Headache & Migraine

Migraine with aura was associated with increased risk of incident atrial fibrillation (AF), according to a recent study, which may potentially lead to ischemic strokes. In the Atherosclerosis Risk in Communities (ARIC) study, participants were interviewed for migraine history from 1993 through 1995 and were followed for incident AF through 2013. AF was adjudicated using electrocardiograms (ECGs), discharge codes, and death certificates. Multivariable Cox proportional hazards models were used to study the relation between migraine and its subtypes with incident AF, compared with controls without headaches. Researchers found:

• Of 11,939 participants assessed for headache and without prior AF or stroke, 426 reported migraine with visual aura, 1090 migraine without visual aura, 1018 non-migraine headache, and 9405 no headache.
• Over a 20-year follow-up period, incident AF was noted in 232 (15%) of 1516 with migraine and 1623 (17%) of 9405 without headache.
• After adjustment for multiple confounders, migraine with visual aura was associated with increased risk of AF compared to no headache as well as when compared to migraine without visual aura.

Sen S, Androulakis XM, Duda V, et al. Migraine with visual aura is a risk factor for incident atrial fibrillation. A cohort study. [Published online ahead of print December 11, 2018]. Neurology. doi:10.1212/WNL.0000000000006650.

Migraine with aura was associated with increased risk of incident atrial fibrillation (AF), according to a recent study, which may potentially lead to ischemic strokes. In the Atherosclerosis Risk in Communities (ARIC) study, participants were interviewed for migraine history from 1993 through 1995 and were followed for incident AF through 2013. AF was adjudicated using electrocardiograms (ECGs), discharge codes, and death certificates. Multivariable Cox proportional hazards models were used to study the relation between migraine and its subtypes with incident AF, compared with controls without headaches. Researchers found:

• Of 11,939 participants assessed for headache and without prior AF or stroke, 426 reported migraine with visual aura, 1090 migraine without visual aura, 1018 non-migraine headache, and 9405 no headache.
• Over a 20-year follow-up period, incident AF was noted in 232 (15%) of 1516 with migraine and 1623 (17%) of 9405 without headache.
• After adjustment for multiple confounders, migraine with visual aura was associated with increased risk of AF compared to no headache as well as when compared to migraine without visual aura.

Sen S, Androulakis XM, Duda V, et al. Migraine with visual aura is a risk factor for incident atrial fibrillation. A cohort study. [Published online ahead of print December 11, 2018]. Neurology. doi:10.1212/WNL.0000000000006650.

Migraine with aura was associated with increased risk of incident atrial fibrillation (AF), according to a recent study, which may potentially lead to ischemic strokes. In the Atherosclerosis Risk in Communities (ARIC) study, participants were interviewed for migraine history from 1993 through 1995 and were followed for incident AF through 2013. AF was adjudicated using electrocardiograms (ECGs), discharge codes, and death certificates. Multivariable Cox proportional hazards models were used to study the relation between migraine and its subtypes with incident AF, compared with controls without headaches. Researchers found:

• Of 11,939 participants assessed for headache and without prior AF or stroke, 426 reported migraine with visual aura, 1090 migraine without visual aura, 1018 non-migraine headache, and 9405 no headache.
• Over a 20-year follow-up period, incident AF was noted in 232 (15%) of 1516 with migraine and 1623 (17%) of 9405 without headache.
• After adjustment for multiple confounders, migraine with visual aura was associated with increased risk of AF compared to no headache as well as when compared to migraine without visual aura.

Sen S, Androulakis XM, Duda V, et al. Migraine with visual aura is a risk factor for incident atrial fibrillation. A cohort study. [Published online ahead of print December 11, 2018]. Neurology. doi:10.1212/WNL.0000000000006650.

Women with active migraine have a lower risk of developing type 2 diabetes (T2D), according to a recent study, and a decrease in active migraine prevalence prior to diabetes diagnosis. Researchers used data from a prospective population-based study initiated in 1990 on a cohort of women born between 1925 and 1950. From eligible women in the study, researchers included those who completed a 2002 follow-up questionnaire with information available on migraine. They then excluded prevalent cases of T2D, leaving a final sample of women who were followed up between 2004 and 2014. All potential occurrences of T2D were identified through a drug reimbursement database. They found:

• From the 98,995 women in the study, 76,403 women completed the 2002 follow-up survey.
• Of these, 2156 were excluded because they had T2D, leaving 74,247 women.
• During 10 years of follow-up, 2372 incident T2D cases occurred.
• A lower risk of T2D was observed for women with active migraine compared with women with no migraine history (univariate hazard ratio, 0.80, multivariable-adjusted hazard ratio, 0.7).

Fagherazzi G, El Fatouhi D, Fournier A, et al. Associations between migraine and type 2 diabetes in women: Findings from the E3N Cohort Study. [Published online ahead of print December 17, 2018]. JAMA Neurology. doi:10.1001/jamaneurol.2018.3960.

Women with active migraine have a lower risk of developing type 2 diabetes (T2D), according to a recent study, and a decrease in active migraine prevalence prior to diabetes diagnosis. Researchers used data from a prospective population-based study initiated in 1990 on a cohort of women born between 1925 and 1950. From eligible women in the study, researchers included those who completed a 2002 follow-up questionnaire with information available on migraine. They then excluded prevalent cases of T2D, leaving a final sample of women who were followed up between 2004 and 2014. All potential occurrences of T2D were identified through a drug reimbursement database. They found:

• From the 98,995 women in the study, 76,403 women completed the 2002 follow-up survey.
• Of these, 2156 were excluded because they had T2D, leaving 74,247 women.
• During 10 years of follow-up, 2372 incident T2D cases occurred.
• A lower risk of T2D was observed for women with active migraine compared with women with no migraine history (univariate hazard ratio, 0.80, multivariable-adjusted hazard ratio, 0.7).

Fagherazzi G, El Fatouhi D, Fournier A, et al. Associations between migraine and type 2 diabetes in women: Findings from the E3N Cohort Study. [Published online ahead of print December 17, 2018]. JAMA Neurology. doi:10.1001/jamaneurol.2018.3960.

Women with active migraine have a lower risk of developing type 2 diabetes (T2D), according to a recent study, and a decrease in active migraine prevalence prior to diabetes diagnosis. Researchers used data from a prospective population-based study initiated in 1990 on a cohort of women born between 1925 and 1950. From eligible women in the study, researchers included those who completed a 2002 follow-up questionnaire with information available on migraine. They then excluded prevalent cases of T2D, leaving a final sample of women who were followed up between 2004 and 2014. All potential occurrences of T2D were identified through a drug reimbursement database. They found:

• From the 98,995 women in the study, 76,403 women completed the 2002 follow-up survey.
• Of these, 2156 were excluded because they had T2D, leaving 74,247 women.
• During 10 years of follow-up, 2372 incident T2D cases occurred.
• A lower risk of T2D was observed for women with active migraine compared with women with no migraine history (univariate hazard ratio, 0.80, multivariable-adjusted hazard ratio, 0.7).

Fagherazzi G, El Fatouhi D, Fournier A, et al. Associations between migraine and type 2 diabetes in women: Findings from the E3N Cohort Study. [Published online ahead of print December 17, 2018]. JAMA Neurology. doi:10.1001/jamaneurol.2018.3960.

