Prospective Analysis of Factors Related to Migraine Attacks: The PAMINA Study

Abstract

Migraine is related to numerous factors such as hormones, stress or nutrition, but information about their actual importance is limited. Therefore, we analysed prospectively a wide spectrum of factors related to headache in migraineurs. We examined 327 migraineurs recruited via newspapers who kept a comprehensive diary for 3 months. Statistical analysis comprising 28 325 patient days and 116 dichotomous variables was based on the interval between two successive headache attacks. We calculated univariate Cox regression analyses and included covariables with a P-value of <0.05 in two stepwise multivariate Cox regression analyses, the first accounting for a correlation of the event times within a subject, the second stratified by the number of headache-free intervals. We performed similar analyses for the occurrence of migraine attacks and for the persistence of headache and migraine. Menstruation had the most prominent effect, increasing the hazard of occurrence or persistence of headache and migraine by up to 96%. All other factors changed the hazard by <35%. The two days before menstruation and muscle tension in the neck, psychic tension, tiredness, noise and odours on days before headache onset increased the hazard of headache or migraine, whereas days off, a divorced marriage, relaxation after stress, and consumption of beer decreased the hazard. In addition, three meteorological factors increased and two others decreased the hazard. In conclusion, menstruation is most important in increasing the risk of occurrence and persistence of headache and migraine. Other factors increase the risk less markedly or decrease the risk.

Reduction in perceived stress as a migraine trigger

“…These results are consistent with and extend prior research. [11][12][13][14][15][16][17][18][19][20] In aggregate, these findings and the prior literature support the let-down hypothesis, which predicts that decline in perceived stress is associated with an increased probability of migraine onset. There are at least 2 alternative mechanisms to explain this phenomenon.…”

“…[4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22] Premonitory features include changes in mood or behavior that precede the onset of an attack. Trigger factors, measurable precipitants associated with an increased probability of an attack, can include stressful events, hormonal changes, weather changes, and certain foods, although some studies demonstrate reduced odds for migraine attacks in relation to certain variables.…”

“…Trigger factors, measurable precipitants associated with an increased probability of an attack, can include stressful events, hormonal changes, weather changes, and certain foods, although some studies demonstrate reduced odds for migraine attacks in relation to certain variables. [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22] In patient surveys, perceived stress was associated with migraine onset in up to 80% of respondents. [13][14][15][16] Diary studies have shown that "daily hassles" significantly increase in the 2-to 3-day period before a migraine day.…”

“…4 Some studies have examined the effects of reduction in stress or "let-down" as a migraine trigger factor, often focused on "weekend" headache attacks. [14][15][16][17][18][19][20][21][22] The roles of level of stress and reduction in stress as migraine triggers remain to be disentangled. Our objective was to examine the association between stress and reduction in stress on migraine attack onset in persons with migraine using electronic diaries.…”

“…Results demonstrate that electronic diaries coupled with appropriate analytic strategies provide a powerful tool for assessing headache triggers. [11][12][13][14][15][16][17][18][19][20][21][22] Random-effects logistic regression modeling provides more accurate summaries of effects both within and among participants. Methodologic issues in studying stress and relaxation after stress exemplify the problems that arise for studying provocative factors for migraine in general.…”