TEXT BOOK REVIEW

OBESITY IS A RISK FACTOR FOR

TRANSFORMED MIGRAINE BUT NOT
CHRONIC TENSION-TYPE HEADACHE
Tutor : dr.Untung G., Sp.S

Created By:
Nurul Arsy M. G4A013038
http://smashtemplates.blogspot.com/

BACKGROUND
Headache are included in the
ten major causes of disability.
Headache is one of the most
common symptom in practices

In British, the symptoms of

headache is 22% the cause of
referral to a specialist neurology

Tension -type headache ,

migraine and headache are not
classified three types of
headache is the most common,
10 % for migraine , 38 % for
TTH and 3% for chronic
headache

Obesity is a risk factor for

chronic daily headache (CDH )

DEFINITION
Headache
Primary Headache
Secondary Headache
Chronic Headache

feeling of not wearing around the head with a lower limit of

the chin to the back of the head.
headaches are not in anatomical abnormalities or
structural abnormalities. Headache is paroxysmal, but
3 % have a primary headache chronic. primary
diagnosis , not due to the presence of other diseases
headache contained anatomical abnormalities or
structural abnormalities. chronic progressive. Due
to other diseases such as hypertension , sinus
inflammation , premenstrual disorder and others
a pain in the head longer than 15 days in a month
and felt more than 3 months

Classification Headache

Based on the International Classification of Headache Disorders edition 2 2013 ( ICHD - 3 )

Migrain
A chronic condition
characterized by episodic
headache with moderate severe intensity that ends
within 4-72 hours

Migrain Without Aura

Diagnostic Criteria
A. At least five attacks1 fulfilling criteria BD
B. Headache attacks lasting 4-72 hours
(untreated or unsuccessfully treated)2,3
C. Headache has at least two of the following
four characteristics:
1. unilateral location
2. pulsating quality
3. moderate or severe pain intensity
4. aggravation by or causing avoidance of routine
physical activity (e.g. walking or climbing stairs)
D. During headache at least one of the following:
1. nausea and/or vomiting
2. photophobia and phonophobia
E. Not better accounted for by another ICHD-3
diagnosis.

Migrain With Aura

Diagnostic Criteria
A. At least two attacks fulfilling criteria B and C
B. One or more of the following fully reversible
aura, symptoms:: visual, sensory, speech and/or
language, motor, brainstem, retinal
C. At least two of the following four characteristics:
1. at least one aura symptom spreads gradually
over 5 minutes, and/or two or more symptoms
occur in succession
2. each individual aura symptom lasts 5-60
minutes1
3. at least one aura symptom is unilateral2
4. the aura is accompanied, or followed within 60
minutes, by headache
D. Not better accounted for by another ICHD-3
diagnosis,
and transient ischaemic attack has been
excluded.

Chronic Migrain (Transformed Migrain)

Headache occurring on 15 or more days per month for more than 3 months, which has the features
of migraine headache on at least 8 days per month
Diagnostic Criteria :
A. Headache (tension-type-like and/or migraine-like) on 15 days per month for >3 months2 and
fulfilling criteria B and C
B. Occurring in a patient who has had at least five attacks fulfilling criteria B-D for 1.1 Migraine
without aura and/or criteria B and C for 1.2 Migraine with aura
C. On 8 days per month for >3 months, fulfilling any of the following3:
1. criteria C and D for 1.1 Migraine without aura
2. criteria B and C for 1.2 Migraine with aura
3. believed by the patient to be migraine at onset and relieved by a triptan or ergot derivative
D. Not better accounted for by another ICHD-3 diagnosis.

Tension Type Headache

(TTH)
intense headache or suppress
or bound , mild to moderate
pain intensity, usually
bilateral. at first may occur
episodically and is associated
with stress, anxiety or
depression, not worsen with
routine activities and can be
accompanied by nausea,
phonophobia or photophobia
without vomiting

Infrequent episodic tension-type

headache
Diagnostic criteria:
A. At least 10 episodes of headache occurring
on <1 day per month on average (<12 days
per year) and fulfilling criteria B-D
B. Lasting from 30 minutes to 7 days
C. At least two of the following four
characteristics:
1. bilateral location
2. pressing or tightening (non-pulsating)
quality
3. mild or moderate intensity
4. not aggravated by routine physical activity
such as walking or climbing stairs
D. Both of the following:
1. no nausea or vomiting
2. no more than 1 of photophobia / phonophobia
E. Not better accounted for by another
ICHD-3 diagnosis.

Frequent episodic tension-type

headache
Diagnostic criteria:
A. At least 10 episodes of headache
occurring on 1-14 days per month on
average for >3 months (12 and <180
days per year) and fulfilling criteria BD
B. Lasting from 30 minutes to 7 days
C. At least two of the following four
characteristics:
1. bilateral location
2. pressing or tightening (nonpulsating) quality
3. mild or moderate intensity
4. not aggravated by routine physical
activity such as walking or climbing
stairs
D. Both of the following:
1. no nausea or vomiting
2. no more than one of photophobia
or
phonophobia
E. Not better accounted for by
another ICHD-3 diagnosis.