Changes in speech occurred in almost half of individuals experiencing migraine attacks who were evaluated in a recent prospective, longitudinal, observational study. Participants provided speech samples 3 times per day using a speech elicitation tool included within a mobile app. Six complementary speech features that capture articulation and prosody were extracted from speech samples. Participants with migraine maintained a daily headache diary using the same app. A total of 56,767 speech samples were collected, including 43,102 from 15 individuals with migraine and 13,665 from matched healthy controls. They found:

• Significant group-level differences in speech features were identified between those with migraine and healthy controls and within the migraine group during the pre-attack vs attack vs interictal periods.
• Most consistently, speech changes occurred in the speaking rate, articulation rate and precision, and phonatory duration.
• Within-subject analysis revealed that 7 of 15 individuals with migraine showed significant change in at least 1 speech feature when comparing the migraine attack vs interictal phase and 4 showed similar changes when comparing the pre-attack vs interictal phases.

Schwedt TJ, Peplinski J, Garcia-Filion P, Berisha V. Altered speech with migraine attacks: A prospective, longitudinal study of episodic migraine without aura. [Published online ahead of print November 17, 2018]. Cephalalgia. doi:10.1177%2F0333102418815505.

Changes in speech occurred in almost half of individuals experiencing migraine attacks who were evaluated in a recent prospective, longitudinal, observational study. Participants provided speech samples 3 times per day using a speech elicitation tool included within a mobile app. Six complementary speech features that capture articulation and prosody were extracted from speech samples. Participants with migraine maintained a daily headache diary using the same app. A total of 56,767 speech samples were collected, including 43,102 from 15 individuals with migraine and 13,665 from matched healthy controls. They found:

• Significant group-level differences in speech features were identified between those with migraine and healthy controls and within the migraine group during the pre-attack vs attack vs interictal periods.
• Most consistently, speech changes occurred in the speaking rate, articulation rate and precision, and phonatory duration.
• Within-subject analysis revealed that 7 of 15 individuals with migraine showed significant change in at least 1 speech feature when comparing the migraine attack vs interictal phase and 4 showed similar changes when comparing the pre-attack vs interictal phases.

Schwedt TJ, Peplinski J, Garcia-Filion P, Berisha V. Altered speech with migraine attacks: A prospective, longitudinal study of episodic migraine without aura. [Published online ahead of print November 17, 2018]. Cephalalgia. doi:10.1177%2F0333102418815505.

Changes in speech occurred in almost half of individuals experiencing migraine attacks who were evaluated in a recent prospective, longitudinal, observational study. Participants provided speech samples 3 times per day using a speech elicitation tool included within a mobile app. Six complementary speech features that capture articulation and prosody were extracted from speech samples. Participants with migraine maintained a daily headache diary using the same app. A total of 56,767 speech samples were collected, including 43,102 from 15 individuals with migraine and 13,665 from matched healthy controls. They found:

• Significant group-level differences in speech features were identified between those with migraine and healthy controls and within the migraine group during the pre-attack vs attack vs interictal periods.
• Most consistently, speech changes occurred in the speaking rate, articulation rate and precision, and phonatory duration.
• Within-subject analysis revealed that 7 of 15 individuals with migraine showed significant change in at least 1 speech feature when comparing the migraine attack vs interictal phase and 4 showed similar changes when comparing the pre-attack vs interictal phases.

Schwedt TJ, Peplinski J, Garcia-Filion P, Berisha V. Altered speech with migraine attacks: A prospective, longitudinal study of episodic migraine without aura. [Published online ahead of print November 17, 2018]. Cephalalgia. doi:10.1177%2F0333102418815505.

While the majority of pregnant women with acute migraine received medications considered relatively safe in pregnancy, there was variation in treatment choice and sequence, a recent study found. Researchers conducted a retrospective chart review of medication administration for pregnant women who presented to an acute care setting with a migraine attack and received neurology consultation between 2009 and 2014. They identified 72 pregnant women with migraine who were treated with pain medications and found:

• Fifty-one percent (37/72) were in the third trimester of pregnancy, 39% (28/72) in the second trimester, and 10% (7/72) in the first trimester.
• Thirty-two percent (23/72) had not tried any acute medications at home before coming to the hospital, and 47% (34/72) presented in status migrainosus.
• Patients received treatment in the hospital for a median of 23 hours.
• Acetaminophen was the most frequent medicine administered first (53%, 38/72).
• Thirty-eight percent (27/72) received an intravenous (IV) fluid bolus, 24% received IV magnesium (17/72), and 6% (4/72) had peripheral nerve blocks performed.

Hamilton KT, Robbins MS. Migraine treatment in pregnant women presenting to acute care: A retrospective observational study. [Published online ahead of print November 7, 2018]. Headache. doi:10.1111/head.13434.

While the majority of pregnant women with acute migraine received medications considered relatively safe in pregnancy, there was variation in treatment choice and sequence, a recent study found. Researchers conducted a retrospective chart review of medication administration for pregnant women who presented to an acute care setting with a migraine attack and received neurology consultation between 2009 and 2014. They identified 72 pregnant women with migraine who were treated with pain medications and found:

• Fifty-one percent (37/72) were in the third trimester of pregnancy, 39% (28/72) in the second trimester, and 10% (7/72) in the first trimester.
• Thirty-two percent (23/72) had not tried any acute medications at home before coming to the hospital, and 47% (34/72) presented in status migrainosus.
• Patients received treatment in the hospital for a median of 23 hours.
• Acetaminophen was the most frequent medicine administered first (53%, 38/72).
• Thirty-eight percent (27/72) received an intravenous (IV) fluid bolus, 24% received IV magnesium (17/72), and 6% (4/72) had peripheral nerve blocks performed.

Hamilton KT, Robbins MS. Migraine treatment in pregnant women presenting to acute care: A retrospective observational study. [Published online ahead of print November 7, 2018]. Headache. doi:10.1111/head.13434.

While the majority of pregnant women with acute migraine received medications considered relatively safe in pregnancy, there was variation in treatment choice and sequence, a recent study found. Researchers conducted a retrospective chart review of medication administration for pregnant women who presented to an acute care setting with a migraine attack and received neurology consultation between 2009 and 2014. They identified 72 pregnant women with migraine who were treated with pain medications and found:

• Fifty-one percent (37/72) were in the third trimester of pregnancy, 39% (28/72) in the second trimester, and 10% (7/72) in the first trimester.
• Thirty-two percent (23/72) had not tried any acute medications at home before coming to the hospital, and 47% (34/72) presented in status migrainosus.
• Patients received treatment in the hospital for a median of 23 hours.
• Acetaminophen was the most frequent medicine administered first (53%, 38/72).
• Thirty-eight percent (27/72) received an intravenous (IV) fluid bolus, 24% received IV magnesium (17/72), and 6% (4/72) had peripheral nerve blocks performed.

Hamilton KT, Robbins MS. Migraine treatment in pregnant women presenting to acute care: A retrospective observational study. [Published online ahead of print November 7, 2018]. Headache. doi:10.1111/head.13434.

Women with active migraines are less likely to have type 2 diabetes mellitus (T2DM) and show a decrease in migraine symptoms prior to diagnosis of T2DM, indicating an inverse relationship between hyperglycemia, hyperinsulinism, and migraines, according to recent research published in JAMA Neurology.

“Because plasma glucose concentration rises with time up to the point of type 2 diabetes occurrence, the prevalence of migraine symptoms may decrease,” Guy Fagherazzi, PhD, at the Center for Research in Epidemiology and Population Health at the Gustave Roussy Institute in Villejuif, France, and his colleagues wrote in their study. “Consequently, tracking the evolution and especially the decrease of migraine frequency in individuals with migraine at high risk of diabetes, such as individuals with obesity, irrespective of age could be the sign of an emerging increased blood glucose levels, prediabetes, or type 2 diabetes.”

The researchers used data from the prospective Etude Epidémiologique Auprès des Femmes de la Mutuelle Générale de l’Education Nationale (E3N) study, initiated in 1990 and identified 74,247 women (mean age, 61 years old) with self-reported migraine in a 2002 follow-up questionnaire who had 10-year follow-up data during 2004-2014. The women in the cohort were born during 1925-1950 and completed biennial questionnaires about their health, including migraine status and medications, since 1992. The participants were divided into groups based on no migraine (49,199 participants), active migraine (7,839 participants), or prior migraine history (17,209 participants), and patients with T2DM at baseline were excluded.

