i
Headache Medicine, v.11, n.2, 2020
Editorial
The
new pathways of orofacial pain: the just released “International Classification of Orofacial Pain" - First
edition (ICOP)
Paulo Cesar Rodrigues Conti, Juliana Stuginski Barbosa, Leonardo R Bonjardim, Daniela Aparecida de Godoi
Gonçalves.............................................................................................................................................................................................................................28-29
Clinical Corr
espondence
Management of chronic orofacial pain in pandemic of COVID-19
Wagner Hummig,
Bianca Lopes Cavalcante-Leão, José Stechman-Neto.........................................................................................30-31
Vessel wall imaging for diagnosis an
d follow-up of basilar artery reversible cerebral vasoconstriction
syndrome (RCVS)
Matheus Kahakura Franco
Pedro, Paulo Sérgio Faro Santos, Bruno Augusto Telles...................................................................32-34
Views and Reviews
Headache
in patients with coronavirus disease (Covid-19): An integrative literature review
Sarah Nilkece Mesquita Araújo Nogueira Bastos, Diego Afonso Cardoso Macedo de Sousa, Simone Santos e Silva
Melo, Bárbara Louise Freire Barbosa, Larisse Giselle Barbosa Cruz, Raimundo Pereira Silva-Néto.....................................35-38
Original Arti
cles
Main symptoms associated to the catastrophizing in women with fibromyalgia and migraine
Amanda de Oliveira Freire Barros, Manuella Moraes Monteiro Barbosa Barros, Reydiane Rodrigues Santana,
Débora Wanderley, Angélica da Silva Tenório, Daniella Araújo de-Oliveira.....................................................................................39-43
Headache trigge
red by sleep deprivation an observational study
Matheus S
araiva Valente Rosado, Raimundo Silva-Néto............................................................................................................................44-47
Recommendations for the management of headaches during the COVID-19 pandemic
Yara Dadalti Fragoso, Marcelo Calderaro, Marcio Nattan Portes Souza, Patrick Emanuell Mesquita Sousa Santos,
Eduardo Nogueira, Shuu-Jiun Wang, Messoud Ashina, Stephen D Silberstein, Mario Peres..................................................48-50
Food avoidance
among patients with headache
Stella
Boreggio Machado, Nayara Cavalcanti Ares, Claudio Scorcine, Yara Dadalti Fragoso..................................................51-53
Scienti
c Publication of the Brazilian Headache Society
Volume 11 ∙ Number 2
∙ 2020
Contents
ISSN 2178-7468, e-ISSN 2763-6178
Headache Medicine, v.11, n.2, 2020
ii
Editores-chefes
Marcelo Moraes Valença
Universidade Federal de Pernambuco, Recife, PE, Brasil.
Mario Fernando Prieto Peres
Hospital Israelita Albert Einstein, IPq – HCFMUSP, São Paulo, SP, Brasil.
Editor Científic
Raimundo Pereira Silva-Néto
Universidade Federal do Delta do Parnaíba, Parnaíba, PI, Brasil.
Editor Emeritus
Wilson Luiz Sanvito
FCM Santa Casa de São Paulo, São Paulo, SP, Brasil.
Pesquisa Básica e Procedimentos
Élcio Juliato Piovesan
Universidade Federal do Paraná, Curitiba, PR, Brasil.
Ensino, alunos e residentes
Yara Dadalti Fragoso – Santos, SP, Brasil.
Cefaleia na Mulher
Eliane Meire Melhado
Universidade de Catanduva, Catanduva, SP, Brasil.
Multiprossional
Juliane Prieto Peres Mercante
IPq – HCFMUSP, São Paulo, SP, Brasil.
Arão Belitardo de Oliveira
ABRACES – Associação Brasileira cefaleia em Salvas e
Enxaqueca, São Paulo, SP, Brasil.
Debora Bevilacqua Grossi
FMUSP – Rebeirão Preto, SP, Brasil.
Cefaleias Secundárias
Pedro Augusto Sampaio Rocha
Universidade Federal de Pernambuco, Recife, PE, Brasil.
Hipertensão e Hipotensão Liquórica
Ida Fortini HC FMUSP, São Paulo, SP, Brasil.
Sandro Matas
UNIFESP, São Paulo, SP, Brasil
Cefaleias Trigêmino-Autonômicas
Maria Eduarda Nobre
Rio de Janeiro, RJ, Brasil
Cefaleia na Infância
Marco Antônio Arruda
Universidade Federal de São Paulo, SP, Brasil.
Dor orofacial
Eduardo Grossmann – Porto Alegre, RS, Brasil.
Controvérsias e Expert Opinion
Joao José Freitas de Carvalho – Fortaleza, CE, Brasil.
Clinical Trials
Fabiola Dach
FMUSP, Ribeirão Preto, SP, Brasil.
Teses
Fernando Kowacs, Porto Alegre, RS, Brasil.
Imagens e Vídeos
Paulo Sergio Faro Santos
INC, Curitiba, PR, Brasil.
Advocacy
Elena Ruiz de La Torre
WHAM (World Headache Association for Migraine)
Madri, Espanha.
A revista Headache Medicine é uma publicação de propriedade da Sociedade Brasileira de Cefaleia, indexada no Latindex e no Index Scholar, publicada
pela Sociedade Brasileira de Cefaleia, www.sbcefaleia.com.br. Os manuscritos aceitos para publicação passam a pertencer à Sociedade Brasileira de
Cefaleia e não podem ser reproduzidos ou publicados, mesmo em parte, sem autorização da HM & SBCe. Os artigos e correspondências deverão ser
encaminhados para a HM através de submissão on-line, acesso pela página www.headachemedicine.com.br - Distribuição gratuita para os membros
associados, bibliotecas regionais de Medicina e faculdades de Medicina do Brasil, e sociedades congêneres
Editores Associados
CONSELHO EDITORIAL
Scientic Publication of the Brazilian Headache Society
ISSN 2178-7468, e-ISSN 2763-6178
iii
Headache Medicine, v.11, n.2, 2020
Scientic Publication of the Brazilian Headache Society
CONSELHO EDITORIAL
Rodrigo Noseda
Harvard Medical School, Boston, MA, EUA
Marlind Alan Stiles
Jefferson Universtty, Philadelphia, PA, EUA
Charles Siow, Singapore
Maurice Borges Vincent, Indianapolis, IN, EUA
Michele Viana, Novara, Itália
Margarita Sanchez Del Rio, Madri, Espanha
Sait Ashina,
Harvard Medical School, Boston, MA, EUA
Todd D Rozen,
Mayo Clinic, Jacksonville, FL, EUA
Elena Ruiz de la Torre, Espanha
Marco Lisicky, Cordoba, Argentina
Maria Teresa Goycochea, Buenos Aires, Argentina
Alex Espinoza Giacomozzi, Santiago, Chile
Joe Munoz Ceron, Bogotá, Colômbia
Faisal Amin, Copenhague, Dinamarca
Uwe Reuter, Berlim, Alemanha
Abouch Valenty Krymchantowski, Rio de Janeiro, RJ
Alan Chester Feitosa Jesus, Aracaju, SE
Ana Luisa Antonniazzi, Ribeirão Preto, SP
Carla da Cunha Jevoux, Rio de Janeiro, RJ
Carlos Alberto Bordini, Batatais, SP
Daniella de Araújo Oliveira, Recife, PE
Djacir D. P. Macedo, Natal, RN
Elder Machado Sarmento, Barra Mansa, RJ
Eliana Meire Melhado, Catanduva, SP
Fabíola Dach, Ribeirão Preto, SP
Fernando Kowacs, Porto Alegre, RS
Henrique Carneiro de Campos, Belo Horizonte, MG
Jano Alves de Sousa, Rio de Janeiro, RJ
João José de Freitas Carvalho, Fortaleza, CE
Luis Paulo Queiróz, Florianópolis, SC
Marcelo C. Ciciarelli, Ribeirão Preto, SP
José Geraldo Speziali, Ribeirão Preto, SP
Marcelo Rodrigues Masruha, Vitória, ES
Pedro Ferreira Moreira Filho, Rio de Janeiro, RJ
Pedro André Kowacs, Curitiba, PR
Mauro Eduardo Jurno, Barbacena, MG
Paulo Sergio Faro Santos, Curitiba, PR
Pedro Augusto Sampaio Rocha Filho, Recife, PE
Renata Silva Melo Fernandes, Recife, PE
Thais Rodrigues Villa, São Paulo, SP
Renan Domingues, Vitória, ES
Conselho Editorial Internacional
Conselho Editorial Nacional
A revista Headache Medicine é uma publicação de propriedade da Sociedade Brasileira de Cefaleia, indexada no Latindex e no Index Scholar, publicada
pela Sociedade Brasileira de Cefaleia, www.sbcefaleia.com.br. Os manuscritos aceitos para publicação passam a pertencer à Sociedade Brasileira de
Cefaleia e não podem ser reproduzidos ou publicados, mesmo em parte, sem autorização da HM & SBCe. Os artigos e correspondências deverão ser
encaminhados para a HM através de submissão on-line, acesso pela página www.headachemedicine.com.br - Distribuição gratuita para os membros
associados, bibliotecas regionais de Medicina e faculdades de Medicina do Brasil, e sociedades congêneres
ISSN 2178-7468, e-ISSN 2763-6178
Headache Medicine 2020, 11(2):28-29 ISSN 2178-7468, e-ISSN 2763-6178
28
ASAA
DOI: 10.48208/HeadacheMed.2020.8
Headache Medicine
© Copyright 2020
Editorial
The new pathways of orofacial pain: the just released
“International Classication of Orofacial Pain" - First edition
(ICOP)
Paulo Cesar Rodrigues Conti
1
Juliana Stuginski Barbosa
1
Leonardo R Bonjardim
1
Daniela Aparecida
de Godoi Gonçalves
2
1
Faculdade de Odontologia de Bauru, Universidade de São Paulo, USP, São Paulo, Brazil.
2
Faculdade de Odontologia de Araraquara, Universidade Estadual Paulista, UNESP, Araraquara, São Paulo, Brazil.
After the extraction of a third molar tooth, and after the normal healing period, Mrs. Maria started
to experience constant, burning, and sometimes electric shock-like pain at the surgery site. She
was treated by several professionals that offered different treatment options, including surgical
procedures, the use of various painkillers, as well as psychological support. However, none of the
approaches was able to ease her suffering. Only after many tentative during several months she
got an accurate diagnosis and adequate therapy. This trajectory brought her anxiety, suffering,
and loss of quality of life. Unfortunately, cases like Mrs. Maria’s are not rare in Dentistry, and
perhaps symbolize the same scenario of headache patients 30 years ago, before the establishment
of validated diagnostic criteria.
1
Chronic Orofacial Pain (OFP) comprises a diverse group of extraoral and intraoral painful manifes-
tations that may include dental pain, muscle, and articular (temporomandibular joint - TMJ) pain, as
well as posttraumatic neuralgias, which are difcult to diagnose and control. Beyond the potential
negative impact on patients’ quality of life, these conditions are also frequently associated with other
comorbidities, such as primary headache, bromyalgia, neck pain, and others.
2,3,4
As illustrated in the case above mentioned, dentists daily deal with critical challenges and dif-
culties in the recognition and diagnosis of such conditions. Such problems are often shared with
other health professionals, such as physicians, psychologists and physical therapists, who may
be involved in the care of patients with such conditions. These facts perhaps are related to the
complexity of the Trigeminal System, which is composed of three nerve branches, sharing neural
pathways with many other cranial and cervical nerves.
5
Another critical problem is the absence
of a worldwide accepted and comprehensive classication able to reect in appropriate and
evidence-based management strategies. An unrecognized and unclassied condition cannot be
treated!
An inherent characteristic of human beings is the tendency to group objects or creatures with
similar characteristics. Primitive man, for example, already divided living beings into two groups:
edible and inedible. In other words, classifying and differentiating is part of the evolution of the
human race.
Some classication systems consider the OFP conditions, such as the “International Classication
of Headaches Disorders” (ICHD)
6
, and the “Diagnostic Criteria for Temporomandibular Disorders”
(DC/DTM).
7
However, none of them encompass, in an organized and hierarchical manner, all
possible painful manifestations of the face and oral cavity.
Thus, a joint initiative was launched with the participation of several entities, such as the Special
Interest Group in Orofacial Pain and Headache (SIG-OFHP) of the IASP (International Association
for the Study of Pain), the International Network for Orofacial Pain & Related disorders Methodology
(INfORM) of the IADR (International Association for Dental Research), the American Academy
of Orofacial Pain (AAOP) and the International Headache Society (IHS). Accordingly, several
professionals, including dentists, neurologists, and psychologists, worked together during a few
years to propose a new classication system that would be helpful in the practice of all health
professionals. Thereby, the “International Classication of Orofacial Pain” -version 1.0 Beta, has
emerged.
8
Daniela Aparecida de Godoi
Gonçalves
daniela.g.goncalves@unesp.br
Edited by
Mario Fernando Prieto Peres
29
ASAA
Conti PCR, Barbosa JS, Bonjardim LR, Gonçalves DAG.
