Children with Migraine More Likely to Have Sleep and Behaviour Problems

Children with migraine are more likely to suffer sleep and behaviour problems than non-migraineur children. These problems were greater in those children with severe migraine.

Parents of children aged 6-18 years were recruited through a neurology clinic in Canada were asked to complete questionnaires for their child with migraine, the second for their child without migraine. In each case and control, three questionnaires were completed.

The first questionnaire determined age, gender, other chronic conditions, medications used and time off school in the previous 4 months, headache frequency and severity. The second asked about their children’s sleep habits, including delay in the time to sleep, sleep duration, sleep anxiety, parasomnias, sleep-disordered breathing, daytime sleepiness and night wakenings. The final questionnaire considered behaviour.

Of the 51 completed questionnaires, it was determined that the average age of the child with migraine was 12.2 years with 32% having headaches less than monthly, 40% monthly to weekly and 26% weekly to daily. Severe migraines occurred weekly or more frequently in 28% of cases.

Among those with migraine the total sleep score was higher, indicating greater sleep disturbance (p < 0.2), with more daytime sleepiness (p < 0.01) and delayed onset of sleep (p < 0.3), compared with their sibling controls. Those using prophylactic medication also had higher total sleep scores than those not using prophylaxis (p < 0.2), as did those with severe migraine (p < 0.1).

For behaviour, only the internalising problems score (covering anxiety, depression and somatisation) was higher for those with migraine, compared to their siblings (p < 0.02). However, those children with higher total sleep scores had behaviour problems on all 4 behaviour measurement scales, including poorer functioning. It is unclear whether sleep disturbances cause behaviour problems, or the other way around.

The reason behind this is that frequent headaches can prevent children from getting to sleep or cause night wakening. Also, many children with migraine can find their symptoms resolved if they sleep during a daytime attack, interrupting the normal sleep-wake cycle.

The authors suggest that sleep disorders should be routinely queried in children suffering migraine and advice on sleep hygiene provided.

Heng K, Wirrell E. Sleep disturbance in children with migraine. J Child Neurol 2006; 21: 761-766.

What the WHA thinks:

  • A useful study, albeit quite small, that may help parents understand any behavioural difficulties with their migraine-suffering children.
  • The recommendation that child migraine sufferers be offered advice on sleep hygiene is to be welcomed
  • However, as the parents recorded the degree of sleep disturbance and behaviour it may be that these effects are underestimated. A child diary or physiologic measures could help give a clearer picture of the impact of migraine on sleep disturbance and behaviour
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Some Migraineurs Need at Least a Year of Topiramate Treatment

Topiramate is usually used for periods of three to six months for the prevention of migraine. However, a new Spanish study concludes almost 50% of migraineurs may need treatment for more than a year.

In an observational study of migraine patients attending a specialist clinic, 80 consecutive migraine patients who had received prophylactic topiramate for three months were selected. All patients had good response and tolerability to treatment and continued therapy for a further three months, after which drug treatment ceased.

Topiramate was reintroduced if there was a worsening of headache and a further six months of treatment completed before discontinuing again. Patients whose headaches worsened after the second withdrawal received topiramate again and were followed up for at least six months.

In half of patients, headaches did not worsen after the first withdrawal, while the remaining half experienced significant worsening. At the end of the first year of treatment, only 5% of this second group were able to discontinue topiramate use without experiencing an increase in headache frequency after two months.

The authors conclude that around half of patients require topiramate treatment lasting longer than a year and recommended that the current practice of using topiramate for 3-6 months to prevent migraine should be reconsidered in many patients.

Pascual J, El Berdei Y, Gomez-Sanchez JC. J Headache Pain 2007. Jan 15

What the WHA thinks:

  • Although a small study, with only 38 patients requiring more than a year of topiramate treatment, it provides a useful practice point for physicians.

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Depression More Common in Women with Chronic Headaches

Women suffering chronic headaches, especially migraine, are more likely to be depressed and tired, according to a new study of over a thousand American women.Women with headache attending six headache speciality clinics were classified using ICHD-II criteria and frequency of attack recorded. Of the 1032 women, 593 had episodic headache (96% with migraine) and 439 had chronic headache (87% with migraine)Those suffering chronic headache were four times more likely to have symptoms of major depression than those experiencing episodic attacks. For women with severely disabling migraine, the chance of having major depression increased 32-fold if the patient also had other severe symptoms. In addition, chronic headache sufferers were more likely to have headache-related symptoms, such as tiredness, lack of energy, nausea, insomnia, dizziness and pain in other parts of the body.Tietjen GE, Brandes JL, Digre KB, et al. High prevalence of somatic symptoms and depression in women with disabling chronic headache. Neurology 2007; 68: 134-140.