Dr. Fagherazzi and his colleagues found 2,372 cases of type 2 diabetes over the follow-up period. Women who had active migraine status were less likely to have T2DM (hazard ratio, 0.80; 95% confidence interval, 0.67-0.96) than were the participants who did not have migraines, and this inverse association persisted after the researchers adjusted for factors such as myocardial infarction, education level, family history of diabetes, body mass index, smoking status, hypertension, physical activity, oral contraceptive use, menopausal status, menopausal hormone therapy, handedness, antimigraine preparations, and other prescribed migraine drugs (HR, 0.70; 95% CI, 0.58-0.85).

In the participants who developed T2DM, the researchers also found that there was a decrease in the prevalence of active migraine in the 24 years prior to T2DM diagnosis from 22% (95% CI, 16%-27%) to 11% (95% CI, 10%-12%) after adjusting for T2DM risk factors, which was then followed by an up to 22-year plateau in migraine prevalence of 11% for these participants.

“The linear decrease of migraine prevalence long before and the plateau long after type 2 diabetes diagnosis is novel and the association deserves to be studied in other populations,” Dr. Fagherazzi and his colleagues wrote. “The potential beneficial role of both hyperglycemia and hyperinsulinism on migraine occurrence needs to be further explored.”

The researchers noted limitations in the study, such as self-reported migraine by participants in the cohort, exclusion of non–pharmacologically treated T2DM cases, observational nature of the study, and homogenized population in the E3N cohort consisting of mainly women in menopause who were teachers and belonged to the same health insurance plan.

This study was funded by a grant from the French Research agency. The E3N cohort study was funded by the “Mutuelle Générale de l’Education Nationale,” European Community, French League against Cancer, Gustave Roussy, and French Institute of Health and Medical Research. Dr. Kurth is an advisory board member for CoLucid and has received funding for a research project from Amgen, honoraria from Lilly, lecture support from Novartis and Daiichi Sankyo, and travel support from the International Headache Society, as well as provided BMJ with editorial services.

SOURCE: Fagherazzi G et al. JAMA Neurol. 2018. doi: 10.1001/jamaneurol.2018.3960.

Women with active migraines are less likely to have type 2 diabetes mellitus (T2DM) and show a decrease in migraine symptoms prior to diagnosis of T2DM, indicating an inverse relationship between hyperglycemia, hyperinsulinism, and migraines, according to recent research published in JAMA Neurology.

“Because plasma glucose concentration rises with time up to the point of type 2 diabetes occurrence, the prevalence of migraine symptoms may decrease,” Guy Fagherazzi, PhD, at the Center for Research in Epidemiology and Population Health at the Gustave Roussy Institute in Villejuif, France, and his colleagues wrote in their study. “Consequently, tracking the evolution and especially the decrease of migraine frequency in individuals with migraine at high risk of diabetes, such as individuals with obesity, irrespective of age could be the sign of an emerging increased blood glucose levels, prediabetes, or type 2 diabetes.”

The researchers used data from the prospective Etude Epidémiologique Auprès des Femmes de la Mutuelle Générale de l’Education Nationale (E3N) study, initiated in 1990 and identified 74,247 women (mean age, 61 years old) with self-reported migraine in a 2002 follow-up questionnaire who had 10-year follow-up data during 2004-2014. The women in the cohort were born during 1925-1950 and completed biennial questionnaires about their health, including migraine status and medications, since 1992. The participants were divided into groups based on no migraine (49,199 participants), active migraine (7,839 participants), or prior migraine history (17,209 participants), and patients with T2DM at baseline were excluded.

Dr. Fagherazzi and his colleagues found 2,372 cases of type 2 diabetes over the follow-up period. Women who had active migraine status were less likely to have T2DM (hazard ratio, 0.80; 95% confidence interval, 0.67-0.96) than were the participants who did not have migraines, and this inverse association persisted after the researchers adjusted for factors such as myocardial infarction, education level, family history of diabetes, body mass index, smoking status, hypertension, physical activity, oral contraceptive use, menopausal status, menopausal hormone therapy, handedness, antimigraine preparations, and other prescribed migraine drugs (HR, 0.70; 95% CI, 0.58-0.85).

In the participants who developed T2DM, the researchers also found that there was a decrease in the prevalence of active migraine in the 24 years prior to T2DM diagnosis from 22% (95% CI, 16%-27%) to 11% (95% CI, 10%-12%) after adjusting for T2DM risk factors, which was then followed by an up to 22-year plateau in migraine prevalence of 11% for these participants.

“The linear decrease of migraine prevalence long before and the plateau long after type 2 diabetes diagnosis is novel and the association deserves to be studied in other populations,” Dr. Fagherazzi and his colleagues wrote. “The potential beneficial role of both hyperglycemia and hyperinsulinism on migraine occurrence needs to be further explored.”

The researchers noted limitations in the study, such as self-reported migraine by participants in the cohort, exclusion of non–pharmacologically treated T2DM cases, observational nature of the study, and homogenized population in the E3N cohort consisting of mainly women in menopause who were teachers and belonged to the same health insurance plan.

This study was funded by a grant from the French Research agency. The E3N cohort study was funded by the “Mutuelle Générale de l’Education Nationale,” European Community, French League against Cancer, Gustave Roussy, and French Institute of Health and Medical Research. Dr. Kurth is an advisory board member for CoLucid and has received funding for a research project from Amgen, honoraria from Lilly, lecture support from Novartis and Daiichi Sankyo, and travel support from the International Headache Society, as well as provided BMJ with editorial services.

SOURCE: Fagherazzi G et al. JAMA Neurol. 2018. doi: 10.1001/jamaneurol.2018.3960.

Women with active migraines are less likely to have type 2 diabetes mellitus (T2DM) and show a decrease in migraine symptoms prior to diagnosis of T2DM, indicating an inverse relationship between hyperglycemia, hyperinsulinism, and migraines, according to recent research published in JAMA Neurology.

“Because plasma glucose concentration rises with time up to the point of type 2 diabetes occurrence, the prevalence of migraine symptoms may decrease,” Guy Fagherazzi, PhD, at the Center for Research in Epidemiology and Population Health at the Gustave Roussy Institute in Villejuif, France, and his colleagues wrote in their study. “Consequently, tracking the evolution and especially the decrease of migraine frequency in individuals with migraine at high risk of diabetes, such as individuals with obesity, irrespective of age could be the sign of an emerging increased blood glucose levels, prediabetes, or type 2 diabetes.”

The researchers used data from the prospective Etude Epidémiologique Auprès des Femmes de la Mutuelle Générale de l’Education Nationale (E3N) study, initiated in 1990 and identified 74,247 women (mean age, 61 years old) with self-reported migraine in a 2002 follow-up questionnaire who had 10-year follow-up data during 2004-2014. The women in the cohort were born during 1925-1950 and completed biennial questionnaires about their health, including migraine status and medications, since 1992. The participants were divided into groups based on no migraine (49,199 participants), active migraine (7,839 participants), or prior migraine history (17,209 participants), and patients with T2DM at baseline were excluded.

Dr. Fagherazzi and his colleagues found 2,372 cases of type 2 diabetes over the follow-up period. Women who had active migraine status were less likely to have T2DM (hazard ratio, 0.80; 95% confidence interval, 0.67-0.96) than were the participants who did not have migraines, and this inverse association persisted after the researchers adjusted for factors such as myocardial infarction, education level, family history of diabetes, body mass index, smoking status, hypertension, physical activity, oral contraceptive use, menopausal status, menopausal hormone therapy, handedness, antimigraine preparations, and other prescribed migraine drugs (HR, 0.70; 95% CI, 0.58-0.85).