The new pathways of orofacial pain: the just released “International Classification of Orofacial Pain - First edition” (icop)
This document represents a signicant improvement for all
professionals involved in the diagnosis and treatment of OFP
and associated morbidities. It aims to increase the integration
among all these specialists in research and clinical settings,
hospitals, and other health services. It also must be incorpo-
rated into ICD-11, representing the recognition of chronic
orofacial pain as a public health problem to be considered
and controlled.
ICOP has a format already established by neurology through
ICHD and embraces the pain from dental and associated
structures, which are the most prevalent types of OFP and
are not considered in the other classication systems. It also
includes the Temporomandibular Disorders (TMD), based on
the well-known DC/TMD, besides the disorders involving inju-
ries of the cranial nerves, facial manifestations similar to the
primary headaches, as well as facial and oral idiopathic pain.
It is well known that some primary headaches may include
facial manifestations during the pain phase. However, some
of them may manifest exclusively in the face, and sometimes,
in the teeth.
9
Although rare, such conditions represent a major
challenge for all of us. They are also listed in the new ICOP,
which may improve our research opportunities, understanding
leading to a more scientic clinical practice.
As aforementioned, there are many similarities, interests, and
intersections between Dentistry, Neurology, Psychology, and
other areas regarding the recognition and integrated treat-
ment of patients with OFP and chronic headaches. The kickoff
for the ICOP translation into Portuguese has already been
given, and we hope to make it available soon. Thus, we invite
everyone to use, interact, and discuss these new pathways
of the OFP. Our patients who has endlessly and desperately
looking for proper diagnosis and treatments to alleviate their
suering will be the most beneted and thankful. And perhaps,
cases like Mrs. Maria’s may become increasingly rare...
References
1. May A. Facial Pain is coming home. Cephalagia. 2020; 40:
227-228.
2. Ferreira MP, Waisberg CB, Conti PCR, et al. Mobility of the
upper cervical spine and muscle performance of the deep exors
in women with temporomandibular disorders. J Oral Rehabil.
2019; 46: 1177-1184.
3. Costa YM, Conti PC, de Faria FA, et al. Temporomandibular
disorders and painful comorbidities: clinical association and
underlying mechanisms. Oral Surg Oral Med Oral Pathol Oral
Radiol. 2017; 12: 288-297.
4. Conti PC, Costa YM, Gonçalves DA, et al. Headaches and
myofascial temporomandibular disorders: overlapping entities,
separate managements? J Oral Rehabil. 2016; 43: 702-15
5. May A, Svensson P. One nerve, three divisions, two professions
and nearly no crosstalk? Cephalalgia. 2017; 37: 603. https://
doi.org/10.1177/0333102417704605
6. Headache Classication Committee of the International Hea-
dache Society. The International Classication of Headache
Disorders. 3rd ed. Cephalalgia. 2018; 38: 1 –211.
7. Schiman E, Ohrbach R, Truelove E, et al. Diagnostic Criteria
for Temporomandibular Disorders (DC/TMD) for Clinical and
Research Applications: of the International RDC/TMD Consor-
tium Network and Orofacial Pain Special Interest Group. J Oral
Facial Pain Headache. 2014; 28: 6-27.
8. The ICOP classication committee. International Classication of
Orofacial Pain. Cephalalgia. 2020; 40: 1 29–221.
9. Ziegeler C , May A. Facial presentations of migraine, TACs,
and other paroxysmal facial pain syndromes. Neurology. 2019;
93: e1138.
Headache Medicine 2020, 11(2):30-31 ISSN 2178-7468, e-ISSN 2763-6178
30
ASAA
DOI: 10.48208/HeadacheMed.2020.9
Headache Medicine
© Copyright 2020
Clinical Correspondence
Management of chronic orofacial pain in pandemic of COVID-19
Wagner Hummig
1
Bianca Lopes Cavalcante-Leão
2
José Stechman-Neto
2
1
Instituto de Neurologia de Curitiba, Setor de Cefaleia e Dor Orofacial (SCEDOF), Curitiba, Paraná, Brazil.
2
Universidade Tuiuti do Paraná, Curso de Odontologia, Curitiba, Paraná, Brazil.
COVID-19 whose etiological factor is the SARS-CoV-2,is a new disease that plagues humanity
and brings with it a real threat to physical integrity and profound repercussions on the individual’s
mental health, especially in the face of doubts and uncertainties of the future.
1
Global governments are adopting social detachment and isolation as measures in order to mitigate
this pandemic. This tactic has revealed an exacerbation of important psychiatric disorders, such
as: anxiety,depression and phobias to the most vulnerable groups.
2
The impact of these protective measures were studied by Wang et al and coworkers
3
during the
initial phase of the COVID-19 outbreak in China, and revealed that 53.8% of respondents rated
the psychological impact of the outbreak as moderate or severe; 16.5% reported moderate to
severe depressive symptoms; 28.8% reported moderate to severe anxiety symptoms; and 8.1%
reported moderate to severe stress levels.
3
It is already known that there is a bidirectional relationship between chronic orofacial pain and psy-
chosocial conditions and/or psychiatric disorders, forming a two-way street, where neural markers
for fear and anxiety show the existence of an exacerbation process of painful symptoms
4
, being
itself social isolation and mitigation methods the possible catalysts of pain events.
It is estimated that chronic orofacial pain (COP) affects 7% of the population
4
, a vulnerable group
that is in social connement and at the mercy of television news and social media that evoke fear
and chaos in the face of the unknown.
The Brazilian government, after the World Health Organization (WHO) decreed a pandemic by
COVID-19, considered that only activities called urgency/emergency should be attended to, and
this caused all elective appointments to be canceled.
Most of the patients with COP who were seen on an outpatient basis at the Chronic Pain Services
(CPS) were considered non-urgent. Thus, in the face of this pandemic scenario, it is important to
note that care for patients with chronic pain is extremely relevant to the individual’s quality and
well-being, in addition to the fact that a large part of this group presents psychosocial changes
as comorbidities in which the possible interruption pharmacological treatment can exacerbate
such problems.
In order to assist the patient with COP in a complete and safe way, we encourage the use of
telemedicine and online prescriptions with digital certication, and face-to-face assistance in
selected urgent cases is recommended.
We consider this moment, that humanity is passing through, unique and with a great oppor-
tunity to implement and execute new clinical care tools, developing interpersonal and virtual
skills.
Wagner Hummig
waghum@hotmail.com
Edited by
Mario Fernando Prieto Peres
31
ASAA
Hummig W, Leão BLC, Neto JS.
Management of chronic orofacial pain in pandemic of COVID-19
References
1. Holmes EA, O’Connor RC, Perry VH, et al. Multidisciplinary
research priorities for the COVID-19 pandemic: a call for action
for mental health science. Lancet Psychiatry. 2020; pii: S2215-
0366(20)30168-1. doi10.1016 S2215-0366(20)30168-1.
[Epub ahead of print] Review.
2. Ho CS, Chee CY, Ho RC. Mental Health Strategies to Combat
the Psychological Impact of COVID-19 Beyond Paranoia and
Panic. Ann Acad Med Singapore. 2020 ; 49: 155-160.
3. Wang C, Pan R, Wan X, et al. Immediate psychological res-
ponses and associated factors during the initial stage of the
2019 coronavirus disease (COVID-19) epidemic among the
general population in China. Int J Environ Res Public Health.
2020; 17: 1729.
4. Zakrzewska JM. Multi-dimensionality of chronic pain of the
oral cavity and face. J Headache Pain. 2013; 14: 37. doi:
10.1186/1129-2377-14-37.
Headache Medicine 2020, 11(2):32-34 ISSN 2178-7468, e-ISSN 2763-6178
32
ASAA
DOI: 10.48208/HeadacheMed.2020.10
Headache Medicine
© Copyright 2020
Clinical Correspondence
Vessel wall imaging for diagnosis and follow-up of basilar artery
reversible cerebral vasoconstriction syndrome (RCVS)
Matheus Kahakura Franco Pedro Paulo Sérgio Faro Santos Bruno Augusto Telles
Department of Interventional Neuroradiology, Instituto de Neurologia de Curitiba, Curitiba, Paraná, Brazil.
Abstract
Reversible Cerebral Vasoconstriction Syndrome (RCVS) is a clinical and radiological syndrome
that is primarily dened by thunderclap headache, with or without further neurological decits,
and segmental intracranial vasoconstriction that resolves within three months. The current no-
menclature was only established in 2007, but it has been known with diferent names for over
fty years. The pathophysiology, while still not completely understood, seems to point towards
a disease based on abnormalities of vascular tonus without structural inammation. It is clear,
however, that patients with RCVS often have triggers, especially drugs or other vasoactive subs-
tances. Distinguishing this entity from others, especially subarachnoid hemorrhage and arterial
dissection, is extremely important, given the particular prognosis and need of immediate treatment
of each disease. The preferred imaging method has long been the angiography; however, new
magnetic resonance imaging (MRI) such as vessel wall imaging have allowed for non-invasive
diagnosis and follow-up. The authors report a case in which MRI was used in a patient with
basilar artery RCVS and present a literature review.
Matheus Kahakura Franco Pedro
matheuskfpedro@hotmail.com
Edited by
Marcelo Moraes Valença
Mario Fernando Prieto Peres
Received: April 2, 2020.
Accepted: April 27, 2020.
Keywords:
Vasoconstriction
Magnetic Resonance Imaging
Vascular Headaches
33
ASAA
Pedro MKF, Santos PSF, Telles BA.
Vessel wall imaging for diagnosis and follow-up of basilar artery reversible cerebral vasoconstriction syndrome (RCVS)
Introduction
R
eversible Cerebral Vasoconstriction Syndrome (RCVS) is a cli-
nical and radiological nosologic entity that is primarily dened
by hyperacute onset of thunderclap headache and segmental
intracranial vasoconstriction that resolves within three months, with
or without further neurological decits
1
. Though digital subtraction
angiography has long been the standard work-up exam, the role
of magnetic resonance imaging, particularly after the renement of
vessel wall imaging, has substantially expanded
2,3
.
Case Report
T h e a u t h o r s p r e s e n t t h e c a s e o f a 3 1 y e a r s - o l d C a u c a s i a n
female with no previous history of headache, who presented to the
ER due to a sudden, thunderclap occipital headache while per-
forming strenuous physical activity (cross-t). No other neurolog-
ical symptoms or decits took place. She underwent an arterial
angiotomography which suggested vascular lumen reduction of
the basilar artery. Her laboratory work-up showed no noteworthy
alteration. Afterwards, she underwent brain MRI with vessel wall
imaging on a 3-Tesla machine, which conrmed a stenosis inferior
to 50% on the middle section of the basilar artery along with gad-
olinium enhancement towards the vertebro-basilar junction (Figure
1). Her headache receded without need for medication and she
was released for outpatient follow-up. After three months without
any symptom, another brain MRI with vessel wall imaging on the
same machine was performed, showing near complete resolution
of the stenosis, as well no further enhancement on the basilar artery
after gadolinium injection (Figure 2). On the same outpatient visit,
the patient reported regular use of a performance enhancement
compound including caffeine and bupropion.
Figure 1. Left - coronal view of reconstruction of arterial angioMRI on a 3
Tesla magnet conrming stenosis of the middle third of the basilar artery
(arrow); right - coronal slice of vessel wall imaging after gadolinium in-
jection, with impregnation of the basilar artery near the vertebro-basilar
junction (arrow).
Figure 2. Left - coronal view of reconstruction of control arterial angioMRI
after twelve weeks showing near complete resolution of the stenosis; right
- coronal slice of control vessel wall imaging after gadolinium injection
showing complete resolution of the gadolinium enhancement by the verte-
bro-basilar junction.
Discussion
Though this nosologic entity was rst reported over fty years
ago, its most consistent description came in 1988 by Call and
Fleming
4
; Calabrese proposed the current nomenclature in 2007
and established formal diagnostic criteria, thus unifying the many
“diseases” with similar clinical and radiologic features under a single
term.
5
No precise data on incidence is currently available, though
it doesn’t appear to be particularly rare
6
. The pathophysiology
remains a mystery, although alteration on vascular tone leading
to vasoconstriction seems to be the main mechanism
1
, which
is supported by the lack of vascular or perivascular histological
abnormalities on biopsy of brain tissue. The role of sympathomimetic
vasoactive substances is well known, with caffeine and bupropion
having been previously recognized as triggers
7,8
. The differential
diagnosis includes subarachnoid hemorrhage, cervical arterial
dissection, and primary angiitis of the central nervous system; as
such, correct differentiation between these entities is of paramount
importance, given the different mechanisms and treatments. In
terms of prognosis, the disease is monophasic and typically self-
limiting, with the criteria establishing resolution within three months.
Conclusion
This case illustrates the typical course of the disease and the need
to recognize it and differentiate from other vascular diseases of the
central nervous system. The use of MRI with vessel wall imaging
allows for both accurate diagnosis and follow-up in a non-invasive
manner.
