Comparative analysis between chronic and episodic migraine

ARTIGO ORIGINAL
Comparative analysis between chronic and episodic
migraine attacks trigger factors in patients from a
headache clinic of the Teaching Hospital of the
Universidade Federal de Sergipe (HU-UFS)
Análise comparativa entre fatores desencadeantes de crises de
migrânea crônica e migrânea episódica em pacientes do ambulatório
de cefaleias do Hospital Universitário (HU-UFS)
Alan Chester Feitosa de Jesus, Felipe José Nascimento Barreto, Larissy Lima Santos,
Philippe Joaquim Oliveira Menezes Macêdo, Luana Karla Braz Fonseca Dantas
Ambulatório de Cefaleia, Liga de Cefaleia (Licese), Hospital Universitário, Universidade Federal de Sergipe
Jesus ACF, Barreto FJN, Santos LL, Macêdo PJOM, Dantas LKBF
Comparative analysis between chronic and episodic migraine attacks trigger factorsin patients from
a headache clinic of the Teaching Hospital of the Universidade Federal de Sergipe (HU-UFS)
Migrâneas cefaleias 2009;12(1):6-9
ABSTRACT
RESUMO
Introduction: As much as its classifications and symptoms,
there is also variation among the trigger factors already
established in clinical practice and literature for migraine
attacks. Objective: Describe the most prevalent trigger factors
in patients suffering from chronic or episodic migraine and
developing a comparative analysis of each factor among
the groups. Method: In this prospective study, 361 patients
have been included. All of them were seen at the Headache
Center of the Teaching Hospital of Federal University of Sergipe
from January 2006 to July 2008. For migraine diagnosis, it
was used current clinical criteria suggested by the ICHD-2,
and for statistical analysis, the Student T test, with p < 0.05.
Results: Among the total of patients, 110 satisfied the
inclusion criteria for chronic migraine and 251 for episodic
migraine. Emotional issues were the most prevalent trigger
factor in both migraine types. When chronic and episodic
types of migraine were compared, there was no statistically
significant difference for trigger factors frequency, except for
sleep (p=0.0001) and smells (p=0.014). Conclusion: Both
sleep and smells seem to trigger headache attacks more
frequently among the patients with chronic migraine when
compared with episodic migraine patients.
Introdução: Tal como suas classificações e sintomatologia,
é variada também a gama de fatores que estão bem estabelecidos na clínica e literatura como precipitantes de crises
de migrânea. Objetivo: Descrever os fatores desencadeantes de crises mais prevalentes em pacientes migranosos crônicos e episódicos e realizar análise comparativa de cada fator entre os grupos. Método: Em caráter
prospectivo, foram incluídos no estudo 361 pacientes. Todos foram atendidos no Ambulatório de Cefaleia do Hospital Universitário (HU-UFS) durante o período compreendido entre janeiro de 2006 a julho de 2008. Para o diagnóstico de migrânea, foram utilizados critérios clínicos
atuais, propostos pela ICHD-2, e para a análise estatística, o Teste T de Student com poder de significância fixado
em 5%. Resultados: Do total de pacientes estudados,
110 foram diagnosticados como portadores de migrânea
crônica e 251 como migranosos episódicos. Questões
emocionais foram os fatores desencadeantes mais prevalentes em ambas as formas de migrânea. Quando as duas
formas de migrânea foram comparadas entre si, não se
observou diferença estatisticamente significativa no tocante
à frequência de fatores desencadeantes, com exceção do
sono (p=0,0001) e dos odores (p=0,014). Conclusão:
Tanto privação e excesso de sono quanto odores parecem
desencadear mais crises de cefaleia entre os pacientes com
Key words: Headache trigger factors; chronic migraine;
episodic migraine; migraine attacks.
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Migrâneas cefaleias, v.12, n.1, p.6-9, jan./fev./mar. 2009
COMPARATIVE ANALYSIS BETWEEN CHRONIC AND EPISODIC MIGRAINE ATTACKS TRIGGER FACTORS IN PATIENTS FROM A HEADACHE CLINIC OF THE
TEACHING HOSPITAL OF THE UNIVERSIDADE FEDERAL DE SERGIPE (HU-UFS)
migrânea crônica quando comparados com os pacientes
com diagnóstico de migrânea episódica.
Palavras
alavras-- chave: Fatores desencadeantes de cefaleia;
migrânea crônica; migrânea episódica; crises de migrânea.
INTRODUCTION
Migraine is a quite common clinical condition in
general population, with a higher incidence in women. It
is a brain syndrome, mostly characterized by recurrent
headaches throbbing-like, unilateral location, placed at
the frontotemporal area of the head. Pain attacks are severe
and associated with nausea, vomiting, photophobia and
phonophobia, besides being preceded by focal
neurological phenomena, which configurates the migraine
with aura.
Although it is not a nosological entity, recognized by
the second edition of the International Classification of
Headache Disorders (ICHD-2)5 published in 2004, the
expression "episodic migraine" is applied to migraine
whose pain attacks frequency are lower than 15 days per
month.11 However, episodic migraine may evolve to the
condition known as chronic migraine,11 once called
transformed migraine, the most frequent type of daily
chronic headache. A wide range of risk factors are involved
in this process, among them: stress and persistent
conflicting events, medication overuse, obesity, depression,
caffeine abusive usage and high frequency of headache
attacks.12
Indeed, either isolated or associated, all these factors
contribute for clinical, anatomic and pathophysiological
progression of migraine, which seems to be not only an
episodic disorder, but also a chronic disorder with episodic
events.2 Mechanisms such as increased vasodilatation of
brain vessels, neurogenic and immunomediated
inflammation are involved centrally, 12 as much as
peripherically.4 It results in progressive dysfunction of pain
modulation, leading to the chronification of migraine.