In the participants who developed T2DM, the researchers also found that there was a decrease in the prevalence of active migraine in the 24 years prior to T2DM diagnosis from 22% (95% CI, 16%-27%) to 11% (95% CI, 10%-12%) after adjusting for T2DM risk factors, which was then followed by an up to 22-year plateau in migraine prevalence of 11% for these participants.

“The linear decrease of migraine prevalence long before and the plateau long after type 2 diabetes diagnosis is novel and the association deserves to be studied in other populations,” Dr. Fagherazzi and his colleagues wrote. “The potential beneficial role of both hyperglycemia and hyperinsulinism on migraine occurrence needs to be further explored.”

The researchers noted limitations in the study, such as self-reported migraine by participants in the cohort, exclusion of non–pharmacologically treated T2DM cases, observational nature of the study, and homogenized population in the E3N cohort consisting of mainly women in menopause who were teachers and belonged to the same health insurance plan.

This study was funded by a grant from the French Research agency. The E3N cohort study was funded by the “Mutuelle Générale de l’Education Nationale,” European Community, French League against Cancer, Gustave Roussy, and French Institute of Health and Medical Research. Dr. Kurth is an advisory board member for CoLucid and has received funding for a research project from Amgen, honoraria from Lilly, lecture support from Novartis and Daiichi Sankyo, and travel support from the International Headache Society, as well as provided BMJ with editorial services.

SOURCE: Fagherazzi G et al. JAMA Neurol. 2018. doi: 10.1001/jamaneurol.2018.3960.

Chronic migraine (CM) patients have significantly greater cortical covariance compared to controls, according to a recent study. Cortical thickness in CM patients was predominantly accounted for by CM duration, posttraumatic stress disorder (PTSD), and poor sleep quality, while improved pain self‐efficacy buffered cortical thickness. Thirty CM cases (mean age 40 years; male‐to‐female 1:4) and 30 sex‐matched healthy controls (mean age 40 years) were enrolled. Participants completed self‐administered and standardized questionnaires assessing headache‐related clinical features and common psychological comorbidities. T1‐weighted brain images were acquired on a 3T MRI and a whole‐brain cortical thickness analysis was performed.

Researchers found:

• The whole brain cortical thickness analysis revealed no significant differences between CM patients and controls.
• However, significant associations between clinical features and cortical thickness were observed for the patients only.
• These associations included the right superior temporal sulcus (R² = 0.72) and the right insula (R²= 0.71) with distinct clinical variables (ie, longer history of CM, PTSD, sleep quality, pain self‐efficacy, and somatic symptoms).

Woldeamanuel YW, DeSouza DD, Sanjanwala BM, Cowan RP. Clinical features contributing to cortical thickness changes in chronic migraine–A pilot study. [Published online ahead of print November 23, 2018]. Headache. doi:10.1111/head.13452.

Chronic migraine (CM) patients have significantly greater cortical covariance compared to controls, according to a recent study. Cortical thickness in CM patients was predominantly accounted for by CM duration, posttraumatic stress disorder (PTSD), and poor sleep quality, while improved pain self‐efficacy buffered cortical thickness. Thirty CM cases (mean age 40 years; male‐to‐female 1:4) and 30 sex‐matched healthy controls (mean age 40 years) were enrolled. Participants completed self‐administered and standardized questionnaires assessing headache‐related clinical features and common psychological comorbidities. T1‐weighted brain images were acquired on a 3T MRI and a whole‐brain cortical thickness analysis was performed.

Researchers found:

• The whole brain cortical thickness analysis revealed no significant differences between CM patients and controls.
• However, significant associations between clinical features and cortical thickness were observed for the patients only.
• These associations included the right superior temporal sulcus (R² = 0.72) and the right insula (R²= 0.71) with distinct clinical variables (ie, longer history of CM, PTSD, sleep quality, pain self‐efficacy, and somatic symptoms).

Woldeamanuel YW, DeSouza DD, Sanjanwala BM, Cowan RP. Clinical features contributing to cortical thickness changes in chronic migraine–A pilot study. [Published online ahead of print November 23, 2018]. Headache. doi:10.1111/head.13452.

Chronic migraine (CM) patients have significantly greater cortical covariance compared to controls, according to a recent study. Cortical thickness in CM patients was predominantly accounted for by CM duration, posttraumatic stress disorder (PTSD), and poor sleep quality, while improved pain self‐efficacy buffered cortical thickness. Thirty CM cases (mean age 40 years; male‐to‐female 1:4) and 30 sex‐matched healthy controls (mean age 40 years) were enrolled. Participants completed self‐administered and standardized questionnaires assessing headache‐related clinical features and common psychological comorbidities. T1‐weighted brain images were acquired on a 3T MRI and a whole‐brain cortical thickness analysis was performed.

Researchers found:

• The whole brain cortical thickness analysis revealed no significant differences between CM patients and controls.
• However, significant associations between clinical features and cortical thickness were observed for the patients only.
• These associations included the right superior temporal sulcus (R² = 0.72) and the right insula (R²= 0.71) with distinct clinical variables (ie, longer history of CM, PTSD, sleep quality, pain self‐efficacy, and somatic symptoms).

Woldeamanuel YW, DeSouza DD, Sanjanwala BM, Cowan RP. Clinical features contributing to cortical thickness changes in chronic migraine–A pilot study. [Published online ahead of print November 23, 2018]. Headache. doi:10.1111/head.13452.

ASHEVILLE, NC—Although neurologists tend to classify disorders as problems of either the CNS or the peripheral nervous system, patients with headache may have symptoms that indicate the involvement of both systems, according to an overview provided at the Eighth Annual Scientific Meeting of the Southern Headache Society. Research has revealed anatomic connections between extracranial and intracranial spaces that could contribute to the generation of headaches. Thus, the central and peripheral nervous systems “do not have to be two separate spaces and two separate pathologies,” said Pamela Blake, MD, Director of the Headache Center of Greater Heights in Houston.

Problems With Prevention and Acute Treatment

One patient presented to Dr. Blake with an eight-year history of throbbing headaches and constant pain and tightness in the neck and occiput. The pain radiated to her temples and forehead two to four times per week with accompanying photophobia, phonophobia, and nausea. The patient also had mild allodynia. The frontal pain and accompanying symptoms were consistent with episodic migraine, but the allodynia and pain in the neck and occiput were not, said Dr. Blake. A possible diagnosis was episodic migraine without aura with chronic tension-type headaches and neck pain, she added.

A 2017 study published in the Journal of Headache and Pain suggested that this headache type is problematic. Among 148 migraineurs, the researchers identified 100 patients who also had tension-type headache and chronic neck pain. Compared with healthy controls, these patients had less physical activity, less psychologic well-being, more perceived stress, and poorer self-rated health. Pain reduced these patients’ ability to perform physical activity, which could make treatment more difficult, according to the authors.

Patients with these symptoms have trigeminal and occipital pain. “These symptoms do not appear to be solely, or even primarily, central,” said Dr. Blake. The frontal pain responds to triptans, but the occipital pain, which is the more constant pain, does not. “Preventive medications do not work well in this population, and that’s why they have chronic headaches,” said Dr. Blake.

Physiologic and Pathophysiologic Mechanisms

Research by Schueler and colleagues suggested a potential physiologic explanation for combined central and peripheral involvement in headache. They applied a fluorescent tracer to proximally cut meningeal nerves in rat skulls and to distal branches of the spinosus nerve in human calvaria that was lined with dura mater. They observed that branches of the spinosus nerve travel “along the middle meningeal artery, supplying the dura, entering the cranial bone, and running through the calvarium,” said Dr. Blake. Branches of the spinosus nerve also “entered the tenderness junctions of the pericranial muscles, including in the neck.”