34
ASAA
Pedro MKF, Santos PSF, Telles BA.
Vessel wall imaging for diagnosis and follow-up of basilar artery reversible cerebral vasoconstriction syndrome (RCVS)
References
1. Miller TR, Shivashankar R, Mossa-Basha M, et al. Reversi-
ble cerebral vasoconstriction syndrome, part 1: Epidemio-
logy, pathogenesis, and clinical course. Am J Neuroradiol.
2015;368:1392–9.
2. Miller TR, Shivashankar R, Mossa-Basha M, et al. Reversiblece-
rebral vasoconstriction syndrome, part 2: Diagnostic work-up,
imaging evaluation, and differential diagnosis. Am J Neurora-
diol. 2015;369:1580–8.
3. Chen CY, Chen SP, Fuh JL, et al. Vascular wall imaging in
reversible cerebral vasoconstriction syndrome - A 3-T contrast-
enhanced MRI study. J Headache Pain. 2018 Aug 30;191.
4. Call GK, Fleming MC, Sealfon S, et al. Reversible cerebral
segmental vasoconstriction. Stroke. 1988;199:1159–70.
5. Calabrese LH, Dodick DW, Schwedt TJ, et al. Narrative review:
Reversible cerebral vasoconstriction syndromes. Ann Intern Med.
2007;1461:34–44.
6. Ducros A. Reversible cerebral vasoconstriction syndrome. Lancet
Neurol [Internet].2012;1110:906–17. Available from: http://
dx.doi.org/10.1016/S1474-44221270135-7
7. Dakay K, McTaggart RA, Jayaraman M V., et al. Reversible-
cerebral vasoconstriction syndrome presenting as an isolated
primary intraventricular hemorrhage. Chinese Neurosurg J.
2018;41:1–4.
8. Marder CP, Donohue MM, Weinstein JR, et al. Multimodal ima-
ging of reversible cerebral vasoconstriction syndrome: A series
of 6 cases. Am J Neuroradiol. 2012;337:1403–10.
Headache Medicine 2020, 11(2):35-38 ISSN 2178-7468, e-ISSN 2763-6178
35
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DOI: 10.48208/HeadacheMed.2020.11
Headache Medicine
© Copyright 2020
Views and Reviews
Headache in patients with coronavirus disease (Covid-19):
An integrative literature review
Sarah Nilkece Mesquita Araújo Nogueira Bastos
1
Diego Afonso Cardoso Macedo de Sousa
2
Simone Santos e Silva Melo
2
Bárbara Louise Freire Barbosa
3
Larisse Giselle Barbosa Cruz
3
Raimundo Pereira Silva-Néto
4
1
Doctorate in Nursing and Medical Student, Federal University of Delta of Parnaíba
2
Master in Nursing and Medical Student, Federal University of Delta of Parnaíba
3
Medical Student, Federal University of Delta of Parnaíba
4
Doctorate in Neurology and Adjunct Professor of Neurology, Federal University of Delta of Parnaíba, Piauí, Brazil
Abstract
Introduction
The disease caused by the new coronavirus was named by the acronym COVID-19 which
means “COrona VIrus Disease”, while “19” refers to the year 2019, when the rst cases in
Wuhan, China, were identied.
Objective
Our objective was to identify the prevalence of headache and to know its clinical characteristics
in COVID-19 patients, available in the literature.
Methods
Based on a literature search in the major medical databases and using the descriptors “heada-
che and coronavirus”, “headache and 2019-nCoV”, “headache and SARS-CoV-2”, “headache
and coronavirus and 2019-nCoV” and “headache and coronavirus and SARS-CoV-2” we
include articles published between January 2019 and April 2020. We found 94 articles, but
only 13 met the inclusion criteria.
Results
In 13 articles analyzed in this review, a total of 3,105 Chinese patients (51.6% men and
48.4% women) had laboratory diagnoses of COVID-19. In 240 (7.7%) patients, headache
was an associated symptom of COVID-19, but in only 52 (21.7%) of them there was some
information about the characteristics of this headache.
Conclusions
COVID-19 patients have several clinical manifestations, including headache that is nonspecic
with a prevalence of 7.7%.
Sarah Nilkece Mesquita Araújo
Nogueira Bastos
Federal University of Delta of
Parnaíba, Avenida São Sebastião,
2819, Fátima, Parnaíba, PI
64001-020, Brazil. Fone: +55
8699470 -0770.
sarahnilkece@hotmail.com
Received: April 24, 2020.
Accepted: April 27, 2020.
Edited by
Marcelo Moraes Valença
Mario Fernando Prieto Peres
Keywords:
Headache
Coronavirus
SARS virus
36
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Bastos SNMAN, Sousa DACM, Melo SSS, Barbosa BLF, Cruz LGB, Silva-Néto RP
Headache in patients with coronavirus disease (Covid-19): An integrative literature review
Introduction
T
he disease caused by the novel coronavirus (2019-nCoV) was
named by the acronym COVID-19 which means “COrona VIrus
Disease”, while “19” refers to the year 2019, when the rst cases in
Wuhan, China, were identied. The virus that causes this disease,
a beta coronavirus, is called SARS-CoV-2 (severe acute respiratory
syndrome coronavirus 2) and it is the same virus that causes Severe
Acute Respiratory Syndrome (SARS), identied in 2002, and Middle
East Respiratory Syndrome (MERS), identied in 2012. Transmission
of 2019-nCoV from humans to humans has been conrmed in Chi-
na and the USA and occurs mainly with the contact of respiratory
droplets from infected patients
1
.
In December 2019, in China, a novel coronavirus was identied
as the cause of a severe acute respiratory syndrome and received
worldwide attention. It is a new emerging zoonotic agent that results
in a severe syndrome that, in some patients, leads to the need for
intensive respiratory treatment with specialized management in
intensive care units
2
.
In January 2020, the World Health Organization (WHO) declared
the outbreak in China as a public health emergency of international
interest. In March 2020, with the spread of the virus in different
countries, the infection caused by SARS-CoV-2 was considered a
pandemic and called COVID-19. In early April, WHO recorded
more than 1 million cases of patients infected with SARS-CoV-2
worldwide and more than 65,000 deaths caused by the pandemic
worldwide. In Brazil, at the time of writing this manuscript, there are
more than 18,000 cases of infection and more than 1,000 deaths
3
.
According to a Chinese study, the main clinical symptoms of patients
with COVID-19 are fever (88.7%), cough (67.8%), fatigue (38.1%),
sputum production (33.4%), dyspnoea (18.6%), sore throat (13.9%)
and headache (13.6%). Gastrointestinal symptoms, such as diarrhea
(3.8%) and vomiting (5.0%) are less frequent
4
. Elderly and people
with underlying diseases are susceptible to infection and more
predisposed to severe outcomes, which may be associated with
acute respiratory distress syndrome (ARDS) and the cytokine storm
5,6
.
Although headache is one of the clinical manifestations of CO-
VID-19, this symptom is still poorly characterized. In this context, our
objective was to identify the prevalence of headache and to know
its clinical characteristics in a patient with COVID-19, available in
the literature.
Methods
This study was an integrative and retrospective review of the articles This study was an integrative and retrospective review of the articles
on headache as a symptom of COVID-19 published in the last 16 on headache as a symptom of COVID-19 published in the last 16
months. The research was performed in the online databases months. The research was performed in the online databases Litera-Litera-
tura Latino-Americana e do Caribe em Ciências da Saúdetura Latino-Americana e do Caribe em Ciências da Saúde (LiLacs), Scientic (LiLacs), Scientic
Electronic Library Online (SciELO), Chinese National KnowledgeElectronic Library Online (SciELO), Chinese National Knowledge
Infrastructure (CNKI) and Medical Literature and Retrivial System on-Infrastructure (CNKI) and Medical Literature and Retrivial System on-
Line (MEDLINE/PubMed®), from January 2019 to April 2020, given Line (MEDLINE/PubMed®), from January 2019 to April 2020, given
the current status of the pandemic by SARS-Cov-19. We have used the current status of the pandemic by SARS-Cov-19. We have used
the descriptors “headache and coronavirus”, “headache and 2019-the descriptors “headache and coronavirus”, “headache and 2019-
nCoV”, “headache and SARS-CoV-2”, “headache and coronavirus nCoV”, “headache and SARS-CoV-2”, “headache and coronavirus
and 2019-nCoV” and “headache and coronavirus and SARS-CoV-2”.and 2019-nCoV” and “headache and coronavirus and SARS-CoV-2”.
Articles written in all languages were included. Editorials, comments,
letters to the editor, review articles, articles that were not fully avail-
able or those that did not have accurate information were excluded.
To ensure the validity of these articles, the selected studies were
analyzed in detail, by all authors, for the presence of headache in
patients with COVID-19.
In our search, we found a total of 94 articles, but with the elimination
of repeated articles, only 49 remained. After reading the abstracts,
we excluded articles that did not describe headache with associated
symptom (36 articles). Only 13 articles describing case series were
included and made up this review, totaling 3,105 patients (Figure).
Figure. Flowchart of search and selection of studies
Data were analyzed based on demographic and clinical character-
istics and are presented as percentages. The percentage is always
related to the total number of patients whose information was avail-
able for the specic issue.
Results
In 13 articles analyzed in this review, a total of 3,105 Chinese pa-
tients (51.6% men and 48.4% women) had laboratory diagnoses
of COVID-19. In 7.7% (240/3,105) patients, headache was an
associated symptom of COVID-19, but in only 21.7% (52/240) of
them there was some information about the characteristics of this
headache, as shown in Table 1.
Discussion
Coronaviruses are a large class of viruses that exist widely in nature
and the newly discovered 2019-nCoV is the seventh coronavirus
37
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Bastos SNMAN, Sousa DACM, Melo SSS, Barbosa BLF, Cruz LGB, Silva-Néto RP
Headache in patients with coronavirus disease (Covid-19): An integrative literature review
currently known to infect humans and also responsible for the current
pandemic that started in China
20
.
To the best of our knowledge, this is the rst study to assess headache
characteristics in patients with COVID-19. We found that headache
was an initial symptom of the disease in 3,105 pacient with this
disease. Its prevalence has been reported in most studies, but its
semiological characteristics have rarely been addressed.
According to the International Classication of Headache Disorders,
3rd edition (ICHD-3)
21
, headache attributed to systemic viral infection
is characterized by its temporal relation to onset of viral infection and
signicant improvement or resolution in parallel with the improvement
or resolution of systemic viral infection. Headache is usually diffuse
and of moderate to severe intensity (Table 2).
Table 2. Diagnostic criteria of ICHD-3 for headache attributed to systemic
viral infection
A. Headache of any duration fullling criterion C
B. Both of the following:
1. systemic viral infection has been diagnosed
2. no evidence of meningitic or encephalitic involvement
C. Evidence of causation demonstrated by at least two of the following:
1. headache has developed in temporal relation to onset of the systemic viral infection
2.
headache has signicantly worsened in parallel with worsening of the systemic
viral infection
3.
headache has signicantly improved or resolved in parallel with improvement in
or resolution of the systemic viral infection
4. headache has either or both of the following characteristics:
a. diffuse pain
b. moderate or severe intensity
D. Not better accounted for by another ICHD-3 diagnosis
Possibly, the neuroinvasive predisposition characteristic of corono-
viruses is an explanation for patients with COVID-19 to develop
headache. Genomic analysis shows that SARS-CoV-2 shares a
highly homologous sequence with SARS-CoV-1 and MERS-CoV, in
addition to a similarity of receptors in human cells. This can affect
the respiratory tract and also the central nervous system, especially
the thalamus and brain stem
20
.
Headache was observed in patients of all age groups, both in
adults
7-13
, as in children
6
. It is important to note that headache is a
characteristic symptom of pneumonia caused by coronavirus and
not exclusive to COVID-19, and does not behave as a differential
symptom between these viral infections
13
.
In the studied cases of COVID-19, headache was usually associated
with other typical symptoms of the disease, such as gastrointestinal
symptoms. When the patient experienced nausea, vomiting and
diarrhea, headache was more frequent, probably due to the higher
fever and hydroelectrolytic imbalance
17
.
We found in the 13 studies a prevalence of headache equal to 7.7%
(240 out of 3,105 patients), ranging from 2.0% to 53.3%. A factor
that may determine a higher prevalence of headache in COVID-19
patients is pneumonia, considered a predictive factor for severe
subtypes of the disease. We observed that in patients with changes
in pulmonary radiological images there was a higher prevalence of
headache when compared to patients with normal exams
19
.
The symptoms of COVID-19 are nonspecic, making the initial clinical
presentation indistinguishable from other viral respiratory diseases.