According to the ICHD-2, the diagnosis of chronic
migraine is established when a patient complains of
headache for more than 15 days per month, during at
least three months, with typical attacks of migraine without
aura, not due to other diseases,5 including medication
overuse. Paradoxically, painkiller abuse is the most
important isolated factor for the transformation of episodic
migraine to chronic.16 This definition, however, is quite
unclear and, in order to resolve this lack of accuracy, many
Migrâneas cefaleias, v.12, n.1, p.6-9, jan./fev./mar. 2009
physicians consider other clinical parameters which define the diagnosis of chronic migraine, like decrease of
intensity associated with increased frequency of migraine
headache attacks for at least three months.15
As much as its classifications and symptoms, there is
also variation among the trigger factors already
established in clinical practice and literature for migraine
attacks.3,6,7 Some examples of those frequently mentioned
by patients are: emotional issues, sleep disturbances
(increased or decreased sleep time), fasting, chocolate,
greasy food, alcohol, physical stress and sensorial stimuli
(visual, hearing and smelling7). Since the migraine patients'
brain is hyperexcitable, the previously quoted circumstances
are capable of setting off acute attacks of migraine.
The objective of this study was to describe the most
prevalent trigger factors in patients suffering from chronic
or episodic migraine, admitted at the Headache Center
of HU-UFS, as well as developing a comparative analysis
of each factor among the groups.
METHODS
Three hundred and sixty-one patients have been
included in this prospective study, from which 299 (82,8%)
are women and 62 (17,2%) are men, in a range of age
from 9 to 76 years. All patients were seen at the Headache
Center of the Teaching Hospital of Federal University of
Sergipe (HU-UFS) from January 2006 to July 2008. Each
patient was assessed according to clinical criteria which
included semi-structured interview and neurologic exam.
The same patient may have reported more than one trigger
factor of headache attacks.
For migraine diagnosis, there have been used current
clinical criteria, suggested by the International Headache
Society in its last classification (ICHD -2).5 Migraineurs who
do not fulfill previously established criteria for chronic
migraine were automatically fit in the episodic migraine
group. In order to assess statistical differences between the
groups, it was applied the Student T test, with p < 0.05.
RESULTS
Among the total of patients, 110 (30.47%) satisfied
the inclusion criteria for chronic migraine and 251
(69.53%), for episodic migraine, out of these, 152
suffering from migraine without aura and 99, with an aura
pattern. Considering gender, migraine was more prevalent
in women, of whom 203 had episodic migraine and 96
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ALAN CHESTER FEITOSA DE JESUS E COLABORADORES
chronic migraine, against 48 men diagnosed as episodic
migraine and 14 as chronic migraine.
In this casuistic, the most frequent triggers factors
involved in precipitating headache attacks were:
emotional issues, tiredness and physical stress, sleep,
fasting, food, alcohol and smells. Of these, emotional
issues were the most prevalent in both migraine types
(80% for chronic migraine attacks and 66.9% for the
episodic ones).
Comparing trigger factors frequency as a whole and
between the chronic and episodic types of migraine, there
was no statistically significant difference, except for sleep
(p = 0.0001) and smells (p = 0.014). These two factors
seem to trigger headache attacks more frequently among
the patients with chronic migraine (smells = 16.36%; sleep
= 75.45%) when compared with episodic migraine
patients (smells = 6.7%; sleep = 55.37%) (Table 1).
although stress, hormonal changes in women and fasting
have been more prevalent. Concerning those most strictly
related to outset of attacks, either stress or hormones were
the top rated of his study.10 Jesus found that 83.5% of his
chronic migraine patients reported emotional issues as
trigger factors for pain attacks.9
In our casuistic, lack or excess of sleep, and smells
were identified as factors that set off more attacks of chronic
migraine than attacks of episodic migraine. Only sleep is
recognized in reviewed literature, which also assembles
diet and hormonal changes as more common triggers
for chronic migraine attacks.10
Nevertheless this conclusion has statistic significance,
it cannot be assured that such factors may be used as
differential diagnosis between the chronic and episodic
forms of migraine. Furthermore, it could be suggested
that sleep, a major trigger factor of chronic migraine
attacks, has some kind of association with high prevalence
of sleep disturbances in these patients.16
It is extremely relevant to research trigger factors for
headache attacks in migraine patients during clinical exam,
not only for comprehension of migraine's pathophysiology,
but also as a valuable tool in therapeutic process. This
knowledge, as well as useful for the patients to understand
their own illness, stresses their important role in improving
health and quality of life through extinguishing or reducing
trigger factors of their particular migraine attacks. In spite
of that, symptomatic and prophylactic drugs available
cannot be excluded, figuring as an important ally for the
treatment of migraine.
DISCUSSION
REFERENCES
The differences between chronic and episodic migraine
are beyond agreed criteria in ICHD-2, not capable of
diagnosing one or other clinical condition. Compared with
episodic migraine patients, those who suffer from chronic
migraine have also associated comorbities, like allergies,1
gastrointestinal and, mainly, psychiatric diseases,8 from
depression to anxiety and post-traumatic stress disorder.13
Besides, they have a greater historic of daily triptans usage,
illicit drugs and alcohol abuse, and significant familiar
record of migraine and arterial hypertension.8 Due to
chronic state, chronic migraine patients are submitted to
Computed Tomography Scan more often than the other
ones with the episodic type.14
In his research about triggering migraine attacks,
Kelman found a huge variance between the factors that
might be occasionally involved with acute headaches,
8
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TEACHING HOSPITAL OF THE UNIVERSIDADE FEDERAL DE SERGIPE (HU-UFS)
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Endereço para correspondência
Dr
eitosa de Jesus
Dr.. Alan Chester FFeitosa
E-mail: [email protected]
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