What the WHA thinks:

  • The link between depression and chronic headache has been previously identified
  • However, it is interesting to note the greater likelihood of depression for those with severely disabling migraine
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Migraineurs More Likely to Have Other Medical Problems

Other medical conditions, such as low blood pressure, allergy and psychiatric problems, are more common in people with migraine, concludes a Finnish study.

The Finnish Migraine Gene Project consecutively identified families with at least three first-degree family members affected by migraine who attended outpatient headache clinics from across Finland. In total 1000 participants from 251 families completed a questionnaire.

Migraine sufferers reported more low blood pressure (OR 1.43), allergy (OR 1.83) and psychiatric disorders (OR 4.09), compared to family members without migraine. These conditions were more common in female migraineurs than in male migraine sufferers and in those individuals who experienced migraine with and without aura.

However, the study did find an association between men who have migraine with aura and stroke and epilepsy. This requires further study.

Artto V, Wessman M, Nissilä, et al. Comorbidity in Finnish migraine families. J Headache Pain 2006; 7: 324-330.

What the WHA thinks:

  • The questionnaire used was not validated for the other medical health problems, therefore precise incidence or prevalence figures cannot be drawn from the data.
  • The link between migraine and allergy or psychiatric conditions has been identified in previous studies.
  • The link to low blood pressure is a new association and more data is needed on this as other studies have suggested high blood pressure is more common in migraine.
  • While the link between migraine and epilepsy has been seen before, in this study it was only found in men, specifically those with aura.
  • However, the numbers in this study (17 men in total) were too small to make any real conclusion.
  • Similarly for stroke, the numbers were too small to reach a definitive conclusion, although the link between stroke and migraine has been identified before.
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Elderly People Suffer Migraine Too

Migraine is most common in younger people, with a peak around puberty. As a result, there is a perception that it is a problem that doesn’t really affect the elderly. However, a new review makes clear that, while it is less common in the older population, those over the age of 60 years of age also suffer.The review focused on those over the age of 60 and revealed headache is less common in elderly migraine sufferers, with only the visual (aura) elements of migraine experienced. People who experience migraine headache for the first time over the age of 60 are likely to have another underlying medical problem that should be investigated.It also made highlighted there are specific issues that need to be considered with respect to other health issues that come with ageing which, in turn, affect treatment choices. In addition, while migraine is also linked to other conditions, some of these are of particular importance to elderly sufferers, such as stroke, depression, vertigo and epilepsy. Some of these, such as depression, can have an impact on migraine itself, while others also impact on treatment choices that can be made to relieve migraine.The authors offer the following guidance:

  • analgesics – paracetamol can be used for acute attacks, with aspirin used with caution because of the risks of stomach bleeding. Non-steroidal anti-inflammatory drugs, such as ibuprofen and diclofenac, should be used with caution, if at all, in elderly people. Opioids, such as codeine, should also be used with caution as they cause drowsiness and other side effects; if used the dose should start low and increase slowly
  • anti-emetics – drugs such as metoclopramide increase the risk of certain side effects, called extrapyramidal side effects
  • ergotamine – should be avoided or used with caution as can cause side effects
  • triptans – can be used but screening for heart problems is advised as these drugs can cause cardiac side effects
  • tricyclic antidepressants – caution is advised, although the doses used for migraine are lower than the doses used for treating depression so there is less likelihood of side effects
  • beta-blockers – their use may be limited as they influence other medical problems and the dosage of propranolol needs to be altered
  • sodium valproate – side effects are more common in the elderly
  • topiramate – high risk of side effects in any age group
  • lisinopril and candesartan – should be used with caution as can cause kidney problems
  • calcium channel blockers – dosage needs to b adjusted and side effects more common.