Initially, there is a predominance of systemic manifestations, such
as fever, fatigue, myalgia and asthenia
10
. However, the headache
Table 1. Clinical characteristics of headache in 3,105 patients with coronavirus disease 2019 (Covid-19) in the period from January 2019 to April 2020
in China
Published studies Number of patients
Age (years)
Sex
Headache prevalence
Clinical characteristics
Average Variation n %
Tian et al., 2020
7
262 47. 5 1–94 M=127; F=135 17 6.5
Mild to moderate intensity in 93.5% of
patients and it appeared at the beginning
of the disease
Xu et.al., 2020
8
62 41.0 19-65 M=35; F=27 21 34.0
It lasted ≥10 days in 71.4% of patients and
it appeared at the beginning of the disease
Huang et. al., 2020
9
41 49.0 18-65 M=30; F=11 3 7.3 NR
Liu et.al., 2020
10
30 35.0±8 21-59 M=10; F=20 16 53.3 It appeared at the beginning of the disease
Cheng et.al., 2020
11
1,078 46.0 0.25-94 M=573; F=505 22 2.0 NR
Wang et.al., 2020
12
31 7. 1 0.5-17 M=15; F=16 3 9.7 NR
Li et.al., 2020
13
54 51.5 25-82 M=22; F=32 ? Rare NR
Chen et al., 2020
14
99 55.5±13.1 21-82 M=67; F=32 8 8.0 NR
Liu et al., 2020
15
137 55.0±16.0 20-82 M=61; F=76 13 9.5 NR
Mi et al., 2020
16
10 68.4±18.5 34-87 M=2; F=8 1 10.0 NR
Jin et al., 2020
17
651 NR NR M=331; F=320 67 10.3
It was more frequent in patients with
gastrointestinal symptoms (21.6% versus
8.8%)
Ding et al., 2020
18
5 50.2±9.8 39-66 M=2; F=3 2 40.0 NR
Zhang et al., 2020
19
645 NR NR M=328; F=317 67 10.4
It was more frequent in patients with abnormal
pulmonary imaging ndings (11.3% versus
2.8%)
Legend: M – male; F – female; NR – not reported.
38
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Bastos SNMAN, Sousa DACM, Melo SSS, Barbosa BLF, Cruz LGB, Silva-Néto RP
Headache in patients with coronavirus disease (Covid-19): An integrative literature review
that can also appear at the beginning of the disease should not be
neglected, but contribute to the diagnosis, especially in those patients
with a positive epidemiological history.
This review had some limitations. All patients were from China,
so some articles found were written in Chinese and needed to
be translated
10 -13
. In addition, as it is pandemic, new studies were
published almost daily and described the headache incompletely.
However, we believe that these ndings are consistent with the
clinical manifestations of this disease.
Concl usion
COVID-19 patients have several clinical manifestations, including
headache that is nonspecic with a prevalence of 7.7%.
Funding:
This research received no specic grant from any funding
agency in the public, commercial, or not-for-prot sectors.
Conflict of Interest:
There is no conict of interest.
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39
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DOI: 10.48208/HeadacheMed.2020.12
Headache Medicine
© Copyright 2020
Original
Main symptoms associated with the catastrophizing in women with
bromyalgia and migraine
Amanda de Oliveira Freire Barros
1
Manuella Moraes Monteiro Barbosa Barros
2
Reydiane Rodrigues
Santana
2
Débora Wanderley
1
Angélica da Silva Tenório
1
Daniella Araújo de Oliveira
1
1
Physical Therapy Department, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil.
2
Post-graduation Program in Neuropsychiatry and Behavioral Sciences, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil.
Abstract
Objective
To evaluate the main symptoms associated with catastrophizing in women with bromyalgia
and migraine.
Methods
We conducted an observational study with 26 women diagnosed with both bromyalgia
and migraine, aged between 30 and 60 yrs (46±8 yrs). The Pain Catastrophizing Scale was
applied as a cut-off point of 30, dividing the volunteers into groups with (n=18) and without
catastrophizing (n=8). We assessed the quality of sleep (Pittsburgh Sleep Quality Index), the
presence of depression and anxiety (Beck's Depression and Anxiety Inventories), the quality
of life perception (Fibromyalgia Impact Questionnaire-revised), the disability due to migraine
(Migraine Disability Assessment), and the level of physical activity (International Physical
Activity Questionnaire).
Results
The time of bromyalgia did not differ (p=0.80) between the group with (8.54±4.88 yrs) and
without catastrophizing (10.04±3.47 yrs). The Fibromyalgia Impact Questionnaire-revised
scores were signicantly higher (p=0.01) among women with catastrophizing (78.0±12.6)
than those without (56.6±22.3). There was no difference between the groups (p>0.05) in
relation to the other outcomes evaluated.
Conclusion
The presence of catastrophizing in women with bromyalgia and migraine are associated
with a worse perception of quality of life.
Manuella Moraes Monteiro Barbosa
Barros
Departamento de Fisioterapia, Laboratório
de Aprendizagem e Controle Motor, Uni-
versidade Federal de Pernambuco.
Av. Jornalista Aníbal Fernandes, 173 - Ci-
dade Universitária, Recife – Pernambuco.
Phone number: +55 81 2126-8492; +55
81 2126-8937.
manu_mmbb@hotmail.com
Received: May 27, 2020.
Accepted: June 5, 2020.
Edited by
Marcelo Moraes Valença
Keywords:
Fibromyalgia
Migraine disorders
Catastrophization
Sleep
Depression
Anxiety Disorders
Quality of life
Disability
Exercise
40
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Freire Barros AOF, Barbosa Barros MMMB, Santana RR, Wanderley D, Tenório AS, Oliveira DA
Main symptoms associated to the catastrophizing in women with fibromyalgia and migraine
Introduction
F
ibromyalgia is a a broad-spectrum disease that has an average
worldwide prevalence of 4.1% in women.
1
Over the years, the
classication of bromyalgia by the American College of Rheuma-
tology has undergone improvements, ceasing to be characterized
only by chronic widespread pain and the presence of tender points
in anatomically specic regions, known as tender points.
2
Currently
the classication takes into account the symptoms associated with
this disease.
3,4
The etiology of bromyalgia is not yet fully understood, but several The etiology of bromyalgia is not yet fully understood, but several
factors contribute to its development, including dysfunctions of the factors contribute to its development, including dysfunctions of the
central and autonomic nervous system, neuroendocrine disorders, central and autonomic nervous system, neuroendocrine disorders,
regulation of neurotransmitters, changes in the hypothalamic-pitui-regulation of neurotransmitters, changes in the hypothalamic-pitui-
tary axis, and exposure to stressors.tary axis, and exposure to stressors.
5,65,6
Sensory stimuli transmitted Sensory stimuli transmitted
to the central nervous system are processed in an altered manner, to the central nervous system are processed in an altered manner,
resulting in generalized pain and changes in the painful threshold.resulting in generalized pain and changes in the painful threshold.
6,76,7
Fibromyalgia presents a complex picture that includes numerous Fibromyalgia presents a complex picture that includes numerous
symptoms such as depression, anxiety, headache, cognitive, and symptoms such as depression, anxiety, headache, cognitive, and
sleep disorders and negative impacts on quality of life.sleep disorders and negative impacts on quality of life.
88
In this In this
context, migraine is a relevant symptom and represents the type of context, migraine is a relevant symptom and represents the type of
headache most found in patients with bromyalgia, whose preva-headache most found in patients with bromyalgia, whose preva-
lence varies between 45% and 80%.lence varies between 45% and 80%.
99
In addition, the cognitive and emotional aspects related to the pain In addition, the cognitive and emotional aspects related to the pain
experienced by bromyalgia patients involve a catastrophizing experienced by bromyalgia patients involve a catastrophizing
thought, recognized as a negative state in the face of a painful thought, recognized as a negative state in the face of a painful
experience.experience.
1010
Depression is part of the factors that interfere with the Depression is part of the factors that interfere with the
painful perception of bromyalgia, but unlike catastrophization, it painful perception of bromyalgia, but unlike catastrophization, it
refers to sadness, discouragement, lack of interest, and unwilling-refers to sadness, discouragement, lack of interest, and unwilling-
ness to perform activities that previously gave you pleasure. In ness to perform activities that previously gave you pleasure. In
turn, catastrophizing is specically related to thoughts and feelings turn, catastrophizing is specically related to thoughts and feelings
linked to the painful situation, such as fear, worry, inability to divert linked to the painful situation, such as fear, worry, inability to divert
attention, and deal with pain.attention, and deal with pain.
1111
There is still a lack of studies in the literatureThere is still a lack of studies in the literature
12–1512–15
evaluating the pre- evaluating the pre-
sence of catastrophization however, it is known that this symptom sence of catastrophization however, it is known that this symptom
is related to chronic pain, feelings of incapacity,is related to chronic pain, feelings of incapacity,
1212
more severe de- more severe de-
grees of depression and anxiety, more migraine attacks,grees of depression and anxiety, more migraine attacks,
1313
exercise exercise
intoleranceintolerance
1414
and sleep disorders and sleep disorders
1515
. Also, catastrophization can . Also, catastrophization can
worsen the perception of these symptoms, which are also present worsen the perception of these symptoms, which are also present
in bromyalgia and migraine, making it necessary to evaluate them in bromyalgia and migraine, making it necessary to evaluate them
to guide the treatment of patients.to guide the treatment of patients.
Despite the above, the catastrophization of pain has not yet been Despite the above, the catastrophization of pain has not yet been
analyzed in women with associated bromyalgia and migraine. analyzed in women with associated bromyalgia and migraine.
Thus, the present study aimed to assess the main symptoms as-Thus, the present study aimed to assess the main symptoms as-
sociated with catastrophization in women with bromyalgia and sociated with catastrophization in women with bromyalgia and
migraine.migraine.
Methods
This is an observational, cross-sectional study. The research was This is an observational, cross-sectional study. The research was
carried out from March to November 2015, at the school clinic of the carried out from March to November 2015, at the school clinic of the
Physiotherapy Department of the Federal University of Pernambuco Physiotherapy Department of the Federal University of Pernambuco
(UFPE), Recife, Pernambuco, Brazil. The research was approved by (UFPE), Recife, Pernambuco, Brazil. The research was approved by
the Human Research Ethics Committee of the Health Sciences Center the Human Research Ethics Committee of the Health Sciences Center
of UFPE (CAAE 37052114.3.0000.5208). All participants signed of UFPE (CAAE 37052114.3.0000.5208). All participants signed
an informed consent form. an informed consent form.
Sample
The participants were recruited from the list of patients seen at the The participants were recruited from the list of patients seen at the
bromyalgia outpatient clinic of the rheumatology sector at Hospital bromyalgia outpatient clinic of the rheumatology sector at Hospital
das Clínicas, UFPE. Patients who met the following inclusion criteria das Clínicas, UFPE. Patients who met the following inclusion criteria
were selected: 1. having a diagnosis of bromyalgia and migraine, were selected: 1. having a diagnosis of bromyalgia and migraine,
simultaneously; and 2. age between 30 and 60 years. Pregnant wo-simultaneously; and 2. age between 30 and 60 years. Pregnant wo-
men were excluded due to hormonal changes and their relationship men were excluded due to hormonal changes and their relationship
with the presence of migraine, and obese participants.with the presence of migraine, and obese participants.
Procedures for data collection
By phone, the participants were invited to participate in the survey By phone, the participants were invited to participate in the survey
and asked about the eligibility criteria. In the initial evaluation, a and asked about the eligibility criteria. In the initial evaluation, a
semi-structured questionnaire was applied to obtain sociodemogra-semi-structured questionnaire was applied to obtain sociodemogra-
phic and clinical data. Then, they went through the evaluation of phic and clinical data. Then, they went through the evaluation of
a neurologist who diagnosed the type of headache, based on the a neurologist who diagnosed the type of headache, based on the
criteria of the International Classication of Headache Disorders, criteria of the International Classication of Headache Disorders,
33
rdrd
edition - beta version. edition - beta version.
1616
The presence of catastrophizing was assessed using the pain catas-The presence of catastrophizing was assessed using the pain catas-
trophizing scale. This instrument, validated and adapted to Portugue-trophizing scale. This instrument, validated and adapted to Portugue-
se (Cronbach alpha= 0.91), assesses the thoughts and feelings of the se (Cronbach alpha= 0.91), assesses the thoughts and feelings of the
volunteers in the face of pain experience and consists of 13 items, volunteers in the face of pain experience and consists of 13 items,
whose score ranges from 0-4, with 52 being the maximum score.whose score ranges from 0-4, with 52 being the maximum score.
1717
The global score of 30 indicates that the individual has clinically The global score of 30 indicates that the individual has clinically
relevant levels of catastrophization.relevant levels of catastrophization.
1818
The sample was then divided The sample was then divided
into two groups, one with catastrophization and one without.into two groups, one with catastrophization and one without.
Outcome Assessment
The sleep quality outcome was assessed using the Pittsburgh Sleep The sleep quality outcome was assessed using the Pittsburgh Sleep
Quality Index (PSQI), validated and adapted for the Brazilian po-Quality Index (PSQI), validated and adapted for the Brazilian po-
pulation, with high reliability (Cronbach α= 0.82). The PSQI has 19 pulation, with high reliability (Cronbach α= 0.82). The PSQI has 19
questions ranging from 0-3 and is divided into seven components questions ranging from 0-3 and is divided into seven components
related to sleep: subjective quality, latency, duration, habitual ef-related to sleep: subjective quality, latency, duration, habitual ef-
ciency, changes and the use of sleep medications, and daytime ciency, changes and the use of sleep medications, and daytime
dysfunction. The total score was given by the sum of all components, dysfunction. The total score was given by the sum of all components,
reaching a maximum of 21 points.reaching a maximum of 21 points.
