Improvement of migraine headaches in severely obese patients after bariatric surgery
Abstract
Objectives:
Research increasingly suggests that obesity is an exacerbating factor for migraine. However, it is less clear whether weight loss may help to alleviate migraine in obese individuals. We examined whether weight loss after bariatric surgery is associated with improvements in migraine headaches.
Methods:
In this prospective observational study, 24 patients who had migraine according to the ID-Migraine screener were assessed before and 6 months after bariatric surgery. At both time points, patients had their weight measured and reported on frequency of headache days, average headache pain severity, and headache-related disability over the past 90 days via the Migraine Disability Assessment questionnaire. Changes in headache measures and the relation of weight loss to these changes were assessed using paired-sample t tests and logistic regression, respectively.
Results:
Patients were mostly female (88%), middle-aged (mean age 39.3), and severely obese (mean body mass index 46.6) at baseline. Mean (±SD) number of headache days was reduced from 11.1 ± 10.3 preoperatively to 6.7 ± 8.2 postoperatively (p < 0.05), after a mean percent excess weight loss (%EWL) of 49.4%. The odds of experiencing a ≥50% reduction in headache days was related to greater %EWL, independent of surgery type (p < 0.05). Reductions in severity were also observed (p < 0.05) and the number of patients reporting moderate to severe disability decreased from 12 (50.0%) before surgery to 3 (12.5%) after surgery (p < 0.01).
Conclusions:
Severely obese migraineurs experience marked alleviation of headaches after significant weight reduction via bariatric surgery. Future studies are needed to determine whether more modest, behaviorally produced weight losses can effect similar migraine improvements.
Classification of evidence:
This study provides Class III evidence that bariatric surgery is associated with reduction of migraine headaches in severely obese individuals.
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Copyright © 2011 by AAN Enterprises, Inc.
Publication History
Received: August 27, 2010
Accepted: December 21, 2010
Published online: March 28, 2011
Published in print: March 29, 2011
Disclosure
Dr. Bond serves on the editorial boards of Surgery for Obesity and Related Diseases and American Journal of Health Behavior and receives research support from the NIH (NIDDK/ NCI). Dr. Vithiananthan reports no disclosures. Dr. Nash serves as an Associate Editor for Annals of Behavioral Medicine and served as an Associated Editor for Journal of Behavioral Medicine; receives publishing royalties for Doing Data Analysis with SPSS version 16 (Cengage Publishing, 2009); and receives research support from the NIH/NCI. Dr. Thomas serves as a consultant for the University of Pennsylvania, School of Medicine, Center for Weight and Eating Disorders; and receives research support from the NIH, the American Diabetes Association, and The Obesity Society. Dr. Wing receives research support from the NIH (NIDDK/NHLBI/NCI).
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We read with great interest the article by Bond et al. who reported an improvement of migraine headaches in severely obese patients after bariatric surgery. [1] The authors speculated that obesity is associated with an increase of proinflammatory molecules implicated as pain mediators in neurovascular inflammation, which generates migraine pain.
In our opinion, the improvement of migraine headaches reported could be due, at least in part, to an improvement in obstructive sleep apnea syndrome (OSAS). Obesity is the principal risk factor for developing OSAS, as a 10% weight gain increases the risk of developing OSAS by six times. [2] The prevalence of OSAS in patients presenting for weight loss surgery is greater than 70% [3], and surgically induced weight loss significantly improves OSAS and parameters of sleep quality. [4]
In the same issue of Neurology, Kallweit et al. reported a decrease in migraine frequency in patients with OSAS effectively treated by CPAP. [5]. If the treatment of OSAS reduces migraine severity and weight loss improves OSAS, the improvement of migraine headaches found by Bond et al. could be due to improvement of OSAS after weight loss following bariatric surgery.
The pathophysiological hypothesis is that hypoxia in the context of OSAS might be a trigger for migraine, but the improvement of migraine could also be due to improvement in sleep quality and continuity induced by treatment of OSAS. We believe that particular attention should be paid to symptoms of sleep apnea in obese patients and future studies evaluating the relationship between obesity and migraine should include routine screening for OSAS.
References
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Disclosure: Dr. Tafti served on the scientific advisory board for UCB Pharma (Belgium); received honorarium, travel funds, and research grants from UCB Pharma (Belgium) and the European Narcolepsy Network (EU-NN). Dr Heinzer received speakers' honoraria from Resmed Inc. and support from the Lancardis Foundation. Dr. Haba-Rubio reports no disclosures.
We appreciate the comments of Haba-Rubio et al. We agree that weight loss following bariatric surgery may affect migraine headaches through a variety of different mechanisms, including improvements in OSAS.
As Haba-Rubio et al. explain, OSAS is highly prevalent in patients presenting for bariatric surgery [3,6], OSAS resolves in most patients postoperatively [4,7], and migraine frequency is reduced in OSAS patients treated with CPAP. [5] However, we would like to clarify that all of the participants in our study underwent polysomnography preoperatively and were prescribed CPAP if needed.
Assuming that participants with OSAS used CPAP to a therapeutic level, improvements in migraine headaches after bariatric surgery may have occurred independent of improvements in OSAS. We also note that previous studies have shown that obesity is associated with increased migraine frequency, independent of snoring and sleep problems.[8,9]
Further research is needed to understand how OSAS influences the associations of obesity and weight loss with migraine frequency and severity. We hope that our study stimulates further study of the relationship between weight loss and migraine and potential underlying mechanisms.
References
6. Sharkey KM, Machan JT, Tosi C, Roye GD, Harrington D, Millman RP. Predicting obstructive sleep apnea among women candidates for bariatric surgery. J Womens Health (Larchmt) 2010;19:1833-1841.
7. Varela JE, Hinojosa MW, Nguyen NT. Resolution of obstructive sleep apnea after laparoscopic gastric bypass. Obes Surg 2007;17:1279-1282.
8. 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.
9. Bigal ME, Liberman JN, Lipton RB. Obesity and migraine: a population study. Neurology 2006;66:545-550.
Disclosures: See original article for full disclosure list.