Mild traumatic brain injury affects the features of migraine

DOI: https://doi.org/10.1186/s10194- 021- 01291- x

Abstract-Summary Patients’ demographics, headache symptoms and triggers, history of physical abuse, allodynia symptoms (ASC-12), migraine disability (MIDAS), depression (PHQ-2), and anxiety (GAD-7) were compared between migraine groups with (n = 413) and without (n = 641) a history of mTBI.

A significantly higher proportion of patients with mTBI had CM (74.3% [307/413] vs. 65.8% [422/641], P = 0.004), had never been married or were divorced (36.6% [147/402] vs. 29.4% [187/636], P = 0.007), self-reported a history of physi- cal abuse (24.3% [84/345] vs. 14.3% [70/491], P < 0.001), had mild to severe anxi- ety (50.5% [205/406] vs. 41.0% [258/630], P = 0.003), had headache-related vertigo (23.0% [95/413] vs. 15.9% [102/640], P  =  0.009), and difficulty finding words (43.0% [174/405] vs. 32.9% [208/633], P < 0.001) in more than half their attacks, and headaches triggered by lack of sleep (39.4% [155/393] vs. 32.6% [198/607], P = 0.018) and reading (6.6% [26/393] vs. 3.0% [18/607], P = 0.016), compared to patients without mTBI.

Patients with a history of mTBI are more likely to have a self-reported a history of physical abuse, vertigo, and allodynia during headache attacks, headaches trig- gered by lack of sleep and reading, greater headache burden and headache disabil- ity, and symptoms of anxiety and depression.

This study suggests that a history of mTBI is associated with the phenotype, burden, clinical course, and associated comorbid diseases in patients with migraine, and highlights the importance of inquiring about a lifetime history of mTBI in patients being evaluated for migraine.

Extended: Future longitudinal studies are needed to better understand the natural

history of migraine relative to recurrent TBI.

• The extent to which a subgroup of patients diagnosed with CM in clinical prac-

tice actually has persistent PTH should be a focus of future research.

Background According to the International Classification of Headache Disorders 3rd edition (ICHD-3), post-traumatic headache (PTH) is defined as headache that begins or substantially worsens within 7 days of a trauma or injury to the head and/or neck [76].

Persistent PTH (i.e. PTH that has been present for longer than 3 months) is more often seen after mild traumatic brain injury (mTBI) than after moderate to severe TBI [77–79].

It is estimated that 19–28% of patients with mTBI will still have headache at 1

year after the trauma [80, 81].

The effect of TBI on headache features, associated symptoms, triggers, and

comorbidities among patients with migraine is not well known.

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This study aimed to investigate the effect of mTBI history in migraine patients enrolled in the American Registry for Migraine Research (ARMR) [82] by examin- ing differences in migraine-related symptoms, clinical attributes, and associated disability among patients diagnosed with migraine with and without a history of mTBI.

Methods Headache specialists assigned one or more ICHD-3 diagnoses to each patient, which were entered into ARMR by a clinician or research staff member.

Of 2218 patients who participated in the ARMR study, and were assigned an ICHD migraine diagnosis between February 2016 and March 2020, 57 (2.6%) indi- viduals were excluded due to having one or more headache diagnoses in addition to migraine: headache attributed to trauma or injury to the head and/or neck (i.e. PTH) (n = 50) or headache attributed to cranial and/or cervical vascular disorder (n = 7).

Data extracted from the ARMR database included the clinician’s assigned ICHD-3 headache diagnosis, and patient-reported age, gender, race, education level, marital status, employment status, household income, history of any type of abuse, and history of physical abuse.

Psychiatric comorbidity data extracted included: Patient Health Questionnaire-2 (PHQ-2) score [83], General Anxiety Disorder-7 (GAD-7) score [84], and self- reported history of post-traumatic stress disorder (PTSD).

Results The proportion of patients who reported being married or in a domestic partnership in the mTBI group was significantly lower than that of the non-TBI groups (63.4% [255/402] vs. 70.6% [449/636], P = 0.016).

The proportion of patients with a CM diagnosis in the mTBI group was signifi- cantly higher than in the non-TBI group (74.3% [307/413] vs. 65.8% [422/641]; p = 0.004).

The patients in the mTBI group had significantly higher Mig-SCog scores

(8.9 ± 4.9 vs. 7.5 ± 4.7, P < 0.001) compared to the non-TBI group.

The patients in the mTBI group had significantly higher WPAI-%Absenteeism

(12.8 ± 22.2 vs. 8.7 ± 17.2, P = 0.012) compared to the non-TBI group.

A greater proportion of patients with a history of mTBI self-reported a history of PTSD (33.3% [68/204] vs. 20.7% [54/261], P  =  0.002) compared to the non- TBI group.

Discussion Within our study population, 38% of patients with migraine reported a history of mTBI, which occurred a median of 14.4 (IQR; 4.7–28.5) years before enrollment into ARMR.

While a history of mTBI did not appear to significantly affect the age of migraine onset, this study found that even a long-ago history of TBI (median 14.4 years) might have a durable effect on migraine, including severity, disability, and associ- ated features such as vertigo, cognitive dysfunction, allodynia, and psychological comorbidities.

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Patients in the mTBI group were more likely to report significant headache- associated allodynia (higher ASC-12 scores), compared to those in the non- TBI group.

In the mTBI group, 145 patients reported “new onset or worsening headache within 7 days of their injury,” and thus may have a history consistent with the ICHD- based diagnosis of persistent PTH with a migraine or CM phenotype that was not coded by providers within the ARMR database.

Conclusion About 38% of patients with migraine in our study had a history of mTBI, which occurred a median of over 14 years before enrollment.

A history of mTBI was found to be associated with increased headache fre- quency, a diagnosis of chronic migraine, and greater headache-related disability, higher rates of cognitive dysfunction, reading/lack of sleep as a headache trigger, vertigo/dizziness, allodynia, and higher rates of anxiety and depression symptoms.

• A history of mTBI is associated with increased diagnosis of chronic migraine, headache frequency, vertigo/dizziness, allodynia, reading/lack of sleep as a trig- ger, headache-related disability, cognitive dysfunction, anxiety, and depression. • Symptoms eliciting a history of prior mTBI should be an integral part of the evaluation of patients with migraine, especially in those with a severe phenotype including chronic migraine.

Acknowledgement A machine generated summary based on the work of Ishii, Ryotaro; Schwedt, Todd J.; Trivedi, Meesha; Dumkrieger, Gina; Cortez, Melissa M.; Brennan, K. C.; Digre, Kathleen; Dodick, David W. 2021 in The Journal of Headache and Pain.

Factors Associated with Sport-Related Post-concussion Headache and Opportunities for Treatment