1919
The depression outcome was assessed by Beck Depression Inventory The depression outcome was assessed by Beck Depression Inventory
(BDI), an instrument consisting of 21 multiple-choice questions ran-(BDI), an instrument consisting of 21 multiple-choice questions ran-
ging from 0-3 points, reaching a maximum total score of 63. From ging from 0-3 points, reaching a maximum total score of 63. From
the score obtained, the participants were classied as absence (0-9 the score obtained, the participants were classied as absence (0-9
41
ASAA
Freire Barros AOF, Barbosa Barros MMMB, Santana RR, Wanderley D, Tenório AS, Oliveira DA
Main symptoms associated to the catastrophizing in women with fibromyalgia and migraine
points), mild depression (10-18 points), moderate (19-29 points), and points), mild depression (10-18 points), moderate (19-29 points), and
severe (>30 points). BDI is validated and adapted for the Brazilian severe (>30 points). BDI is validated and adapted for the Brazilian
population (Cronbach α= 0.81).population (Cronbach α= 0.81).
20,2120,21
Anxiety was assessed by the Anxiety was assessed by the
Beck Anxiety Inventory (BAI), which is also validated and adapted for Beck Anxiety Inventory (BAI), which is also validated and adapted for
the Brazilian population. Composed of 23 multiple-choice questions the Brazilian population. Composed of 23 multiple-choice questions
(ranges from 0-4), the total score was achieved by the sum of all (ranges from 0-4), the total score was achieved by the sum of all
items, reaching a maximum of 63 points, generating the classication: items, reaching a maximum of 63 points, generating the classication:
minimal anxiety (0-10 points), mild (11-19 points), moderate (20-30 minimal anxiety (0-10 points), mild (11-19 points), moderate (20-30
points) and severe (> 31 points).points) and severe (> 31 points).
2222
The impact of bromyalgia on the quality of life of the volunteers The impact of bromyalgia on the quality of life of the volunteers
was measured by Fibromyalgia Impact Questionnaire-Revised (FI-was measured by Fibromyalgia Impact Questionnaire-Revised (FI-
Q-R), with validation and adaptation for the Brazilian population Q-R), with validation and adaptation for the Brazilian population
(Cronbach's alpha of 0.96). The instrument contains 21 questions (Cronbach's alpha of 0.96). The instrument contains 21 questions
that can vary from 0-10, with 100 being the maximum score. The that can vary from 0-10, with 100 being the maximum score. The
FIQ-R is divided into three domains: function, global impact, and FIQ-R is divided into three domains: function, global impact, and
symptom intensity. The nal score was given by the sum of these and symptom intensity. The nal score was given by the sum of these and
the higher, the greater the impact of bromyalgia on quality of life. the higher, the greater the impact of bromyalgia on quality of life.
The level of pain resulting from bromyalgia was assessed using this The level of pain resulting from bromyalgia was assessed using this
questionnaire, which presents a specic scale related to pain, whose questionnaire, which presents a specic scale related to pain, whose
domain of symptom intensity varies from zero to ten.domain of symptom intensity varies from zero to ten.
2323
Migraine disability was assessed by the Migraine Disability As-Migraine disability was assessed by the Migraine Disability As-
sessment Test (MIDAS). From the sum of the scores, the volunteers sessment Test (MIDAS). From the sum of the scores, the volunteers
were classied as minimal disability (0-5 points), mild (6-10 points), were classied as minimal disability (0-5 points), mild (6-10 points),
moderate (11-20 points), and severe (> 20 points).moderate (11-20 points), and severe (> 20 points).
2424
The level of physical activity was veried by the International Physi-The level of physical activity was veried by the International Physi-
cal Activity Questionnaire (IPAQ), in its short version. It consists of cal Activity Questionnaire (IPAQ), in its short version. It consists of
four questions containing two sub-items that allowed measuring the four questions containing two sub-items that allowed measuring the
frequency, duration of activities, intensity during the week, and also frequency, duration of activities, intensity during the week, and also
the periods of inactivity of the participants. Among the categories the periods of inactivity of the participants. Among the categories
provided by IPAQ, it was possible to classify the volunteers as very provided by IPAQ, it was possible to classify the volunteers as very
active, active, irregularly active and sedentary, through data related active, active, irregularly active and sedentary, through data related
to the frequency and duration reported by them.to the frequency and duration reported by them.
2525
Statistical Analysis
The data were analyzed using the Statistical Package for Social The data were analyzed using the Statistical Package for Social
Sciences (SPSS) version 22.0. A descriptive analysis was performed Sciences (SPSS) version 22.0. A descriptive analysis was performed
with a calculation of the standard deviation for the averages of the with a calculation of the standard deviation for the averages of the
measurement variables and frequency of the other variables that measurement variables and frequency of the other variables that
characterize the sample. To test the normality of the variables, the characterize the sample. To test the normality of the variables, the
Shapiro-Wilk test was used. The Student t-test was used for variables Shapiro-Wilk test was used. The Student t-test was used for variables
with normal distribution and the Mann-Whitney test for variables with with normal distribution and the Mann-Whitney test for variables with
non-normal distribution. In the analysis of categorical variables, the non-normal distribution. In the analysis of categorical variables, the
chi-square test (chi-square test (cc
22
) was applied. The level of signicance considered ) was applied. The level of signicance considered
was p<0.05.was p<0.05.
Results
Of the 29 women evaluated, one was excluded for having another
type of headache and two for not completing the questionnaires. The
general characterization of the sample of the 26 included participants
(45.9 ± 7.9 years) and the clinical level of pain catastrophization
is shown in Table 1. There was no difference between the groups
regarding the time of diagnosis of bromyalgia.
Table 2 shows the characteristics of the sample in relation to the asso-
ciated symptoms. The presence of migraines had a serious impact on
the daily and professional life of half of the sample. When observing
the psychological characteristics of the studied population, it was
possible to identify that 76.93% of the volunteers had a degree of
depression from mild to moderate and 65.39% reported a moderate
to severe degree of anxiety.
Fibromyalgia Impact Questionnaire-Revised scores were signicantly
higher (p = 0.01) among women with catastrophization (78.0 ± 12.6)
than those without (56.6 ± 22.3). There was no difference between
groups (p> 0.05) in relation to the other outcomes assessed (Table 2).
Discussion
In the present study, only the perception of quality of life was associ-
ated with the presence of catastrophization in women with bromy-
algia and migraine. Despite the lack of association in relation to the
other outcomes studied, the results of our study are of great clinical
relevance, as they demonstrate that catastrophization can worsen
the perception of function, global impact, and intensity of symptoms
in patients with bromyalgia and migraine, generating negative
repercussions in the quality of life of this population. In addition, this
is a pioneering study, since the catastrophizing of pain has not yet
been analyzed in women with associated bromyalgia and migraine.
In the present study, more than half of women with bromyalgia and
migraine exhibited clinically relevant levels of pain catastrophization,
differing from the results of another study
13
, in which only a quarter of
the sample, composed of migrant women, presented this symptom. In
this way, it is possible that the presence of associated bromyalgia
and migraine, which share similar pathophysiological pathways
7,10
,
has contributed to greater susceptibility to pain, potentiating changes
in central processing and generating greater impact on catastroph-
izing symptoms.
Another relevant aspect, frequently cited in the literature, is that cata-
strophization provides a more intense experience of pain in patients
with chronic pain.
14
For this reason, women with the presence of
associated bromyalgia and migraine were expected to experience
greater pain intensity and changes in pain threshold.
6,7
Despite this,
in our study, no great variations were observed in the intensity of
pain due to migraine and bromyalgia.
On the other hand, our study showed that bromyalgia and migraine
women with catastrophization had greater impacts on the perception
of quality of life. It is known that both bromyalgia
8
and migraine
26
promote negative impacts on patients’ quality of life. Thus, the associ-
42
ASAA
Freire Barros AOF, Barbosa Barros MMMB, Santana RR, Wanderley D, Tenório AS, Oliveira DA
Main symptoms associated to the catastrophizing in women with fibromyalgia and migraine
ation between different disabling clinical conditions could aggravate
catastrophizing symptoms, making it difcult for the patient to deal
with the painful situation.
11
It is also often cited that women with bromyalgia are less physically
active than healthy women
27
, which could be explained by the fear
that bromyalgia patients have that physical activity could worsen
their symptoms.
28
In addition, people with high levels of catastroph-
ization may have worse physical performance
14
, probably due to
intolerance to pain-related activity.
Another common association is the presence of catastrophization,
sleep disorders
15
, and more severe degrees of depression and anx-
iety.
13
Despite the ndings, in our study the catastrophizing group
did not present lower levels of physical activity and no association
was observed with worsening migraine impact, sleep disorders,
depression, and anxiety. It is possible that the lack of association
between the variables studied in the present research is related to
the small sample size.
The results of the present study have some limitations. As it is an
observational study, it is not possible to establish cause-and-effect
relationships in this research. In addition, the small sample size
makes it impossible to perform statistical analysis with multiple linear
regression, which would make it possible to verify the inuence of
dependent variables with catastrophization.
Table 1. Characterization of the sample with and without the clinical level
of catastrophization.
Variables
Total sample (n
= 26)
Catastrophizing
p
*
With (n=18)
Without
(n=8)
Age (years) 45.92 ± 7.88 47.11 ± 7.79 43.25 ± 7.9 0.17
BMI (Kg/m
2
) 27.97 ± 4.94 28.09 ± 4.92 27.7 ± 5.32 1.00
Time of medication
(years)
3.95 ± 2.52 4.05 ± 2.51 3.62 ± 2.93 0.85
Time diagnosis of
bromyalgia (years)
7.42 ± 8.65 8.54 ± 10.04 4.88 ± 3.47 0.80
Race n(%)
White 9/26 (34.6) 5/26 (27.7) 4/8 (50)
Brown 13/26 (50.0) 11/26 (61.1) 2/8 (25)
Black 4/26 (15.3) 2/18 (11.1) 2/8 (25)
Marital status n(%)
Single 11/26 (42.3) 9/18 (50.0) 2/8 (25.0)
Married 12/26 (46.1) 7/18 (38.8) 5/8 (62.5)
Divorced 3/26 (11.5) 2/18 (11.1) 1/8 (12.5)
*Student t-test.
Data are presented as mean ± standard deviation or n (%). BMI – Body
Mass Index.
Table 2 . Characterization of the sample with and without the clinical level
of catastrophization.
Variables Total sample (n=26)
Catastrophizing (n=18)
p*
With (n=18) Without (n=8)
FIQ-R 71.42 ±18.68 78 ± 12.62 56.63 ± 22.30 0.01
PSQI 13.62 ± 4.36 14.5 ± 4.22 11.63 ± 4.27 0.11
MIDAS n(%)
Minimal
Disability
5/26 (19.3) 4/18 (22.2) 1/8 (12.5)
0.44
Light 3/26 (11.5) 2/18 (11.1) 1/8 (12.5)
Moderate 5/26 (19.2) 2/18 (11.1) 3/8 (37.5)
Severe 13/26 (50.0) 10/18 (55.0) 3/8 (37.5)
BDI n(%)
Absence (0-9) 1/26 (3.8) - 1/8 (12.5)
0.19
Light (10-18) 11/26 (42.3) 7/18 (38.8) 4/8 (50.0)
Moderate
(19-29)
9/26 (34.6) 6/18 (33.3) 3/8 (37.7)
Severe (>30) 5/26 (19.2) 5/18 (27.7) -
BAI n(%)
Minimal (0-10) 6/26 (23.0) 3/18 (16.6) 3/8 (37.5)
0.09
Light (11-19) 3/26 (11.5) 2/18 (11.1) 1/8 (12.5)
Moderate
(20-30)
8/26 (30.7) 4/18 (22.2) 4/8 (50.0)
Severe (>31) 9/26 (34.6) 9/18 (50.0) -
IPAQ n(%)
Very active - - -
0.11
Active 5/26 (19.2) 2/18 (11.1) 3/8 (37.5)
Irregularly
activa
14/26 (53.8) 12/18 (66.6) 2/8 (25.0)
Sedentary 7/26 (26.9) 4/18 (22.2) 3/8 (37.5)
* χ2 Test.Data are presented as mean ± standard deviation or n=number of
patients and (%). FIQ-R – Fibromyalgia Impact Questionnaire-Revised; PSQI
– Pittsburgh Sleep Quality Index; MIDAS – Migraine Disability Assessment
Test; BDI – Beck Depression Inventory; BAI – Beck Anxiety Inventory; IPAQ
– International Physical Activity Questionnaire.
