Headache in the course of multiple sclerosis: a prospective study

DOI: https://doi.org/10.1007/s00702- 018- 1959- 0

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Abstract-Summary Early diagnosis and treatment is important to prevent progression of disability in the course of the chronic disease.

Headache is generally not recognized as an early symptom of MS, although

numerous studies could show a high prevalence of headache in MS patients.

The aim of this study is to investigate the prevalence as well as the phenomenol-

ogy of headache in MS especially with regard to the progression of the disease.

In a prospective, multicenter study, we unbiasedly recruited 150 patients with

manifest MS based on the criteria of McDonald.

50 patients at the timepoint of initial diagnosis and 100 of them with a long-term

course of the disease were included.

Prevalence of headache in all patients was 67%. Patients at the timepoint of symptom manifestation of MS showed the highest

prevalence of headache that was ever been recorded of 78%.

Patients with headache were younger, had a shorter duration of the disease, and

were less physically affected.

In the course of the disease, patients without disease-modifying drug (DMD)

complained more frequently headaches than patients with any kind of therapy.

That way these patients could get the earliest possible treatment, which is impor-

tant to stop the progression of the disease.

Background 50% of patients with MS are younger than 30 years at the time of initial diagnosis (Flachenecker and others [454]; Skierlo and others [455]).

A number of studies in the last few years showed a high prevalence of headache in MS (Kister and others [456]; Villani and others [457]; D’Amico and others [458]; Nicoletti and others [459]; Putzki and others [460]; Möhrke and others [461]; Vacca and others [462]; Boneschi and others [463]).

Möhrke and others could show that young patients with a relapsing course are particularly prone to suffer from headache in the early stage of the disease com- pared to patients with the progressive form (Möhrke and others [461]).

There seems to be a correlation between the course of MS and the type of head- ache: TTH seems to be associated with a progressive course, migraine without aura with a relapsing course (D’Amico and others [458]).

Other types of headache like cluster headache are rarely reported for MS patients

(Möhrke and others [461]).

The aim of this study is to investigate the prevalence as well as the phenomenol- ogy of headaches in MS, especially in correlation with the duration of the disease.

Methods All study participants underwent a detailed and structured clinical interview about their case history as well as a detailed clinical examination, including the evaluation of disease severity on the Expanded Disability Status Scale (EDSS, Kurtzke [464]). The Rokoko allows classification of headaches into migraine with and without

aura, TTH, and cluster headache.

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2 Mechanisms

The sensitivity of the test for migraine without aura is 0.87, and the specificity is

0.51, for migraine with aura 0.71/0.95 and for TTH 0.57/0.93, respectively.

Using the “Fatigue Scale for Motor and Cognitive Functions” (FSMC, Penner

and others [465]), participants were tested for fatigue.

The test separates between mild, moderate, or severe fatigue for overall fatigue

as well as for cognitive and motor fatigue, respectively.

All participants got pertinent information and gave their permission to be part of

a study.

Results The 100 MS patients had a median disease duration of 11 years (range 45, min 0, max 45).

Patients with CIS had a prevalence of 78%, patients with MS of 62%. A high number especially of migraine-like headache among CIS patients was

observed.

Patients with headache tended to be younger (46 vs 49 years), had a shorter dis- ease duration (3 vs 9 years), were more often female (73% vs 63%), and had a lower EDSS Score (4 vs 4.5) than patients without headache.

Regarding the course of the disease patients with headache most commonly suf-

fered from CIS (38.6%), patients without headache from SPMS (38.8%).

40.6% of patients with headache, but only 24.5% of patients without headache

received no immunomodulatory therapy.

No relationship between headache and therapy with Beta-Interferons was observed, as this therapy was even more common in patients without headache (10.2% vs 6.9%).

Discussion The main reason for misdiagnosis were MS untypical symptoms, and because the patients complained about headache, the most common false diagnosis was migraine.

In accordance with the data above, we found a noticeable high number of

migraine-like headache in our MS patients.

The frequent misdiagnosis of migraine in MS patients, which was described by Solomon and others, could only be avoided with the help of a thorough differential diagnosis, because both diseases have differences in MRI and CSF as well as thera- peutically: In MRI of the head cortical lesions could be found among 60% of MS patients and in none of the migraine patients (Absinta and others [466]).

Additional prospective studies are needed to verify our findings and investi- gate the phenomenology of headache especially at the beginning of MS in more detail, find more possibilities of differentiation between migraine-like headache in MS and episodic migraine as well as shedding light on the relationship between MS and migraine including the coincidence of both diseases (Kropp and oth- ers [467]).

Conclusion Headache and MS were clearly separated clinically and therapeutically.

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We could show that headache in young, physical less affected patients without DMD occurred frequently, suggesting a relation to the inflammatory activity, which is as highest at the beginning of the disease.

Our data suggest that young patients with headache could benefit from an MRI

of the head and a subsequent differential diagnosis of MS.

The fact, that headache could be a symptom of the inflammatory disease, is par- ticularly important, given that it is often unclear if RIS patients with headaches and a MS typical MRI should be treated immunotherapeutically.

Acknowledgement A machine generated summary based on the work of Gebhardt, Marcel; Kropp, Peter; Hoffmann, Frank; Zettl, Uwe K. 2018 in Journal of Neural Transmission.

Vestibular drop attacks in Ménière’s disease and its association with migraine