Haan J, Hollander J, Ferrari MD. Migraine in the elderly: a review. Cephalalgia, 2006. doi:10.1111/j.1468-2982.2006.01250.x

What the WHA thinks

  • A useful review for an under-recognised group of migraine sufferers
    The information on co-morbid conditions and the impact of age on treatment choices is particularly valuable.
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Headache is One of the Top Ten Most Disabling Health Problems Says New Study

Almost 50 per cent of the world’s population are affected by headache, making it one of the top ten most disabling global health problems, concludes a study in March’s issue of Cephalalgia.

An international research group, chaired by Professor Lars Jacob Stovner of the Norwegian University of Science and Technology, collated all studies on headache prevalence and its consequences published up to 2006. The review shows that headache is a truly global complaint, with a major impact on both quality of life and the economy.

According to the review, one in nine (11 per cent) of the world’s adult population have migraine. Ordinary headache, correctly called tension-type headache, afflicts almost half (42 per cent) of all adults. While migraine tends to be more burdensome for the individual, the review authors claim that, because of the numbers of people affected, tension-type headache has an even greater impact on society as a whole.

This finding is confirmed by studies from developed countries that show more work days are lost each year from tension-type headache than from migraine.

The review also reveals some interesting differences in headache prevalence across the world. For example, both migraine and tension-type headache seem to be less prevalent in Africa, although the authors call for more studies in this region as the evidence there is limited.
For most individual people, headache is a minor ailment that is coped with quite easily, but the authors warn this leads to complacency. Professor Stovner explains: “We often hear that headache is a trivial disorder. For the many with a serious headache problem this attitude can be very disheartening.

“A most disquieting finding of the study is that 3% of the world’s adult population suffer from chronic daily headache – that is, headache on more than every other day for at least several months. This group of more than 100 million people worldwide probably carry the greatest headache burden, and possibly also a stigma since their disorder is not generally acknowledged as a proper disease.

Dr. Timothy Steiner at Imperial College, London, UK, co-author of the article and chairman of Lifting The Burden: The Global Campaign to Reduce the Burden of Headache Worldwide, adds: “This study is important in helping us to understand the scale of the headache burden everywhere in the world. It shows, starkly, why we need a Global Campaign, and it strongly supports the messages the Campaign takes to governments and others responsible for health-service policy and delivery. There are still parts of the world, such as China, India and Africa, where the Campaign needs to undertake more research to improve our knowledge of how headache affects both people and society, but elsewhere the evidence is crystal clear.
“In many cases, headache disorders such as migraine and tension-type headache can be simply and effectively treated, but first they must be recognised as needing treatment and doctors and other health-care providers trained in their diagnosis and management. The public need to know that treatments are available and governments must understand the benefits – in public health and in better productivity – of making these treatments available. The Global Campaign, with the committed support of the World Health Organization, has precisely these objectives.”

Key points:

  • A total of 107 publications were analysed: 48 from Europe, 20 from Asia, 14 from North America, 13 from Central/South America, eight from Africa and four from Australia/Oceania. Table 1 lists the global prevalences of current (within the last year) and lifetime experience of headache.
  • These new figures bring headache disorders into the top ten of the World Health Organization’s ranking of causes of disability for both men and women. In women alone, headache is almost certainly among the top five most disabling conditions.
  • The number of people affected by headache varies around the globe: about 50% of people in Asia, Australia, Europe and North America, but possibly only 20% in Africa.
  • The individual headache burden during an average migraine attack was more than twice as high as the burden during a tension-type headache. However, when the frequency of each type of headache is considered (headache days per person in the population), tension-type headache (including chronic daily headache) contributed 58% of the total burden of headache and migraine 42%.

Stovner LJ, Hagen K, Jensen R, Katsarava Z, Lipton R, Scher AI et al. The global burden of headache: a documentation of headache prevalence and disability worldwide. Cephalalgia 2007;27:193-210.

What the WHA thinks

  • This is a milestone study, giving us a greater understanding of how many people are affected by headache around the globe.
  • Although more work is needed to determine the prevalence of headache in parts of the world where there are few data available, it is clear that headache exerts an enormous impact on global health.
  • The finding that headache is among the top ten most disabling conditions, and probably among the top five for women, makes clear to all that this is a serious problem demanding treatment as such.
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Harry Potter Cursed with Headache Too!

It’s a hard life being a boy wizard, even harder if you suffer from childhood headache. So, imagine how it must feel being Harry Potter. Dr Fred Sheftell and Dr Timothy Steiner (with the assistance of teenage Potter fan Hallie Thomas) have a good idea of just how headache has affected the young wizard, and report their findings in the latest issue of Headache.