Concl usion
The presence of catastrophization in women with bromyalgia and
migraine is associated with a worsening perception of quality of life.
The authors declare that there is no conict of interest
Place where the study was conducted: Departamento de Fisiotera-
pia, Laboratório de Aprendizagem e Controle Motor, Universidade
Federal de Pernambuco.
The research was approved by the Comitê de ética em pesquisa com
seres humanos do Centro de Ciências da Saúde from - UFPE (CAAE
37052114.3.0000.5208).
43
ASAA
Freire Barros AOF, Barbosa Barros MMMB, Santana RR, Wanderley D, Tenório AS, Oliveira DA
Main symptoms associated to the catastrophizing in women with fibromyalgia and migraine
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Headache Medicine 2020, 11(2):44-47 ISSN 2178-7468, e-ISSN 2763-6178
44
ASAA
DOI: 10.48208/HeadacheMed.2020.13
Headache Medicine
© Copyright 2020
Original
Headache triggered by sleep deprivation: an observational study
Matheus Saraiva Valente Rosado
Raimundo Silva-Néto
Neurology Federal University of Delta of Parnaíba, Parnaíba, Piauí, Brazil.
Abstract
Introduction
Sleep deprivation is one of the main triggers of primary headaches, especially in migraine
patients.
Objective
To determine the prevalence of headache triggered by sleep deprivation in night workers.
Methods
The study was cross-sectional, observational, non-random and convenience. We interviewed
71 night workers of a public hospital with diagnosis of primary headaches and presence of
headache the day after night shift.
Results
The 71 night workers (50 women and 21 men) had a mean age of 36.7±7.7 years, ranging
from 22 to 50 years. Of these workers, 83.2% were diagnosed with migraine and 16.9%
with tension-type headache (TTH). The number of monthly night shifts was greater than 10,
in 50.8% of migraine patients and in 58.3% of those with TTH. It was observed that 91.5%
of migraine patients and 83.3% of patients with TTH slept ≥ 6 hours a night when they were
at home, but when they were at work, they all slept ≤ 4 hours a night. Headache occurred
the following day of night work in 83.1% of migraine patients and in 41.7% of those with
TTH (p=0.005).
Conclusion
Headache triggered by sleep deprivation was highly prevalent, predominating in migraine
patients.
Raimundo Silva-Néto
netoesperantina@terra.com.br
Received: April 13, 2020.
Accepted: April 27, 2020.
Edited by
Mario Fernando Prieto Peres
Keywords:
Headache
Sleep
Migraine Disorders
Prevalence
45
ASAA
Rosado MSV, Silva-Néto RN.
Headache triggered by sleep deprivation an observational study
Introduction
I
n primary headaches, headache attacks may be triggered by
several factors, such as stress, eating habits, sensory stimuli,
menstrual changes and sleep deprivation, especially in patients with
migraine.
1,2
The prevalence of headache attacks triggered by sleep
deprivation in migraine patients ranges from 28.5% to 56.7%
3,4,5
and in patients with tension-type headache (TTH) it is 28.8%
3
.
There is a relationship between sleep and primary headaches as
a trigger for headache attacks, both deprivation and excess sleep
6
,
but this mechanism is not fully understood, despite being a frequent
complaint of migraine and TTH patients
7
. On the other hand, res-
torative sleep with sufcient sleep hours works as a relief factor for
headache attacks.
8
Almost half of the population has some sleep disorder, mainly
insomnia
9
. Sleep disorders represent an important public health
problem in the world and are comorbidities of primary headaches.
In contrast, primary headaches have great social impact and risk
of chronication.
10,11
Despite the social impact, headache attacks triggered by sleep de-
privation in patients with migraine or TTH have not been sufciently
studied. This is the rst Brazilian population study on headache
triggered by sleep deprivation.
Patients and methods
Study design and patients
A prospective, cross-sectional, group comparative study was conduc-A prospective, cross-sectional, group comparative study was conduc-
ted on a non-random and convenience sampling which was selected ted on a non-random and convenience sampling which was selected
from night workers of a public hospital and invited to participate in from night workers of a public hospital and invited to participate in
this research. The sample consisted of 71 night workers diagnosed this research. The sample consisted of 71 night workers diagnosed
with primary headaches according to the ICHD-3 criteria.with primary headaches according to the ICHD-3 criteria.
1212
Inclusion and exclusion criteriaInclusion and exclusion criteria
The study included night workers of a public hospital, aged 18 to 50 The study included night workers of a public hospital, aged 18 to 50
years diagnosed with primary headaches according to the ICHD-3 years diagnosed with primary headaches according to the ICHD-3
criteriacriteria
1212
who agreed to undergo an interview. Those who reported who agreed to undergo an interview. Those who reported
daily or almost daily headache, no headache in the last 12 months, daily or almost daily headache, no headache in the last 12 months,
association of two or more primary headaches, concomitantly or at association of two or more primary headaches, concomitantly or at
different times, secondary headaches, and pregnant women weredifferent times, secondary headaches, and pregnant women were
excluded.excluded.
Data collection
After fulfilling the inclusion and exclusion criteria, a structured
interview was conducted, based on a questionnaire to diagnose the
presence of headache on the day after night shift. The number of
times the worker slept at work and the number of hours he/she slept
at home and at work were investigated.
Statistical analysis
Organized the information in a database, the Statistical Package
for Social Sciences (SPSS™) version 22.0 was used for statistical
analysis. The chi-square test with Yates correction, Student’s t-test and
Fisher’s exact test were used for the difference of means of unpaired
samples, with a signicance level of 0.05.
Ethical aspects
This study was approved by the Ethics in Research Involving Human
Subjects Committee at the Federal University of Piauí, protocol
number 3,305,167 and the National Ethics in Research System,
registry number 08850918.0.0000.5214, on May 6, 2019. Data
were collected from May to June 2019 and all volunteers signed the
Informed Consent Form.
Results
Seventy-one night workers, aged 36.7±7.7 years, ranging from 22
to 50 years, were investigated, of which 50 (70.4%) were women,
corresponding to the sex ratio of 1:4.9 male/female. After headache
diagnosis, it was found that 59 (83.1%) workers had migraine and
12 (16.9%) met the diagnostic criteria for TTH. Migraine affected
workers aged 36.0±7.6 years, while in TTH, the age was 35.8±8.8
years (p=0.935) (Table 1).
Table 1. Distribution of sex and age according to diagnosis of 59 migraine
patients and 12 with tension-type headache
Variables Diagnosis Migraine TTH
Gender
Female (n; %) 45 (76.3) 5 (41.7) 0.032*
Male (n; %) 14 (23.7) 7 (58.3)
Age (years)
Mean (SD) 36.0 (7.6) 35.8 (8.8) 0.935**
Variation 23-50 22-50
Note: TTH - tension-type headache; SD - standard deviation; * - p-value
based on Fisher's exact test for mean difference of unpaired samples. ** - p
value based on Student's t-test for mean differences in unpaired samples
The number of monthly night shifts was greater than 10 in 50.8%
of migraine patients and 58.3% of patients with TTH (p=0.876).
We found that 91.5% of migraine patients and 83.3% of patients
with TTH slept six or more hours a night when they were at home,
but when on duty, 100% slept four hours or less a night (Table 2).
46
ASAA
Rosado MSV, Silva-Néto RN.
Headache triggered by sleep deprivation an observational study
Table 2. Distribution of the number of monthly night shifts, hours the worker
slept at home and night work, and the presence of headache the day after
night shift in 59 migraine patients and 12 with tension-type headache
Variables
Diagnosis
p-value
Migraine TTH
Monthly night shifts 0.876*
< 10 29 (49.5) 5 (41.7)
≥ 10 30 (50.8) 7 (58.3)
Number of hours he/she slept at home 0.592**
< 6 5 (8.5) 2 (16.7)
≥ 6 54 (91.5) 10 (83.3)
Number of hours he/she slept at work 0.717**
< 3 15 (25.4) 2 (16.6)
3 or 4 44 (74.6) 10 (83.3)
Presence of headache the day after
night shift
0.005**
Yes 49 (83.1) 5 (41.7)
No 10 (16.9) 7 (58.3)
It was found that 83.1% (49/59) of migraine patients and 41.7%
(5/12) of those with TTH presented headache the next day after night
shift. These differences were signicant (p = 0.005) (Tables 2 and 3).
Table 3. Distribution of the frequency of headache triggered by sleep depri-
vation in 59 migraine patients and 12 with tension-type headache
Variables
Diagnosis
p-value
Migraine TTH
Never 10 (16.9) 7 (58.3) 0.005*
Rarely 27 (45.8) 3 (25.0)
Most of the time 20 (33.9) 2 (16.7)
Every times 2 (3.4) 0 (0.0)
Note: TTH - tension-type headache; p value calculated by Fisher's exact test, comparing:
* no versus ≥ rarely, most of the time or every time.
Discussion
In this study, two groups of night workers diagnosed with migraine or
TTH were compared by the relationship between headache and sleep
deprivation. Therefore, in order to obtain valid and consistent data,
a correct diagnosis was established for each headache, according
to the criteria of ICHD-3.
12
Primary headaches, especially migraine and TTH, are the main diag-
noses found in hospitals and clinics worldwide.
13-15
These headaches
have signicant morbidity and socioeconomic effect
16
, demonstrating
a great importance for public health as it affects patients at the most
productive age of their lives, between 30 and 40 years of age
17
, as
noted in this study.
Sleep deprivation has always been known as one of the factors that
trigger a headache attack in migraine patients
1
, but a community
study in Malaysia has shown that sleep deprivation triggers headache
attacks in both migraine and TTH patients.
18
Many patients have both migraine and TTH. In this case, the dif-
ferentiation between these two primary headaches, especially in
mild forms, represents a diagnostic challenge. Some factors serve
to differentiate migraine from TTH, such as headache triggered by
odors that occurs only in migraine patients.
19
In our study, headache
triggered by sleep deprivation was more prevalent in migraine
patients, with statistical signicance, and could be a differentiating
factor between these headaches.
Sleep deprivation triggers headache attacks in the general popula-
tion, but mainly in people who work at night. Some of these workers
sleep a few hours or sometimes do not have time to sleep. In addition,
those who sleep a few hours do so in a different bed than the one
they usually sleep on.
There was a higher percentage of migraine patients who had head-
ache triggered by sleep deprivation. According to ICHD-3, in mi-
graine, headache attacks are more severe than in TTH12 and this has
a negative impact with a signicant socioeconomic effect due to the
greater probability of missing work and having more days lost.
10,11,16
The brain mechanisms underlying altered pain processing after sleep
deprivation are unknown. However, it is believed that inadequate
sleep or even total sleep deprivation may reduce pain thresholds
and amplify pain reactivity in the primary somatosensory cortex.
20,21
Conclusion
Headache triggered by sleep deprivation is highly prevalent, pre-
dominating in migraine patients.
Funding:
This research received no specic grant from any funding agency
in the public, commercial, or not-forprot sectors.
Conflict of Interest:
There is no conict of interest.
Matheus Saraiva Valente Rosado
https://orcid.org/0000-0001-9426-0425
Raimundo Silva-Néto
https://orcid.org/0000-0002-2343-9679
References
1. Fukui PT, Gonçalves TRT, Strabelli CG, et al. Trigger factors in
migraine patients. Arq Neuropsiquiatr. 2008; 66: 494–499.
2. Kelman L. The triggers or precipitants of the acute migraine
attack. Cephalalgia. 2007; 27: 394–402.
3. Wang J, Huang Q, Li N, et al. Triggers of migraine and tension-
-type headache in China: a clinic-based survey. Eur J Neurol.
2013; 20: 689–696.
4. Andress-Rothrock D, King W, Rothrock J. An analysis of migraine
triggers in a clinic-based population. Headache. 2010; 50:
1366 –1370.
5. Carod-Artal FJ, Ezpeleta D, Martín-Barriga ML, et al. Triggers,
symptoms, and treatment in two populations of migraneurs in
Brazil and Spain. a cross-cultural study. J Neurol Sci. 2011;
304: 25–28.
47
ASAA
Rosado MSV, Silva-Néto RN.
Headache triggered by sleep deprivation an observational study
6. Bruni, O, Russo PM, Ferri R, et al. Relationships between hea-
dache and sleep in a non-clinical population of children and
adolescents. Sleep Medicine. 2008; 9: 542–548.
7. Engstrøm M, Hagen K, Bjørk MH, et al. Sleep quality, arousal
and pain thresholds in migraineurs: A blinded controlled poly-
somnographic study. J Headache Pain. 2013; 14: 12.
8. Yagihara F, Lucchesi LM, Smith AKA, et al. Primary headaches
and their relationship with sleep. Sleep Science. 2012; 5: 28–32.
9. Ferré-Masó A, Rodriguez-Ulecia I, García-Gurtubay I. Dieren-
tial diagnosis of insomnia from other comorbid primary sleep
disorders. Aten Primaria. 2020. pii: S0212-6567(20)30005-6.
[Epub ahead of print].