This work indicates a connection between intracranial and extracranial areas but does not shed light on the pathophysiology of a headache with central and peripheral symptoms, said Dr. Blake. In 2016, she and her colleagues took perivascular biopsies from healthy controls and subjects with chronic migraine and predominantly occipital headache. They found a significant increase in the expression of proinflammatory genes and a decrease in the expression of anti-inflammatory genes among migraineurs, compared with controls. “This was the first evidence of localized extracranial pathophysiology in chronic migraine,” said Dr. Blake.

This inflammation could result from compression of the occipital nerves. A 2013 study by Schmid et al found that progressive nerve compression results in chronic local and remote immune-mediated inflammation. Stress also can cause inflammation. “Many patients who present with occipital nerve compression headaches had the onset of their pain during a time of intense stress,” said Dr. Blake.

The Role of the Occipital Nerve

Occipital nerve compression headache is characterized by daily or near-daily pain in the distribution of the occipital nerve. Patients describe the pain as a tight, imploding pressure that sometimes radiates to frontal areas and becomes a throbbing pain. This headache rarely has a neuropathic component.

Allodynia is “almost a requirement of this diagnosis,” said Dr. Blake. The allodynia symptom checklist, however, does not capture it well in these patients because it focuses on pain in the trigeminal nerve distribution. Patients report that the back of the head is tender to the touch and that it hurts to rest the head on a pillow.

The cervical muscles compress the nerve and contribute to the symptoms as well. Patients often report that moving the head or neck exacerbates the pain. The headache also may have migrainous features. It takes skill and expertise to elicit an adequate history from these patients, said Dr. Blake. “Careful questioning is helpful. I often find … that a second visit is more helpful to obtain this history after reviewing the anatomy with the patient, reviewing this pathophysiology, and sending them back out to keep a careful log for two weeks.”

Nerve Blocks and Nerve Decompression

Occipital nerve blocks provide relief for these patients, but they may not be easy to administer. A large dorsal occipital nerve may be mistaken for the greater occipital nerve, for example. Physiologic abnormalities in some patients also can complicate this treatment.

Another effective treatment is nerve decompression surgery. Dr. Blake and colleagues conducted a retrospective review of patients who had undergone decompression of the greater occipital nerves at the point where they traverse the musculature of the posterior neck. The intervention provided complete relief for three to six years in one patient with new daily persistent headache and two patients with chronic posttraumatic headache. Two patients with chronic headache or migraine had partial relief. Surgery provided no relief for two patients with episodic migraine, one patient with chronic migraine, and one patient with chronic tension-type headache.

“In our experience, … 75% to 80% of patients experience a greater than 50% reduction in their headaches, measured by headache frequency and intensity,” said Dr. Blake. She and her colleagues compared outcomes between 18 chronic migraineurs with predominantly occipital pain who underwent surgical decompression of the occipital nerve and 23 patients who were referred for surgery but unable to receive it. In the surgical group, the number of predominantly occipital chronic migraine days per month decreased from 28.9 at baseline to 7.28 at a mean of 46 months later. The outcome in the control group did not change.

Correct patient selection “is the first, most important step” toward treatment success, said Dr. Blake. This process includes a preoperative psychologic evaluation that screens surgical candidates for somatic symptom disorder, mood disorders, a history of trauma, and catastrophizing. If indicated, neurologists may begin providing cognitive behavioral therapy or supportive psychotherapy before surgery. “We have a comprehensive program with postoperative management, including physical therapy and gradual taper of medications,” said Dr. Blake. Central migraine processes may contribute to headache in some of these patients. “Menstrual migraines are not going to go away with nerve decompression. Chronic migraine sometimes does not go away. This is a complex group of patients who definitely require a lot of follow-up.”

—Erik Greb

Suggested Reading

Blake P, Nir RR, Perry CJ, Burstein R. Tracking patients with chronic occipital headache after occipital nerve decompression surgery: a case series. Cephalalgia. 2018 Sep 14 [Epub ahead of print].

Krøll LS, Hammarlund CS, Westergaard ML, et al. Level of physical activity, well-being, stress and self-rated health in persons with migraine and co-existing tension-type headache and neck pain. J Headache Pain. 2017;18(1):46. Perry CJ, Blake P, Buettner C, et al. Upregulation of inflammatory gene transcripts in periosteum of chronic migraineurs: implications for extracranial origin of headache. Ann Neurol. 2016;79(6):1000-1013.

Schmid AB, Coppieters MW, Ruitenberg MJ, McLachlan EM. Local and remote immune-mediated inflammation after mild peripheral nerve compression in rats. J Neuropathol Exp Neurol. 2013;72(7):662-680.

Schueler M, Neuhuber WL, De Col R, Messlinger K. Innervation of rat and human dura mater and pericranial tissues in the parieto-temporal region by meningeal afferents. Headache. 2014;54(6):996-1009.

ASHEVILLE, NC—Although neurologists tend to classify disorders as problems of either the CNS or the peripheral nervous system, patients with headache may have symptoms that indicate the involvement of both systems, according to an overview provided at the Eighth Annual Scientific Meeting of the Southern Headache Society. Research has revealed anatomic connections between extracranial and intracranial spaces that could contribute to the generation of headaches. Thus, the central and peripheral nervous systems “do not have to be two separate spaces and two separate pathologies,” said Pamela Blake, MD, Director of the Headache Center of Greater Heights in Houston.

Problems With Prevention and Acute Treatment

One patient presented to Dr. Blake with an eight-year history of throbbing headaches and constant pain and tightness in the neck and occiput. The pain radiated to her temples and forehead two to four times per week with accompanying photophobia, phonophobia, and nausea. The patient also had mild allodynia. The frontal pain and accompanying symptoms were consistent with episodic migraine, but the allodynia and pain in the neck and occiput were not, said Dr. Blake. A possible diagnosis was episodic migraine without aura with chronic tension-type headaches and neck pain, she added.

A 2017 study published in the Journal of Headache and Pain suggested that this headache type is problematic. Among 148 migraineurs, the researchers identified 100 patients who also had tension-type headache and chronic neck pain. Compared with healthy controls, these patients had less physical activity, less psychologic well-being, more perceived stress, and poorer self-rated health. Pain reduced these patients’ ability to perform physical activity, which could make treatment more difficult, according to the authors.

Patients with these symptoms have trigeminal and occipital pain. “These symptoms do not appear to be solely, or even primarily, central,” said Dr. Blake. The frontal pain responds to triptans, but the occipital pain, which is the more constant pain, does not. “Preventive medications do not work well in this population, and that’s why they have chronic headaches,” said Dr. Blake.

Physiologic and Pathophysiologic Mechanisms

Research by Schueler and colleagues suggested a potential physiologic explanation for combined central and peripheral involvement in headache. They applied a fluorescent tracer to proximally cut meningeal nerves in rat skulls and to distal branches of the spinosus nerve in human calvaria that was lined with dura mater. They observed that branches of the spinosus nerve travel “along the middle meningeal artery, supplying the dura, entering the cranial bone, and running through the calvarium,” said Dr. Blake. Branches of the spinosus nerve also “entered the tenderness junctions of the pericranial muscles, including in the neck.”

This work indicates a connection between intracranial and extracranial areas but does not shed light on the pathophysiology of a headache with central and peripheral symptoms, said Dr. Blake. In 2016, she and her colleagues took perivascular biopsies from healthy controls and subjects with chronic migraine and predominantly occipital headache. They found a significant increase in the expression of proinflammatory genes and a decrease in the expression of anti-inflammatory genes among migraineurs, compared with controls. “This was the first evidence of localized extracranial pathophysiology in chronic migraine,” said Dr. Blake.