Chronic Tension Type

Headache
Diagnosis criteria:
A. Headache occurring on 15 days
per month on average for >3
months (180 days per year),
fulfilling criteria B-D
B. Lasting hours to days, or
unremitting
C. At least two of the following four
characteristics:
1. bilateral location
2. pressing or tightening (nonpulsating) quality
3. mild or moderate intensity
4. not aggravated by routine
physical activity such
as walking or climbing stairs
D. Both of the following:
1. no more than one of
photophobia, phonophobia or mild
nausea
2. neither moderate or severe
nausea nor vomiting
E. Not better accounted for by

OBESITY IS A RISK FACTOR

FOR TRANSFORMED
MIGRAINE BUT NOT
CHRONIC TENSION-TYPE
HEADACHE

 The National Health and Nutrition Examination Survey indicated that 64% of the
adults in the United States had a BMI > 25
Obesity is a risk factor for chronic daily headaches (CDHs), headaches occurring 15
or more days per month
The two most frequent subtypes of CDH are transformed migraine (TM) and
chronic tension-type headache (CTTH)

A longitudinal population study identified that among individuals

with episodic headache, obesity was associated with a fivefold
increased annual incidence of new-onset CDH.
A large population study also suggested that obesity is associated
with the frequency and severity of migraine attacks

Hypothesized : obesity being a risk factor for migraine frequency and

severity, obesity is a stronger risk factor for TM than for CTTH.

Methods
Population sample and computer-assisted telephone interview
in three large metropolitan areas in the United States, from
1997 to 2000
Include : All age-eligible individuals (>18 years old) from the
household who agreed to participate were interviewed,
approved the informed consent,.
Who were subsequently scheduled for an interview with
trained interviewers, using a validated computer-assisted
telephone interview (CATI).

Contd
In the CATI, will asked:
History the headache not due to a head injury, hangover, pregnancy, flu
Whether they have a at least five headache in the previous year
how many different types of headache they had
about the most severe self-defined headache type that the respondent had in
the last 12 months
assessed demographic information (age, gender, race, educational level,
marital status) and health status (history of several other medical conditions).
Information about their weight and height
Headache severity 10-point scale
analgesik drug used in the last 3 months

Sampel

Group 1: Persons with CDH had an average of 15 or more headache

days per month, with an average duration of more than 4 hours per
day
Group 2: Controls had no headaches or had fewer than 108
headaches per year and did not fill criteria for migraine.

Headache Status
Silberstein and Lipton [S-L] criteria, CDH divide it in four groups: TM,
CTTH, new daily persistent headache (NDPH), and hemicrania
continua (HC)
The ICHD-2 defines a disorder analogous to TM, chronic
migraine(CM), and presents criteria for the other CDH. It is important
to emphasize that all subjects with CM also fill criteria for TM.
The studies subdivided the persons with CDH into those with migraine
attacks (herein called TM) and without migraine attacks (CTTH).
Define TM as CDHs associated with at least 12 migraine attacks in the
prior year.

Severity and disability

A. Severity
mild pain intensity ranged from 1 - 3
moderate pain ranging from 4 - 7
severe pain ranging from 8 10
B. Disability
the subject missed activities because of their headache over a 3-month period

Analysis
Using Stata (Intercooled Stata 6.0 for Windows, College Station, TX)
BMI was calculated = (weight [lbs]/height2 [in]) * 703
Underweight (<18.5), normal weight (18.5 - 24.9), overweight (25- 29.9), obese
(30 - 34.9), and morbidly obese (>35)
X2 test compare proportions, Multivariate logistic regression estimate the
odds ratio (OR), Multivariate model to estimate the differential effects of

Result

Contd

Contd

Contd

Discussion
Obesity is associated with CDH in our large population sample. The association is
stronger for TM than for CTTH. Finally, in a longitudinal study, obesity was a risk
factor for new-onset CDH

CDH prevalence increases with increasing BMI category from normal to overweight,
obese, and morbidly obese

In a study of patients with episodic migraine from this sample, obesity was a risk
factor for very frequent headaches (10 to 14 days per month) after adjusting for
covariates
Whereas BMI category had a consistent and increasing relationship with TM
prevalence, the relationship between obesity and CTTH is less clear in our data. BMI
category was not associated with CTTH, with the exception of the morbidly obese
group.

Contd
Obesity is associated with increased frequency and severity of attacks in
patients with episodic migraine.

BMI category is a risk factor for CDH, reflecting a later stage in the process of
chronification. Obese subjects with CDH have more frequent attacks than
normal-weighted subjects with CDH

Obesity is it self a pro-inflammatory state. Obese persons with migraine may

have more frequent and severe attacks and may be more likely to develop
central sensitization. This would explain why obesity is comorbid with TM and
not with migraine.

Obesity may influence migrain through

several mechanism:
Proinflammatory states
Prothrombotic states
Adiponectin, leptin , resistin
Orexin
CGRP
Autonomic nervous system

Conclusion

Tension -type headache and migraine is a type of primary headache are the
most common. Primary headache usually paroxysmal , but there is chronic.
Chronic headache is a pain in the head > 15 days in a month and felt > 3
months
Risk factors associated with chronic headache were obese (body mass index
> 30), women, low education, low socioeconomic status, history of head
injury, snoring (sleep apnea), stressful life events, high caffeine
consumption, excessive use drugs - drugs acutely, and depression
Obesity may influence migrain through several mechanism:
Proinflammatory states Prothrombotic states, Adiponectin, leptin , resistin,
Orexin, CGRP , Autonomic nervous system
Chronic daily headache and obesity are associated. Obesity is a stronger risk
factor for transformed migraine than for chronic tension-type headache.

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