10. Guglielmetti M, Raggi A, Ornello R, et al. The clinical and
public health implications and risks of widening the denition
of chronic migraine. Cephalalgia. 2019:15:333102419895777.
[Epub ahead of print].
11. Sanya EO, Desalu OO, Aderibigbe SA, et al. Prevalence and
clinical characteristics of headaches among undergraduate
students in three tertiary institutions in Ilorin, Nigeria. Niger J
Clin Pract. 2017; 20: 1411–1416.
12. Headache Classication Subcommittee of the International
Headache Society. The International Classication of Headache
Disorders, 3rd Edition. Cephalalgia. 2018; 38: 1– 211.
13. Kim SK, Moon HS, Cha MJ, et al. Prevalence and features
of a probable diagnosis in rst-visit headache patients ba
sed on the criteria of the third beta edition of the internatio-
nal classication of headache disorders: a prospective. Cross
sectional multicenter study. Headache. 2016; 56: 267–75.
14. Tai ML, Jivanadham JS, Tan CT, et al. Primary headache in the
elderly in South-East Asia. J Headache Pain. 2012; 13: 291–7.
15. Wöber C, Wöber-Bingöl C. Triggers of migraine and tension-
-type headache. Handb Clin Neurol. 2010; 97: 161–72.
16. Kahriman A, Zhu S. Migraine and Tension-Type Headache.
Semin Neurol. 2018; 38: 608-618.
17. Vos T, Flaxman AD, Naghavi M, et al. Years lived with disability
(YLDs) for 1160 sequelae of 289 diseases and injuries 1990-
2010: A systematic analysis for the global burden of disease
study 2010. Lancet. 2012; 380: 2163–2196.
18. Alders EEA, Hentzen A, Tan CT. A community-based prevalence
study on headache in Malaysia. Headache. 1996; 36: 379–84.
19. Silva-Néto RP, Peres MF, Valença MM. Accuracy of osmophobia
in the dierential diagnosis between migraine and tensiontype
headache. J Neurol Sci. 2014; 339: 118– 122.
20. Krause AJ, Prather AA, Wager TD, et al. The pain of sleep
loss: A brain characterization in humans. J Neurosci. 2019;
39: 2291–2300.
21. Engstrøm M, Hagen K, Bjørk MH, . Sleep quality and arousal
in migraine and tension type headache: the headache sleep
study. Acta Neurol Scand 2014; 129: 47– 54.
Headache Medicine 2020, 11(2):48-50 ISSN 2178-7468, e-ISSN 2763-6178
48
ASAA
DOI: 10.48208/HeadacheMed.2020.14
Headache Medicine
© Copyright 2020
Original
Recommendations for the management of headaches during the
COVID-19 pandemic
Yara Dadalti Fragoso
1
Marcelo Calderaro
2
Marcio Nattan Portes Souza
2
Patrick Emanuell Mesquita
Sousa Santos
3
Eduardo Nogueira
1
Shuu-Jiun Wang
4,5
Messoud Ashina
6
Stephen D Silberstein
7
Mario F P Peres
8,9
1
Universidade Metropolitana de Santos, Santos, Brazil.
2
Hospital das Clínicas da Universidade de São Paulo, São Paulo, Brazil.
3
Universidade Federal do Delta do Parnaíba, Parnaíba, Brazil.
4
Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan.
5
Brain Research Center, National Yang-Ming University, Taipei, Taiwan.
6
Department of Neurology, Copenhagen University, Copenhagen, Denmark.
7
Je󰀨erson Headache Center, Department of Neurology, Thomas Je󰀨erson University, Philadelphia, USA.
8
Hospital Israelita Albert Einstein, Sao Paulo, Brazil.
9
Instituto de Psiquiatria, Hospital das Clínicas da Universidade de São Paulo, Brazil.
Abstract
Background
During the novel coronavirus - COVID-19 pandemic, health care systems are facing one of
its greatest challenges.
Results
Secondary headaches may need urgent care at an emergency department. Primary heada-
ches exacerbations may require intravenous infusion. Treatment optimization is key for a better
outpatient management.
Conclusion
We give recommendations on when a headache patient should go to the hospital despite
the current limited resources, and primary headache management aspects during the ou-
tbreak.
Yara Dadalti Fragoso
yara@bsnet.com.br
Received: April 18, 2020.
Accepted: April 27, 2020.
Edited by
Marcelo Moraes Valença
Keywords:
Headache management
COVID-19
Emergency department
49
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Fragoso YD, Calderaro M, Souza MNP, Sousa Santos PEM, Nogueira E, Wang SJ, Ashina M, Silberstein SD, Peres, MFP
Recommendations for the management of headaches during the COVID-19 pandemic
Introduction
H
ealthcare worldwide is facing one of its greatest crises in
history
1
. With the fast spread of the novel coronavirus, health-
care systems are collapsing in some countries, with depletion of
resources and crowding of emergency rooms, wards and intensive
care units
2
.
Since the World Health Organization’s declaration that a pandemic Since the World Health Organization’s declaration that a pandemic
exists, interruption of non-urgent healthcare has been generating exists, interruption of non-urgent healthcare has been generating
insecurity and helplessness for people with other health problems, insecurity and helplessness for people with other health problems,
including headache disorders. We need strength and compassion including headache disorders. We need strength and compassion
to face up to and overcome this crisis and its imposed difculties. to face up to and overcome this crisis and its imposed difculties.
One important step is to seek reliable information, and to prevent One important step is to seek reliable information, and to prevent
the spread of false news that generate confusion and panic. Here, the spread of false news that generate confusion and panic. Here,
we provide guidelines for the management of headaches during we provide guidelines for the management of headaches during
the COVID-19 pandemic.the COVID-19 pandemic.
Recommendations for the emergency Recommendations for the emergency
care of headache disorders during the care of headache disorders during the
covid-19 pandemiccovid-19 pandemic
With the emergency department (ED) as a potential source of
COVID-19 infection, patients experiencing headaches need advice
on when to seek emergency care.
Patients should avoid ED visits for treatment of their regular
headache, but if they experience a headache with red ags, urgent
care may be needed. Delay in treatment may increase morbidity
and mortality, telemedicine is one key tool for the management of
headaches during the pandemic.
When should headache patients go to the
emergency department?
COVID-19 and its symptoms are an independent determinant COVID-19 and its symptoms are an independent determinant
of ED care especially with breathing difculties. Headache is of ED care especially with breathing difculties. Headache is
reported in patients with COVID-19 from 8 to 34%.reported in patients with COVID-19 from 8 to 34%.
3,43,4
However, However,
headache and mild symptoms alone that patients may think might headache and mild symptoms alone that patients may think might
be a symptom of COVID-19 should not be considered as not be a symptom of COVID-19 should not be considered as not
an indication. The list below shows conditions that accompany an indication. The list below shows conditions that accompany
headache and may indicate that it is a lifethreatening disorder headache and may indicate that it is a lifethreatening disorder
requiring special management requiring special management
55
::
1. Headache and Fever1. Headache and Fever A new-onset acute headache that differs A new-onset acute headache that differs
from those that were previously experienced, in association with a from those that were previously experienced, in association with a
documented increase in temperature (>37.8 °C or >100 °F) is a documented increase in temperature (>37.8 °C or >100 °F) is a
sign of ongoing infection. This may be managed by telemedicine sign of ongoing infection. This may be managed by telemedicine
if another symptom such as painful urination suggests the site of if another symptom such as painful urination suggests the site of
infection (urinary, pulmonary, sinus, common cold). Evaluation infection (urinary, pulmonary, sinus, common cold). Evaluation
and treatment can be given by telemedicine with possible referral and treatment can be given by telemedicine with possible referral
to the ED (change in mental status, diplopia, weakness , stiff neck, to the ED (change in mental status, diplopia, weakness , stiff neck,
etc.) and patient monitoring for clinical worsening. If the patient’s etc.) and patient monitoring for clinical worsening. If the patient’s
condition worsens over time, or mental status is declining, this must condition worsens over time, or mental status is declining, this must
be urgently revaluated by the healthcare provider.be urgently revaluated by the healthcare provider.
2. Headache and stiff neck 2. Headache and stiff neck Headaches associated with stiff neck Headaches associated with stiff neck
may be due to meningitis or subarachnoid hemorrhage (SAH). may be due to meningitis or subarachnoid hemorrhage (SAH).
Meningitis evolves over a few days, generally associated with Meningitis evolves over a few days, generally associated with
fever. In SAH, headache usually presents with sudden onset, as fever. In SAH, headache usually presents with sudden onset, as
an abrupt and very severe headache, i.e. thunderclap headache.an abrupt and very severe headache, i.e. thunderclap headache.
3. Headache and change in mental status 3. Headache and change in mental status Headaches associated Headaches associated
with mental confusion, change in behavior, excessive sleepiness orwith mental confusion, change in behavior, excessive sleepiness or
disorientation may originate from a central nervous system (CNS) disorientation may originate from a central nervous system (CNS)
disorder, stroke, neoplasia or infection. Adequate care should disorder, stroke, neoplasia or infection. Adequate care should
be given, otherwise the primary condition may worsen without be given, otherwise the primary condition may worsen without
treatment. treatment.
4. Eye pain, redness and/or vision loss.4. Eye pain, redness and/or vision loss. Headaches occurring in Headaches occurring in
one or both eyes, associated with redness are more likely to be due one or both eyes, associated with redness are more likely to be due
to conjunctivitis. Glaucoma can present with eye pain or redness, to conjunctivitis. Glaucoma can present with eye pain or redness,
but is usually accompanied by peripheral loss of vision. Vision loss but is usually accompanied by peripheral loss of vision. Vision loss
may also occur in migraine auras. If a patient has experienced may also occur in migraine auras. If a patient has experienced
a headache associated with vision loss for the rst time, medical a headache associated with vision loss for the rst time, medical
attention is needed. Acute headaches that are unilateral or attention is needed. Acute headaches that are unilateral or
periorbital and occur in association with vision loss in the elderly periorbital and occur in association with vision loss in the elderly
should give rise to suspicion of temporal arteritis.should give rise to suspicion of temporal arteritis.
5. Headaches associated with physical exertion or fainting5. Headaches associated with physical exertion or fainting Physical Physical
activity can exacerbate migraine pain and is part of the diagnostic activity can exacerbate migraine pain and is part of the diagnostic
criteria for this condition. However, headaches occurring only criteria for this condition. However, headaches occurring only
after or during physical exertion or sexual activity may be a after or during physical exertion or sexual activity may be a
sign of a secondary headache due to aneurysm, arteriovenous sign of a secondary headache due to aneurysm, arteriovenous
malformation, cerebral venous thrombosis or reversible cerebral malformation, cerebral venous thrombosis or reversible cerebral
vasoconstriction syndrome (RCVS). Headache associated with vasoconstriction syndrome (RCVS). Headache associated with
fainting or seizure can be secondary to brain tumors, infections orfainting or seizure can be secondary to brain tumors, infections or
stroke. stroke.
6. Vomiting6. Vomiting Headaches associated with vomiting only need ED Headaches associated with vomiting only need ED
attention if oral uid intake is not possible. Antiemetics should be attention if oral uid intake is not possible. Antiemetics should be
considered in the early phase of a migraine attack with nausea. considered in the early phase of a migraine attack with nausea.
Vomiting is an associated feature of migraine, but may also be a Vomiting is an associated feature of migraine, but may also be a
symptom of intracranial hypertension.symptom of intracranial hypertension.
7. New-onset headaches starting after 50 years of age7. New-onset headaches starting after 50 years of age If this is an If this is an
ongoing problem, telemedicine is appropriate for initial evaluation. ongoing problem, telemedicine is appropriate for initial evaluation.
A visit to the ER should be made if an early onset acute headache A visit to the ER should be made if an early onset acute headache
is present. is present.
8. Sudden-onset, abrupt headaches (Thunderclap Headache) 8. Sudden-onset, abrupt headaches (Thunderclap Headache)
Sudden-onset severe headaches that reach their peak in seconds Sudden-onset severe headaches that reach their peak in seconds
demand immediate evaluation. They can be due to a SAH, cerebraldemand immediate evaluation. They can be due to a SAH, cerebral
venous thrombosis, carotid or vertebral dissection, meningitis, venous thrombosis, carotid or vertebral dissection, meningitis,
pituitary apoplexy, or RCVS. Recurrent thunderclap headache is apituitary apoplexy, or RCVS. Recurrent thunderclap headache is a
50
ASAA
Fragoso YD, Calderaro M, Souza MNP, Sousa Santos PEM, Nogueira E, Wang SJ, Ashina M, Silberstein SD, Peres, MFP
Recommendations for the management of headaches during the COVID-19 pandemic
hallmark of RCVS until proven otherwise.hallmark of RCVS until proven otherwise.
9. Headaches in chronic non-communicable disorders or 9. Headaches in chronic non-communicable disorders or
immunodeficiencyimmunodeficiency A new-onset headache in patients with ongoing A new-onset headache in patients with ongoing
infection, HIV or cancer, or in those taking immunosuppressants, infection, HIV or cancer, or in those taking immunosuppressants,
needs urgent attention. If headaches started gradually but are needs urgent attention. If headaches started gradually but are
worsening, medical attention is also needed.worsening, medical attention is also needed.