This inflammation could result from compression of the occipital nerves. A 2013 study by Schmid et al found that progressive nerve compression results in chronic local and remote immune-mediated inflammation. Stress also can cause inflammation. “Many patients who present with occipital nerve compression headaches had the onset of their pain during a time of intense stress,” said Dr. Blake.

The Role of the Occipital Nerve

Occipital nerve compression headache is characterized by daily or near-daily pain in the distribution of the occipital nerve. Patients describe the pain as a tight, imploding pressure that sometimes radiates to frontal areas and becomes a throbbing pain. This headache rarely has a neuropathic component.

Allodynia is “almost a requirement of this diagnosis,” said Dr. Blake. The allodynia symptom checklist, however, does not capture it well in these patients because it focuses on pain in the trigeminal nerve distribution. Patients report that the back of the head is tender to the touch and that it hurts to rest the head on a pillow.

The cervical muscles compress the nerve and contribute to the symptoms as well. Patients often report that moving the head or neck exacerbates the pain. The headache also may have migrainous features. It takes skill and expertise to elicit an adequate history from these patients, said Dr. Blake. “Careful questioning is helpful. I often find … that a second visit is more helpful to obtain this history after reviewing the anatomy with the patient, reviewing this pathophysiology, and sending them back out to keep a careful log for two weeks.”

Nerve Blocks and Nerve Decompression

Occipital nerve blocks provide relief for these patients, but they may not be easy to administer. A large dorsal occipital nerve may be mistaken for the greater occipital nerve, for example. Physiologic abnormalities in some patients also can complicate this treatment.

Another effective treatment is nerve decompression surgery. Dr. Blake and colleagues conducted a retrospective review of patients who had undergone decompression of the greater occipital nerves at the point where they traverse the musculature of the posterior neck. The intervention provided complete relief for three to six years in one patient with new daily persistent headache and two patients with chronic posttraumatic headache. Two patients with chronic headache or migraine had partial relief. Surgery provided no relief for two patients with episodic migraine, one patient with chronic migraine, and one patient with chronic tension-type headache.

“In our experience, … 75% to 80% of patients experience a greater than 50% reduction in their headaches, measured by headache frequency and intensity,” said Dr. Blake. She and her colleagues compared outcomes between 18 chronic migraineurs with predominantly occipital pain who underwent surgical decompression of the occipital nerve and 23 patients who were referred for surgery but unable to receive it. In the surgical group, the number of predominantly occipital chronic migraine days per month decreased from 28.9 at baseline to 7.28 at a mean of 46 months later. The outcome in the control group did not change.

Correct patient selection “is the first, most important step” toward treatment success, said Dr. Blake. This process includes a preoperative psychologic evaluation that screens surgical candidates for somatic symptom disorder, mood disorders, a history of trauma, and catastrophizing. If indicated, neurologists may begin providing cognitive behavioral therapy or supportive psychotherapy before surgery. “We have a comprehensive program with postoperative management, including physical therapy and gradual taper of medications,” said Dr. Blake. Central migraine processes may contribute to headache in some of these patients. “Menstrual migraines are not going to go away with nerve decompression. Chronic migraine sometimes does not go away. This is a complex group of patients who definitely require a lot of follow-up.”

—Erik Greb

Suggested Reading

Blake P, Nir RR, Perry CJ, Burstein R. Tracking patients with chronic occipital headache after occipital nerve decompression surgery: a case series. Cephalalgia. 2018 Sep 14 [Epub ahead of print].

Krøll LS, Hammarlund CS, Westergaard ML, et al. Level of physical activity, well-being, stress and self-rated health in persons with migraine and co-existing tension-type headache and neck pain. J Headache Pain. 2017;18(1):46. Perry CJ, Blake P, Buettner C, et al. Upregulation of inflammatory gene transcripts in periosteum of chronic migraineurs: implications for extracranial origin of headache. Ann Neurol. 2016;79(6):1000-1013.

Schmid AB, Coppieters MW, Ruitenberg MJ, McLachlan EM. Local and remote immune-mediated inflammation after mild peripheral nerve compression in rats. J Neuropathol Exp Neurol. 2013;72(7):662-680.

Schueler M, Neuhuber WL, De Col R, Messlinger K. Innervation of rat and human dura mater and pericranial tissues in the parieto-temporal region by meningeal afferents. Headache. 2014;54(6):996-1009.

ASHEVILLE, NC—Although neurologists tend to classify disorders as problems of either the CNS or the peripheral nervous system, patients with headache may have symptoms that indicate the involvement of both systems, according to an overview provided at the Eighth Annual Scientific Meeting of the Southern Headache Society. Research has revealed anatomic connections between extracranial and intracranial spaces that could contribute to the generation of headaches. Thus, the central and peripheral nervous systems “do not have to be two separate spaces and two separate pathologies,” said Pamela Blake, MD, Director of the Headache Center of Greater Heights in Houston.

Problems With Prevention and Acute Treatment

One patient presented to Dr. Blake with an eight-year history of throbbing headaches and constant pain and tightness in the neck and occiput. The pain radiated to her temples and forehead two to four times per week with accompanying photophobia, phonophobia, and nausea. The patient also had mild allodynia. The frontal pain and accompanying symptoms were consistent with episodic migraine, but the allodynia and pain in the neck and occiput were not, said Dr. Blake. A possible diagnosis was episodic migraine without aura with chronic tension-type headaches and neck pain, she added.

A 2017 study published in the Journal of Headache and Pain suggested that this headache type is problematic. Among 148 migraineurs, the researchers identified 100 patients who also had tension-type headache and chronic neck pain. Compared with healthy controls, these patients had less physical activity, less psychologic well-being, more perceived stress, and poorer self-rated health. Pain reduced these patients’ ability to perform physical activity, which could make treatment more difficult, according to the authors.

Patients with these symptoms have trigeminal and occipital pain. “These symptoms do not appear to be solely, or even primarily, central,” said Dr. Blake. The frontal pain responds to triptans, but the occipital pain, which is the more constant pain, does not. “Preventive medications do not work well in this population, and that’s why they have chronic headaches,” said Dr. Blake.

Physiologic and Pathophysiologic Mechanisms

Research by Schueler and colleagues suggested a potential physiologic explanation for combined central and peripheral involvement in headache. They applied a fluorescent tracer to proximally cut meningeal nerves in rat skulls and to distal branches of the spinosus nerve in human calvaria that was lined with dura mater. They observed that branches of the spinosus nerve travel “along the middle meningeal artery, supplying the dura, entering the cranial bone, and running through the calvarium,” said Dr. Blake. Branches of the spinosus nerve also “entered the tenderness junctions of the pericranial muscles, including in the neck.”

This work indicates a connection between intracranial and extracranial areas but does not shed light on the pathophysiology of a headache with central and peripheral symptoms, said Dr. Blake. In 2016, she and her colleagues took perivascular biopsies from healthy controls and subjects with chronic migraine and predominantly occipital headache. They found a significant increase in the expression of proinflammatory genes and a decrease in the expression of anti-inflammatory genes among migraineurs, compared with controls. “This was the first evidence of localized extracranial pathophysiology in chronic migraine,” said Dr. Blake.

This inflammation could result from compression of the occipital nerves. A 2013 study by Schmid et al found that progressive nerve compression results in chronic local and remote immune-mediated inflammation. Stress also can cause inflammation. “Many patients who present with occipital nerve compression headaches had the onset of their pain during a time of intense stress,” said Dr. Blake.

