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ARTICLES: Marcelo E. Bigal, Joshua N. Liberman, and Richard B. Lipton Obesity and migraine: A population study Neurology 2006; 66: 545-550 [Abstract] [Full text] [PDF]

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Obesity and migraine: A population study

Yasuo Iwasaki, Ken Ikeda   (7 August 2006)

Obesity and migraine: A population study

Gordon J. Gilbert   (7 August 2006)

Reply from the authors

Marcelo E. Bigal, Richard B. Lipton   (7 August 2006)

Obesity and migraine: A population study 7 August 2006
Yasuo Iwasaki, Toho University Omori Hospital 6-11-1,Omorinishi,Ota-ku,Tokyo ,Japan, Ken Ikeda Send Correspondence to journal: Re: Obesity and migraine: A population study yaso{at}med.toho-u.ac.jp Yasuo Iwasaki, et al.	We read with interest the recent article by Bigal et al concerning migraine and obesity.[1] They concluded that obesity is not comorbid to migraine but is significantly associated with the number of headache days, severity, and some clinical features. We would like to introduce our survey of headache in nurses who are working in our hospital. Almost 700 nurses participated in this survey and 10% of them are suffering from migraine. According to the results, the proportion of migraine subjects with 10 or more headache days per month is nearly 10% in normal or underweight subjects. There was no one whose BMI was greater than 25 and who had headache 10 days or more. We would like the authors to clarify the following points: Are those who are obese in childhood or adolescence at greater risk for developing migraine than those who are not? In addition, overweight people may have sleep apnea syndrome(SAS), hyperglycemia, and hypercholesteremia. These factors may also play a role in migraine. Migraine is asociated with elevated cholesterol level [2] and mitochondria plays a role in migraine pathogenesis. [3] In addition, is it possible that reduction of body weight may improve headache in obese subjects? It would be interesting to investigate whether reduction of body weight in normal or underweight subjects would impact migraine. Disclosure: The authors report no conflicts of interest.
Obesity and migraine: A population study 7 August 2006
Gordon J. Gilbert, Dept. of Physiology and Biophysics, University of South Florida School of Medicine 500 Pasadena Avenue South, St. Petersburg, FL 33707 Send Correspondence to journal: Re: Obesity and migraine: A population study drgg22{at}tampabay.rr.com Gordon J. Gilbert	I read the Bigal et al article with interest. [1] Is it possible that the increased severity and frequency of migraine demonstrated by the authors in patients with obesity relate to the known relationship between obesity and sleep apnea? An increased occurrence of migraine headache in patients with obstructive sleep apnea has been demonstrated [4,5], so it is possible that the increased frequency of migraine in the authors' obese patients occurred only in those with sleep apnea. The mechanism may operate through hypoxia, and the obese also have an increased susceptibility to hypoxia (e.g. Pickwickian syndrome). It was recently suggested [6] that hypoxia may be the common precipitator of migraine, as also reflected in migraine's increased occurrence at altitude [7] and in patients with arteriovenous malformations (AVM) with reduction in migraine following embolization of the AVM. [8] Disclosure: The author reports no conflicts of interest.
Reply from the authors 7 August 2006
Marcelo E. Bigal, Albert Einstein College of Medicine , Richard B. Lipton Send Correspondence to journal: Re: Reply from the authors mbigal{at}aecom.yu.edu Marcelo E. Bigal, et al.	Thank you for the opportunity to respond to Iwasaki and Gilbert. Though obesity was not a risk factor for migraine in our study, we found that obese migraine sufferers had more frequent, painful and disabling headaches than those who were normal weighted. [1] In separate studies, we also showed that obesity is a longitudinal risk factor for incident chronic daily headache (headache > 15 days per month) and that the association of obesity with transformed migraine is robust while the association of obesity with chronic tension type headache is modest. [2,9] Iwasaki and Gilbert both ask about the potential role of sleep apnea in the exacerbation of migraine in obese subjects. Though we can not directly test this hypothesis, obesity and snoring are independent risk factors for chronic daily headache. [2] If snoring is a reasonable proxy for sleep apnea, then the influence of obesity on migraine frequency appears to be independent of sleep apnea. This is an excellent area for further research. Iwasaki and Ikeda also identify hyperlipidemia and mitochondrial dysfunction as factors which may confound or contribute to the relationship between migraine and obesity. Unfortunately, we do not have the data to test these reasonable hypotheses. Obesity is a proinflammatory state, associated with hyperlipidemia, hypertension and insulin resistance in the metabolic syndrome. [10]. Additional research is required to disentangle the contribution of these features, separately and in combination, to the worsening of migraine and the emergence of chronic daily headache. Though we recently reviewed mitochondrial dysfunction in migraine [11]), we do not know how this is connected with obesity. Nor do we know if the duration of obesity contributes to migraine exacerbations or if weight loss reduces headache frequency or severity. The identification of factors that exacerbate migraine and contribute to its progression is in its infancy. We look forward to finding more satisfactory answers to the excellent questions raised in these letters. References 1.Bigal ME, Liberman JN, Lipton RB. Obesity and migraine:A population study.Neurology 2006;66:545-550. 2.Scher AI, Stewart WF,Ricci JA, Lipton RB.Factors associated with the onset and remission of chronic daily headache in a population-based study.Pain 2003;106:81-89. 3.Schoenen J. Deficient habituration of evoked cortical potentials in migraine:A link between biology,behavior and trigeminovascular activation? Biomed Pharmavother 1996;50:71-78. 4. Loh NK, Dinner DS, Foldvary N, Skobieranda F, Yew WW. Do patients with obstructive sleep apnea wake up with headaches? Ann Intern Med 1999;159:1765-1768. 5. Ulfberg J, Carter N, Talback M, and Edling C. Headache, snoring, and sleep apnea. J Neurol 1996; 243:621-625. 6. Gilbert GJ. The Purpose of Migraine. Quarterly J. FL Med. Assn 2005;26-27. 7. Silber E, Sonnenberg P, Collier DJ, Pollard AJ, Murdoch DR, Goadsby PI. Clinical features of headache at altitude. A prospective study. Neurology 2003;60:1167-1171. 8. Post MC, Thijs V, Schonewille WJ, Budts W, Snijder RJ, Plokker HWM, and Westermann CJJ. Embolization of pulmonary arteriovenous malformations and decrease in prevalence of migraine. Neurology 2006;66:202-205. 9. Bigal ME, Lipton RB. Obesity is a risk factor for transformed migraine but not chronic tension-type headache. Neurology 2006; 67: 252-257. 10. Shoelson SE, Lee J, Goldfine AB. Inflammation and insulin resistance. J Clin Invest. 2006;116:1793-801. 11. Sparaco M, Feleppa M, Lipton RB, Rapoport AM, Bigal ME. Mitochondrial dysfunction and migraine: evidence and hypotheses. Cephalalgia. 2006;26:361-72. Disclosure: Ortho-McNeil Neurologics funded the analysis of this study discussed in this Correspondence. Drs. Bigal and Lipton have received honoraria from Ortho-McNeil Neurologics unrelated to this study.