Management of primary headaches during
the covid-19 pandemic
Primary headache patients will need special attention during the Primary headache patients will need special attention during the
COVID-19 pandemic, particularly if social isolation measures have COVID-19 pandemic, particularly if social isolation measures have
been imposed by health authorities.been imposed by health authorities.
Mental health managementMental health management
Mental health can be severely impaired, leading to anxiety, panic or Mental health can be severely impaired, leading to anxiety, panic or
depression. Suicide rates increased in China during connementdepression. Suicide rates increased in China during connement
66
. .
Primary headache patients may be more susceptible to mental Primary headache patients may be more susceptible to mental
health issues and/or may have more attacks under these conditions. health issues and/or may have more attacks under these conditions.
Lifestyle measures should be reinforced, since food intake, mood Lifestyle measures should be reinforced, since food intake, mood
and physical activity may be affected during the pandemic. Self and physical activity may be affected during the pandemic. Self
help tools are often available on the internet.help tools are often available on the internet.
Acute headache managementAcute headache management
Primary headaches may be exacerbated during the pandemic. Primary headaches may be exacerbated during the pandemic.
Headaches typically account for 1-3% of ER visitsHeadaches typically account for 1-3% of ER visits
77
. In order to avoid . In order to avoid
delays in the ED, over taxing urgent care, hospitalization, acute delays in the ED, over taxing urgent care, hospitalization, acute
treatment may need optimization. This may include addition of non-treatment may need optimization. This may include addition of non-
parenteral options such as subcutaneous injections [(i.e. sumatriptan parenteral options such as subcutaneous injections [(i.e. sumatriptan
or dihydroergotamine (DHE)] or nasal spray formulations or dihydroergotamine (DHE)] or nasal spray formulations
(sumatriptan or zolmitiptan). Patients are suggested to increase (sumatriptan or zolmitiptan). Patients are suggested to increase
acute treatment toolbox to better self-manage their headache acute treatment toolbox to better self-manage their headache
attacks. This includes the use of prochlorperazine suppositories. attacks. This includes the use of prochlorperazine suppositories.
Patients may be at risk of worsening of their headache in isolation, Patients may be at risk of worsening of their headache in isolation,
consider new preventive methods to mitigate the risk.consider new preventive methods to mitigate the risk.
Avoiding corticosteroidsAvoiding corticosteroids
Cluster headache and other primary headaches are commonly Cluster headache and other primary headaches are commonly
treated with corticosteroids. If possible, this should be avoided, treated with corticosteroids. If possible, this should be avoided,
because immunosuppression is considered to be a risk factor because immunosuppression is considered to be a risk factor
for negative health outcomes among individuals infected with for negative health outcomes among individuals infected with
COVID-19.COVID-19.
Concl usion
Headache patients will need special management during the CO-
VID-19 pandemic. New-onset acute headaches will still need medical
care. Delays in treating other life-threatening conditions caused by
diversion of resources to treat cases of the novel coronavirus may
lead to additional morbidity burdens, or mortality. Primary headache
patients may be at risk of worsening headache control due to the
limited healthcare resources available and because of changes to
lifestyle due to social-distancing connement.
References
1. MacIntyre CR. On a knife’s edge of a COVID-19 pandemic: is
containment still possible? Public Health Res Pract. 2020; 301:
3012000. doi: 10.17061/phrp3012000
2. Panati, K., Narala, V.R. COVID-19 Outbreak: an Update on
Therapeutic Options. SN Compr. Clin. Med. 2020. https://doi.
org/10.1007/s42399-020-00264-6
3. Huang C, Wang Y, Li X, et al. Clinical features of patients infec-
ted with 2019 novel coronavirus in Wuhan, China. Lancet. 2020;
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4. Xu XW, Wu XX, Jiang XG, et al. Clinical ndings in a group of
patients infected with the 2019 novel coronavirus (SARSCov-2)
outside of Wuhan, China: retrospective case series. BMJ. 2020;
368: m606. doi: 10.1136/bmj.m606.
5. Do TP, Remmers A, Schytz HW, et al. Red and orange ags
for secondary Neurology. 2019; 923: 134-144. doi: 10.1212/
WNL.0000000000006697.
6. Qiu J, Shen B, Zhao M, et al. A nationwide survey of psycholo-
gical distress among Chinese people in the COVID-19 epidemic:
implications and policy recommendations. Gen Psychiatr. 2020;
332: e100213. doi: 10.1136/gpsych-2020-100213.
7. Munoz-Ceron J, Marin-Careaga V, Peña L, et al. Headache at
the emergency room: Etiologies, diagnostic usefulness of the
ICHD 3 criteria, red and green ags. PLoS One. 2019; 141:
e0208728. doi: 10.1371/journal.pone.0208728.
Headache Medicine 2020, 11(2):51-53 ISSN 2178-7468, e-ISSN 2763-6178
51
ASAA
DOI: 10.48208/HeadacheMed.2020.15
Headache Medicine
© Copyright 2020
Original
Food avoidance among patients with headache
Stella Boreggio Machado
1
Nayara Cavalcanti Ares
2
Claudio Scorcine
3
Yara Dadalti Fragoso
4
1
Universidade Metropolitana de Santos, Nutrition, Santos, São Paulo, Brazil.
2
Universidade Metropolitana de Santos, Physical Education, Santos, São Paulo, Brazil.
3
Universidade Metropolitana de Santos, Post Graduate Studies, Santos, São Paulo, Brazil.
4
MS & Headache Research, Research, Santos, São Paulo, Brazil.
Abstract
Objective
To assess food and drink avoidance among patients with headache by means of an online
survey.
Methods
Individuals with frequent headaches were invited to answer a Google Form questionnaire
[https://form.jotformz.com/200233754863656]. The survey included sex, age and cha-
racteristics of headache. Dietary habits were assessed as the number of times the individual
consumed certain foods, on a daily, weekly, or monthly basis. The participants could state up
to three foods that they avoided for fear of headache attacks.
Results
120 complete forms were received. Alcoholic beverages were the most frequent trigger fac-
tor, reported by 26.7% of the patients. 95.5% of the participants did not consume alcohol
regularly. Cheese, caffeine and fat were also recognized as potential triggers of headaches.
There was no standard prole of dietary triggers and, therefore, everyone has to be personally
approached in this subject.
Conclusion
The online survey conrmed that individual characteristics of headache were dietary triggers in
half the participants. Alcohol was the most frequently mentioned trigger, followed by cheese,
fat and caffeine.
Yara Dadalti Fragoso
yara@bsnet.com.br
Received: April 24, 2020.
Accepted: April 27, 2020.
Edited by
Marcelo Moraes Valença
Keywords:
Diet
Headache
Carbohydrates
52
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Machado SB, Ares- NC, Scorcine C, Fragoso YD.
Food avoidance among patients with headache
Introduction
T
he association of dietary factors and primary headaches is
controversial.
1
Certain foods can trigger headache in up to 64%
of patients, but not all the attacks and not all the time.
2
The literature
on this subject is conicting since no mechanism for supporting the
existence of a food-headache association has yet been established
with adequate evidence.
3
Among the proposed mechanisms for the
onset of headache attacks through dietary triggers are the “amine
hypothesis”, “allergy vasodilation”, “dysregulation of neurotransmit-
ters involved in appetite” and “inammatory diet”.
3
Perhaps one of the best examples of the conicting evidence on
triggering foods relates to chocolate. Although eating chocolate
is widely believed to trigger migraine attacks, the risk of having
a migraine after doing this is as likely as after eating placebo.
4
Another confounding factor may be the masticatory trigger for
headache attacks: this could be misinterpreted as the food itself (for
example, chewing red meat).
5
Anxiety and anticipatory behavior
can also play a role among patients who believe a certain food
will trigger an attack.
6
The objective of the present study was to assess headache patients’
food avoidance and consumption using an online survey.
Methods
This study was approved by the Ethics Committee at Univer-This study was approved by the Ethics Committee at Univer-
sidade Metropolitana de Santos, SP, Brazil, under CAAE sidade Metropolitana de Santos, SP, Brazil, under CAAE
17241719.1.0000.5509. Individuals with headache at least once 17241719.1.0000.5509. Individuals with headache at least once
a month over the last three months were invited to answer a Google a month over the last three months were invited to answer a Google
Forms survey [https://form.jotformz. com/200233754863656].Forms survey [https://form.jotformz. com/200233754863656].
This study was approved by the Ethics Committee at Univer-
sidade Metropolitana de Santos, SP, Brazil, under CAAE
17241719.1.0000.5509. Individuals with headache at least once
a month over the last three months were invited to answer a Google
Forms survey [https://form.jotformz.com/200233754863656].
The Kolmogorov-Smirnov test assessed the sample normality, Stu-
dent’s t test was used for parametric variables and Pearson’s cor-
relation and the chi-square test were used for comparisons.
Results
A total of 120 individuals answered the survey (95 women). Their
average age was 36 years and 65.8% of them had presented head-
aches for four or more years. Migraine or probable migraine was
identied in 104 subjects. The remaining 16 patients presented the
characteristics of tension-type headache. Table 1 presents the list of
foods that the patients avoided because they believed that these foods
could induce headache attacks. Alcohol, greasy food, cheese and
caffeine were the most cited triggers of headaches. Figure 1 presents
Table 1. Number (and percentage from n=120) of participants who sponta-
neously referred specic dietary components that could trigger headaches.
Food/drink Number of patients (n) %
Triggers?
Yes 63 52.5%
Alcohol 32 26.6%
Bread 1 0.8%
Caffeine 9 7. 5 %
Cheese 9 7. 5 %
Chocolate 7 5.8%
Cured meats 4 3.3%
Egg 1 0.8%
Fat 15 12.5%
Nuts 3 2.5%
Red meat 2 1.6%
Salt 3 2.5%
Soda 3 2.5%
Spicy food 4 3.3%
Sweets 9 7. 5 %
the frequencies of food consumption. In summary, alcoholic beverag-
es, zzy drinks, fruits, processed fruit juices, sh, prawns, soya prod-
ucts and cured meats were often avoided by these patients. Bread,
cheese, natural fruit juices, beans, eggs, read meats, chocolates and
coffee were frequently consumed by these patients. Only 13 patients
(10.8%) reported ve or more dietary triggers for their headaches
that they never consumed.
There were no differences in food preference and/or avoidance
regarding sex, age, frequency or type of headache. Caffeine and
cheese, which were spontaneously cited as headache triggers by
10% of the patients, were among the ve items most consumed by
them. Cheese was consumed by 73% of the patients while black
coffee was consumed by 77% of them. Canned sh and prawns
were consumed by less than 10% of the patients, although none of
them regarded these items as potential triggers.
Discussion
The association between headaches (particularly migraine) and
dietary components is complex and often misunderstood. Physicians
frequently tell patients to avoid a list of standard foods and drinks that
are not triggers for all headache sufferers. In addition, it is important
to acknowledge that, beyond diet, other lifestyle changes may have
a role in the therapeutic success of these patients.
7
Rather than im-
plementing a standard list of foods and drinks that are “forbidden”,
identication of dietary triggers for each patient is ideal. This can be
done with the help of food diaries, which are an inexpensive way to
understand which foods and drinks may trigger headache attacks in
that individual.
8
It was interesting to observe that half the patients considered that at
least one dietary component was a headache trigger. While alcohol
53
ASAA
Machado SB, Ares- NC, Scorcine C, Fragoso YD.
Food avoidance among patients with headache
was believed to trigger headache attacks by over a quarter of our
patients, other dietary factors were remarkably different among the
patients. For example, some participants could not tolerate cheese,
while other ate it regularly without problems. This reinforces the idea
that, like the pharmacological approach to headaches, a tailor-made
dietary recommendation for each patient is necessary. While patients
may give us details of their food avoidance, the biological mechanism
through which dietary triggers precipitate headache attacks remains
obscure.
9
Our study had limitations. It used a small sample of individuals who
answering an online survey. The diagnosing their headache was not
ideal, and the sample comprised a mixture of cases of migraine, prob-
able migraine, and tension-type headache. However, the aim of this
study was not to study any specic primary headache. There were no
evaluations for micronutrients or the percentage of proteins, car-
bohydrates, and fat in the patients’ diet. All of these factors will be
addressed in future studies in our group.
Concl usion
The online survey used in this study conrmed the individual charac-
teristics of headache dietary triggers. Alcohol, the most frequently
reported trigger, affected 26% of the participants. Overall, half the
patients had at least one food or drink that was associated with
headaches.
Acknowledgement:
SB Machado received a Scientic Initiation
Grant from the Brazilian National Council for Scientic and
Technological Development (CNPq) for which the authors are
grateful.
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Figure 1. Percentage of individuals with headache (n=120) who avoided consuming each of these foods or drinks. Note that avoidance of dietary factors
is higher than that spontaneously cited by patients.