaches (CDH), as well as the presence of symptoms of temporomandibular disorders (TMD) in the adult population. Background.— The potential comorbidity of headache syndromes and TMD has been established mostly based on clinic‐based studies. Methods.— A representative sample of 1230 inhabitants (51.5% women) was interviewed by a validated phone survey. TMD symptoms were assessed through 5 questions, as recommended by the American Academy of Orofacial Pain, in an attempt to classify possible TMD. Primary headaches were diagnosed based on the International Classification of Headache Disorders. Results.— When at least 1 TMD symptom was reported, any headache happened in 56.5% vs 31.9% (P < .0001) in those with no symptoms. For 2 symptoms, figures were 65.1% vs 36.3% (P < .0001); for 3 or more symptoms, the difference was even more pronounced: 72.8% vs 37.9%. (P < .0001). Taking individuals without headache as the reference, the prevalence of at least 1 TMD symptom was increased in ETTH (prevalence ratio = 1.48, 95% confidence interval = 1.20‐1.79), migraine (2.10, 1.80‐2.47) and CDH (2.41, 1.84‐3.17). At least 2 TMD symptoms also happened more frequently in migraine (4.4, 3.0‐6.3), CDH (3.4; 1.5‐7.6), and ETTH (2.1; 1.3‐3.2), relative to individuals with no headaches. Finally, 3 or more TMD symptoms were also more common in migraine (6.2; 3.8‐10.2) than in no headaches. Differences were significant for ETTH (2.7 1.5‐4.8), and were numerically but not significant for CDH (2.3; 0.66‐8.04). Conclusion.— Temporomandibular disorder symptoms are more common in migraine, ETTH, and CDH relative to individuals without headache. Magnitude of association is higher for migraine. Future studies should clarify the nature of the relationship.     

Use of antimigraine treatments by general practitioners

(Headache 2011;51:1122‐1131) Objectives.— To assess headache treatment patterns in 2 groups: general practitioners (GPs) who suffered from migraine themselves (GP‐M) and GPs having a close family member with migraine (GP‐CFM). The secondary objective was to assess the impact of migraine on activities of daily living in these 2 groups. Background.— Personal experience of migraine may influence prescribing practices of physicians treating patients with migraine. Little data are available on perceptions of migraine by GPs. Methods.— This was an observational, cross‐sectional, pharmacoepidemiological survey conducted in primary care in France. Most GPs completed 1 of 2 questionnaires, and GPs belonging to both groups could complete both. Data were collected on headache treatments used (GP‐M) or prescribed (GP‐CFM), and on self‐reported (GP‐M) or described (GP‐CFM) migraine features and impact on daily activities. Results.— The most frequently reported acute headache treatments in both groups were triptans and non‐steroidal anti‐inflammatory drugs (>75% of GPs); >81% of GPs in both groups were satisfied with acute headache treatments. Only 6.9% of the GP‐M group used and 17.2% of the GP‐CFM group prescribed a prophylactic treatment, which was considered satisfactory by 46.2% and 56.1%, respectively. In the preceding 3 months, 79.4% of the GP‐M group reported handicap in daily activities due to migraine, 23.6% interruption of extraprofessional activities and 7.6% interruption of work. In the GP‐CFM group, 32.6% described interruption of extraprofessional activities and 57.3% interference with daily activities or work. Conclusions.— Acute headache treatment prescribed by French GPs for their own migraines or those of their relatives respect practice guidelines and is considered as effective and satisfactory. Use of prophylactic medication is low and its effectiveness perceived as limited. Better use of prophylactic treatments may attenuate the impact of migraine on daily activities.