Harry has suffered from recurrent, short-lasting but intense and disabling headaches since just before his 11th birthday. In every case the site of pain has been around the lightning bolt scar of his forehead. A total of nine headaches have been documented in the Harry Potter books; initially the only symptoms were headache but as Harry has become older he has started to experience nausea, vomiting, visual disturbances and lacrimation (watering eyes). The authors conclude that Harry suffers from probably migraine, that is, he has most of the diagnostic criteria for migraine, apart from one.

However, Harry does make rapid recoveries from his headaches, with the assistance of magical powers. As the authors comment: “perhaps it is not surprising that a classification constructed by Muggles failed to consider this.”

While the paper seems a light-hearted look at the impact of headache on a fictional character, it makes a serious point regarding the wider problem of headache in children and adolescents. “In the Muggle worlds, the burden of child and adolescent headache is often of under-recognized importance; as in adults, it is very often under-treated.”

Indeed, estimates of one-year prevalence of headache in the Muggle population suggest 58-80% of children and adolescents aged between 7 and 15 years are affected by headache, with 3.6-12% suffering migraines. Headache, in particular migraines, can have an adverse effect on the lives of young sufferers, impacting on concentration, school performance and attendance.

However, the authors add: “headache need not be a curse for Muggles or Wizards: it can be lifted with research, better to understand it, and education, better to manage it.”

Sheftell F, Steiner TJ, Thomas H. Harry Potter and the curse of headache. Headache 207; 47: 911-916.

What the WHA thinks

  • This is an entertaining, sideways look at an often over-looked problem, childhood headache.
  • By examining the headaches of one of the world’s most popular fictional characters, just ahead of the publication of his final book, the authors have been able to highlight the impact headache can have on children and demonstrated how the nature of headache can evolve over time in children and adolescents.
  • However, unlike Harry, most sufferers don’t have the benefit of magical powers to shorten the duration of attack!
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Hayfever and Asthma Sufferers More Likely to Have Headache and Migraine

Hayfever and asthma sufferers more likely to have headache and migraine
Headache and migraine is 1.5 times more common in those with asthma, asthma-related symptoms, hayfever and chronic bronchitis, than in those without these conditions, according to a study of over 50,000 Norwegian adults in Headache.

The HeadHUNT study asked adults to complete 2 questionnaires containing more than 200 health-related questions. The first questionnaire included six questions about cough and asthma; while the second included 13 questions relating to headache, hayfever and family history of allergy and asthma.

Headache prevalence was higher among those with asthma, hayfever and chronic bronchitis, than among those without these conditions. The association increases with increasing headache frequency.

While this link has been seen in other studies, the reason for the association is, as yet, unknown and it is not clear whether it is the headache that causes the asthma/hayfever or the other way round. The authors do state, however, that it does underline the importance of considering additional health problems among frequent headache sufferers.

Aamodt AH, Stovner LJ, Langhammer A et al. Is Headache Related to Asthma, Hay Fever, and Chronic Bronchitis? The Head-HUNT Study. Headache 2007;47:204-212.

What the WHA thinks

  • This is an interesting paper and echoes findings of other studies.
  • However, there are problems with the methodology; for example, the conditions were reported by patients, which gives room for error.
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Placebo is as Effective as Botox in Relieving Migranes

Despite media reports that suggest botox could be an effective way to prevent migraines, a new study reveals botox injections are no more effective than placebo.

The Headache paper reported the results of an exploratory 11-month randomised, double-blind, placebo-controlled study. Some 369 subjects entered a single-blind, placebo run-in period for 30 days and divided into placebo and non-placebo responders. They were then randomised to receive three botox treatments or placebo at 90-day intervals.

Patients in both the botox and placebo groups experienced an average of 2.4 and 2.2 migraine episodes per month, with at least 50% of all patients in each group experiencing fewer migraines per 30 day period. Among those with between 12-15 headache days per month, those in the botox group had four fewer headache episodes at the end of the study, compared with less than two fewer headaches in the placebo group. This difference was not significant, however.

The authors note that while there was no difference in treatments, there were several factors affecting the trial, including a strong placebo response and the fact subjects were allowed to use symptom-relieving and preventative medication throughout the trial.

A second study in Europe, found similar results, with improvements seen in both the placebo and botox groups, but not significant difference between groups.