The Role of the Occipital Nerve

Occipital nerve compression headache is characterized by daily or near-daily pain in the distribution of the occipital nerve. Patients describe the pain as a tight, imploding pressure that sometimes radiates to frontal areas and becomes a throbbing pain. This headache rarely has a neuropathic component.

Allodynia is “almost a requirement of this diagnosis,” said Dr. Blake. The allodynia symptom checklist, however, does not capture it well in these patients because it focuses on pain in the trigeminal nerve distribution. Patients report that the back of the head is tender to the touch and that it hurts to rest the head on a pillow.

The cervical muscles compress the nerve and contribute to the symptoms as well. Patients often report that moving the head or neck exacerbates the pain. The headache also may have migrainous features. It takes skill and expertise to elicit an adequate history from these patients, said Dr. Blake. “Careful questioning is helpful. I often find … that a second visit is more helpful to obtain this history after reviewing the anatomy with the patient, reviewing this pathophysiology, and sending them back out to keep a careful log for two weeks.”

Nerve Blocks and Nerve Decompression

Occipital nerve blocks provide relief for these patients, but they may not be easy to administer. A large dorsal occipital nerve may be mistaken for the greater occipital nerve, for example. Physiologic abnormalities in some patients also can complicate this treatment.

Another effective treatment is nerve decompression surgery. Dr. Blake and colleagues conducted a retrospective review of patients who had undergone decompression of the greater occipital nerves at the point where they traverse the musculature of the posterior neck. The intervention provided complete relief for three to six years in one patient with new daily persistent headache and two patients with chronic posttraumatic headache. Two patients with chronic headache or migraine had partial relief. Surgery provided no relief for two patients with episodic migraine, one patient with chronic migraine, and one patient with chronic tension-type headache.

“In our experience, … 75% to 80% of patients experience a greater than 50% reduction in their headaches, measured by headache frequency and intensity,” said Dr. Blake. She and her colleagues compared outcomes between 18 chronic migraineurs with predominantly occipital pain who underwent surgical decompression of the occipital nerve and 23 patients who were referred for surgery but unable to receive it. In the surgical group, the number of predominantly occipital chronic migraine days per month decreased from 28.9 at baseline to 7.28 at a mean of 46 months later. The outcome in the control group did not change.

Correct patient selection “is the first, most important step” toward treatment success, said Dr. Blake. This process includes a preoperative psychologic evaluation that screens surgical candidates for somatic symptom disorder, mood disorders, a history of trauma, and catastrophizing. If indicated, neurologists may begin providing cognitive behavioral therapy or supportive psychotherapy before surgery. “We have a comprehensive program with postoperative management, including physical therapy and gradual taper of medications,” said Dr. Blake. Central migraine processes may contribute to headache in some of these patients. “Menstrual migraines are not going to go away with nerve decompression. Chronic migraine sometimes does not go away. This is a complex group of patients who definitely require a lot of follow-up.”

—Erik Greb

Suggested Reading

Blake P, Nir RR, Perry CJ, Burstein R. Tracking patients with chronic occipital headache after occipital nerve decompression surgery: a case series. Cephalalgia. 2018 Sep 14 [Epub ahead of print].

Krøll LS, Hammarlund CS, Westergaard ML, et al. Level of physical activity, well-being, stress and self-rated health in persons with migraine and co-existing tension-type headache and neck pain. J Headache Pain. 2017;18(1):46. Perry CJ, Blake P, Buettner C, et al. Upregulation of inflammatory gene transcripts in periosteum of chronic migraineurs: implications for extracranial origin of headache. Ann Neurol. 2016;79(6):1000-1013.

Schmid AB, Coppieters MW, Ruitenberg MJ, McLachlan EM. Local and remote immune-mediated inflammation after mild peripheral nerve compression in rats. J Neuropathol Exp Neurol. 2013;72(7):662-680.

Schueler M, Neuhuber WL, De Col R, Messlinger K. Innervation of rat and human dura mater and pericranial tissues in the parieto-temporal region by meningeal afferents. Headache. 2014;54(6):996-1009.

Comorbidity between headaches with a range of physical conditions that have been associated with adult migraine demonstrates that multimorbidity occurs early in development. This according to a recent study that examined the associations between headaches and migraine with physical and mental disorders in a large pediatric registry. The study included 9,329 youth aged 8-21 years from the Philadelphia Neurodevelopmental Cohort. Physical conditions, including headache, were ascertained from electronic medical records and in-person interviews. Modified International Classification of Headache Disorders (ICHD-II) criteria were used to classify migraine symptoms. Forty-two other physical conditions were classified into 14 classes of medical disorders. Researchers found:

• Lifetime prevalence of any headache was 45.5%, and of migraine was 22.6%.
• Any headache was associated with a broad range of physical disorders, attention-deficit/hyperactivity disorder (odds ratio [OR] 1.2), and behavior disorders (1.3).
• Youth with migraine had greater odds of specific physical conditions and mental disorders, including respiratory, neurologic/central nervous system, developmental, anxiety, behavior, and mood disorders than those with non-migraine headache (OR ranged from 1.3 to 1.9).

Lateef T, He J-P, Nelson K, et al. Physical–mental comorbidity of pediatric migraine in the Philadelphia Neurodevelopmental Cohort. [Published online ahead of print October 29, 2018]. J Pediatr. doi:10.1016/j.jpeds.2018.09.033.

Comorbidity between headaches with a range of physical conditions that have been associated with adult migraine demonstrates that multimorbidity occurs early in development. This according to a recent study that examined the associations between headaches and migraine with physical and mental disorders in a large pediatric registry. The study included 9,329 youth aged 8-21 years from the Philadelphia Neurodevelopmental Cohort. Physical conditions, including headache, were ascertained from electronic medical records and in-person interviews. Modified International Classification of Headache Disorders (ICHD-II) criteria were used to classify migraine symptoms. Forty-two other physical conditions were classified into 14 classes of medical disorders. Researchers found:

• Lifetime prevalence of any headache was 45.5%, and of migraine was 22.6%.
• Any headache was associated with a broad range of physical disorders, attention-deficit/hyperactivity disorder (odds ratio [OR] 1.2), and behavior disorders (1.3).
• Youth with migraine had greater odds of specific physical conditions and mental disorders, including respiratory, neurologic/central nervous system, developmental, anxiety, behavior, and mood disorders than those with non-migraine headache (OR ranged from 1.3 to 1.9).

Lateef T, He J-P, Nelson K, et al. Physical–mental comorbidity of pediatric migraine in the Philadelphia Neurodevelopmental Cohort. [Published online ahead of print October 29, 2018]. J Pediatr. doi:10.1016/j.jpeds.2018.09.033.

Comorbidity between headaches with a range of physical conditions that have been associated with adult migraine demonstrates that multimorbidity occurs early in development. This according to a recent study that examined the associations between headaches and migraine with physical and mental disorders in a large pediatric registry. The study included 9,329 youth aged 8-21 years from the Philadelphia Neurodevelopmental Cohort. Physical conditions, including headache, were ascertained from electronic medical records and in-person interviews. Modified International Classification of Headache Disorders (ICHD-II) criteria were used to classify migraine symptoms. Forty-two other physical conditions were classified into 14 classes of medical disorders. Researchers found:

• Lifetime prevalence of any headache was 45.5%, and of migraine was 22.6%.
• Any headache was associated with a broad range of physical disorders, attention-deficit/hyperactivity disorder (odds ratio [OR] 1.2), and behavior disorders (1.3).
• Youth with migraine had greater odds of specific physical conditions and mental disorders, including respiratory, neurologic/central nervous system, developmental, anxiety, behavior, and mood disorders than those with non-migraine headache (OR ranged from 1.3 to 1.9).

