The prevalence of headache disorders in Postural Tachycardia Syndrome: A systematic review and meta-analysis of the literature

Abstract

Background Headache is a common presentation of postural tachycardia syndrome, yet robust prevalence data is lacking. Objectives To undertake a systematic review and meta-analysis to estimate the prevalence of headache disorders in postural tachycardia syndrome, and to explore the potential shared pathophysiological mechanisms that underpin these conditions as well as treatment options. Methods Three databases were searched for publications evaluating prevalence of migraine (primary outcome) and general and orthostatic headache (secondary outcomes) in patients with postural tachycardia syndrome. Two independent reviewers selected studies and extracted data. A random-effects meta-analysis calculated the pooled prevalence of migraine in postural tachycardia syndrome. A narrative literature review explored the pathophysiology and treatment options for concurrent headache disorders and postural tachycardia syndrome. Results Twenty-three articles met inclusion criteria. Estimated pooled prevalence of migraine in postural tachycardia syndrome was 36.8% (95% CI 2.9–70.7%). Various shared pathophysiological pathways for these conditions, as well as proposed treatment strategies, were identified. Limitations: Heterogeneity of study design, populations, and methodology for identifying headache disorders and postural tachycardia syndrome limited the generalisability of results. Conclusions Migraine is a commonly reported comorbidity in POTS, however the true prevalence cannot be determined from the current literature. Further studies are required to assess this comorbidity and investigate the underlying mechanisms, as well as identify effective treatment strategies.

Autonomic symptoms in migraine: Results of a prospective longitudinal study

“…A speculative theory on precipitating factors of autonomic symptoms in migraine would include the previously discussed sensitization of the sympathetic nervous system and upregulation of post-synaptic transmitters ( 6 , 7 ). Contribution from dysregulation of sensory processing pathways is also possible.…”

“…Contribution from dysregulation of sensory processing pathways is also possible. Disruption of descending inhibitory pathways, required for the perception of nociception in a migraine attack, may be facilitated by excess inhibitory GABA pathways interfacing with noradrenergic pathways in the locus coeruleus, and the parasympathetic reflex arc arising from the superior salivatory nucleus ( 7 , 15 – 18 ). Disruption of GABA inhibition in the locus coeruleus and possibly by extension, facilitatory networks in the rostral ventral medulla and periaqueductal gray region, have been hypothesized to result in the facilitation of transmission of sensory information ( 18 ).…”

“…Given the burden of autonomic symptoms in migraine, studies have previously attempted to assess sympathetic and parasympathetic function in migraine. This literature has been ably summarized elsewhere ( 6 , 7 ). The majority, but not all, of the studies suggest a trend to sympathetic hypoactivity inter-ictally, and an exaggerated sympathetic response ictally ( 7 ).…”

“…This literature has been ably summarized elsewhere ( 6 , 7 ). The majority, but not all, of the studies suggest a trend to sympathetic hypoactivity inter-ictally, and an exaggerated sympathetic response ictally ( 7 ). One hypothesis for this observation is that repeated ictal stimulation of the sympathetic autonomic system leads to downregulation and reduced plasma norepinephrine release, which over time leads to upregulation of postsynaptic adrenergic receptors and the resultant ictal hypersensitivity ( 6 ).…”

Narrative Review of Postural Orthostatic Tachycardia Syndrome: Associated Conditions and Management Strategies

“…Migraines are frequently reported among POTS patients, although the etiology of this association is not understood. 44 Autonomic symptoms seen with migraines could result from activation of brain regions that control autonomic regulation, although activation of the nervous system may also play a role. 30 Central sensitization, an increased response to nociceptors, is a key feature of migraines and has been demonstrated in POTS patients.…”