Aurora SK; Gawel M, Brandes JL et al for the Botox North American Episodic Migraine Study Group. Botulinum Toxin Type A Prophylactic Treatment of Episodic Migraine: A Randomized, Double-Blind, Placebo-Controlled Exploratory Study. Headache 2007;47:486-499.

Relja M, Poole AC, Schoenen J et al for the European BoNTA Headache Study Group. A multicentre, double-blind, randomized, placebo-controlled,parallel group study of multiple treatments of botulinum toxin type A (BoNTA) for the prophylaxis of episodic migraine headaches. Cephalalgia 2007. doi:10.1111/j.1468-2982.2007.01315.x

What the WHA thinks

  • It’s still not been proven that botox can make a difference in preventing migraines.
  • These studies found there was no difference between placebo or botox, although the results looked more promising for those who experience headaches for at least 12 days per month (but less than 15 days, i.e. they do not have chronic daily headache).
  • The authors suggest that higher doses may be more effective but further study is needed.
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All the latest on Topiramate

Several papers have been published over the past few months on the benefits of topiramate in preventing migraine. We summarise some of the key findings.

Topiramate is effective in preventing chronic migraine

  • Topiramate is effective in preventing chronic migraine in adults, according to a randomised, double-blind, placebo-controlled trial. Topiramate use began at 25 mg weekly and gradually increased to a dose of 100 mg/day, allowing dosing flexibility from 50-200 mg/day. Existing migraine prevention treatments were continued throughout the trial. Some 32 patients received topiramate and 27 placebo, with subjects experiencing an average number of 15-16 migraine days per four weeks. The average duration of treatment was 100 days for topiramate users and 92 days for placebo users. Topiramate significantly reduced the average number of monthly migraine days by 3.5, compared with 0.2 for placebo (Study 1)
  • Low dose topiramate is effective in preventing migraine, compared with placebo and lamotrigine, says an Indian study. Some 60 patients with more than four migraine attacks per month were randomized to receive 50 mg topiramate/lamotrigine or matching placebo for 1 month each in 2 divided doses in 4 phases in a crossover manner with a washout period of 7 days in between. Topiramate was more effective in reducing the frequency of migraine compared to placebo (63% response rate; 30% for placebo) and lamotrigine (63% for topiramate; 46% for lamotrigine) and in reducing the intensity of headache (50% for topiramate versus 10% for placebo and 41% for lamotrigine). (Study 2)
  • A third study considered the effects of 100mg/day topiramate, compared with placebo in a randomised, placebo-controlled, parallel-group, multi-centre study consisting of 16 weeks of double-blind treatment. The 306 subjects were divided into two groups, with topiramate users having, on average an 86mg/day dose. Topiramate reduced the number of migraine days compared to placebo (by 6.4 days, vs 4.7) (Study 3).

Topiramate’s side effects

  • Adverse effects were reported by 75% of subjects in Study 1, compared with 37% of placebo users. The most common side effects were nausea, tingling, dizziness, dyspepsia, fatigue, anorexia and attention disturbance
  • Adverse events for topiramate were similar to lamotrigine and placebo at around 7-15% (Study 2)
  • Adverse effects occurred in 82.5% and 70.2% of topiramate and placebo users, respectively (Study 3).

Study 1: Diener H-C, Bussone G,Van Oene JC et al on behalf of the
TOPMAT-MIG-201(TOP-CHROME) Study Group. Topiramate reduces headache days in chronic migraine: a randomized, double-blind, placebo-controlled study. Cephalalgia 2007 doi:10.1111/j.1468-2982.2007.01326.x
Study 2: Gupta P; Singh S, Goyal V et al Low-Dose Topiramate Versus Lamotrigine in Migraine
Prophylaxis (The Lotolamp Study). Headache 2007;47:402-412.
Study 3: Silberstein SD, Lipton RB, Dodick DW et al, on behalf of the Topiramate Chronic Migraine Study Group. Efficacy and Safety of Topiramate for the Treatment of Chronic Migraine: A Randomized, Double-Blind, Placebo-Controlled Trial. Headache 2007;47:170-180.

What the WHA thinks

  • All three studies are consistent and confirm that topiramate, at various doses is effective in reducing the frequency and intensity of chronic migraine.
  • The risk of adverse events is high and it is notable that Study 2 has a lower incidence of adverse effects compared to the other two studies.

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