Lateef T, He J-P, Nelson K, et al. Physical–mental comorbidity of pediatric migraine in the Philadelphia Neurodevelopmental Cohort. [Published online ahead of print October 29, 2018]. J Pediatr. doi:10.1016/j.jpeds.2018.09.033.

Recent findings suggest an abnormal sensory integration for spatial orientation in vestibular migraine (VM), related to daily dizziness in these patients. Researchers investigated the effect of static head tilts on errors of upright perception in a group of 27 patients with VM in comparison with a group of 27 healthy controls. Perception of upright was measured in a dark room using a subjective visual vertical (SVV) paradigm at 3 head tilt positions (upright, ±20°). VM patients were also surveyed about the quality of their dizziness and spatial symptoms during daily activities. Researchers found:

• In the upright head position, SVV errors were within the normal range for VM patients and healthy controls (within 2° from true vertical).
• During the static head tilts of 20° to the right, VM patients showed larger SVV errors consistent with overestimation of the tilt magnitude (ie, as if they felt further tilted toward the right side) (VM: −3.21° ± 0.93 vs control: 0.52° ± 0.70).
• During the head tilt to the left, SVV errors in VM patients did not differ significantly from controls (VM: 0.77° ± 1.05 vs control: −0.04° ± 0.68).

Winnick A, Sadeghpour S, Otero-Millan J, Chang T-P, Kheradmand A. Errors of upright perception in patients with vestibular migraine. [Published online ahead of print October 30, 2018]. Front Neurol. doi:10.3389/fneur.2018.00892.

Recent findings suggest an abnormal sensory integration for spatial orientation in vestibular migraine (VM), related to daily dizziness in these patients. Researchers investigated the effect of static head tilts on errors of upright perception in a group of 27 patients with VM in comparison with a group of 27 healthy controls. Perception of upright was measured in a dark room using a subjective visual vertical (SVV) paradigm at 3 head tilt positions (upright, ±20°). VM patients were also surveyed about the quality of their dizziness and spatial symptoms during daily activities. Researchers found:

• In the upright head position, SVV errors were within the normal range for VM patients and healthy controls (within 2° from true vertical).
• During the static head tilts of 20° to the right, VM patients showed larger SVV errors consistent with overestimation of the tilt magnitude (ie, as if they felt further tilted toward the right side) (VM: −3.21° ± 0.93 vs control: 0.52° ± 0.70).
• During the head tilt to the left, SVV errors in VM patients did not differ significantly from controls (VM: 0.77° ± 1.05 vs control: −0.04° ± 0.68).

Winnick A, Sadeghpour S, Otero-Millan J, Chang T-P, Kheradmand A. Errors of upright perception in patients with vestibular migraine. [Published online ahead of print October 30, 2018]. Front Neurol. doi:10.3389/fneur.2018.00892.

Recent findings suggest an abnormal sensory integration for spatial orientation in vestibular migraine (VM), related to daily dizziness in these patients. Researchers investigated the effect of static head tilts on errors of upright perception in a group of 27 patients with VM in comparison with a group of 27 healthy controls. Perception of upright was measured in a dark room using a subjective visual vertical (SVV) paradigm at 3 head tilt positions (upright, ±20°). VM patients were also surveyed about the quality of their dizziness and spatial symptoms during daily activities. Researchers found:

• In the upright head position, SVV errors were within the normal range for VM patients and healthy controls (within 2° from true vertical).
• During the static head tilts of 20° to the right, VM patients showed larger SVV errors consistent with overestimation of the tilt magnitude (ie, as if they felt further tilted toward the right side) (VM: −3.21° ± 0.93 vs control: 0.52° ± 0.70).
• During the head tilt to the left, SVV errors in VM patients did not differ significantly from controls (VM: 0.77° ± 1.05 vs control: −0.04° ± 0.68).

Winnick A, Sadeghpour S, Otero-Millan J, Chang T-P, Kheradmand A. Errors of upright perception in patients with vestibular migraine. [Published online ahead of print October 30, 2018]. Front Neurol. doi:10.3389/fneur.2018.00892.

Migraine with aura was associated with increased risk of incident atrial fibrillation (AF), according to a recent study, and this may potentially lead to ischemic strokes. In the Atherosclerosis Risk in Communities (ARIC) study, a longitudinal, community-based cohort study, participants were interviewed for migraine history between 1993 and 1995 and were followed for incident AF through 2013. AF was adjudicated using electrocardiographs (ECGs), discharge codes, and death certificates. Researchers found:

• Of 11,939 participants assessed for headache and without prior AF or stroke, 426 reported migraines with visual aura, 1090 with migraine without visual aura, 1018 non-migraine headache, and 9405 no headache.
• Over a 20-year follow-up period, incident AF was noted in 232 (15%) of 1516 with migraine and 1623 (17%) of 9405 without headache.
• After adjustment for multiple confounders, migraine with visual aura was associated with increased risk of AF compared to no headache (hazard ratio 1.30) as well as when compared to migraine without visual aura (hazard ratio 1.39).
• The data suggest that AF may be a potential mediator of migraine with visual aura–stroke risk.

Sen S, Androulakis XM, Duda V, et al. Migraine with visual aura a risk factor for incident atrial fibrillation. A cohort study. [Published online ahead of print November 14, 2018]. Neurology. doi:10.1212/WNL.0000000000006650.

Migraine with aura was associated with increased risk of incident atrial fibrillation (AF), according to a recent study, and this may potentially lead to ischemic strokes. In the Atherosclerosis Risk in Communities (ARIC) study, a longitudinal, community-based cohort study, participants were interviewed for migraine history between 1993 and 1995 and were followed for incident AF through 2013. AF was adjudicated using electrocardiographs (ECGs), discharge codes, and death certificates. Researchers found:

• Of 11,939 participants assessed for headache and without prior AF or stroke, 426 reported migraines with visual aura, 1090 with migraine without visual aura, 1018 non-migraine headache, and 9405 no headache.
• Over a 20-year follow-up period, incident AF was noted in 232 (15%) of 1516 with migraine and 1623 (17%) of 9405 without headache.
• After adjustment for multiple confounders, migraine with visual aura was associated with increased risk of AF compared to no headache (hazard ratio 1.30) as well as when compared to migraine without visual aura (hazard ratio 1.39).
• The data suggest that AF may be a potential mediator of migraine with visual aura–stroke risk.

Sen S, Androulakis XM, Duda V, et al. Migraine with visual aura a risk factor for incident atrial fibrillation. A cohort study. [Published online ahead of print November 14, 2018]. Neurology. doi:10.1212/WNL.0000000000006650.

Migraine with aura was associated with increased risk of incident atrial fibrillation (AF), according to a recent study, and this may potentially lead to ischemic strokes. In the Atherosclerosis Risk in Communities (ARIC) study, a longitudinal, community-based cohort study, participants were interviewed for migraine history between 1993 and 1995 and were followed for incident AF through 2013. AF was adjudicated using electrocardiographs (ECGs), discharge codes, and death certificates. Researchers found:

• Of 11,939 participants assessed for headache and without prior AF or stroke, 426 reported migraines with visual aura, 1090 with migraine without visual aura, 1018 non-migraine headache, and 9405 no headache.
• Over a 20-year follow-up period, incident AF was noted in 232 (15%) of 1516 with migraine and 1623 (17%) of 9405 without headache.
• After adjustment for multiple confounders, migraine with visual aura was associated with increased risk of AF compared to no headache (hazard ratio 1.30) as well as when compared to migraine without visual aura (hazard ratio 1.39).
• The data suggest that AF may be a potential mediator of migraine with visual aura–stroke risk.

Sen S, Androulakis XM, Duda V, et al. Migraine with visual aura a risk factor for incident atrial fibrillation. A cohort study. [Published online ahead of print November 14, 2018]. Neurology. doi:10.1212/WNL.0000000000006650.