Trigger factors in migraine patients

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BACKGROUND: Migraine is a chronic neurological disease with several trigger factors, including dietary, hormonal and environmental factors. PURPOSE: To analyse precipitating factors in a sample of migraine patients. METHOD: Two hundred consecutive
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  Arq Neuropsiquiatr 2008;66(3-A):494-499494 Trigger facTors in Migraine PaTienTs Patrícia Timy Fukui 1  , Tessa Rachel Tranquillini Gonçalves 1  , Cintia Giunchetti Strabelli 1  , Natalia Maria Fernandes Lucchino 1  , Fernanda Cunha Matos 1  , Juliana Pinto Moreira dos Santos 1  , Eliova Zukerman  2  , Vera Zukerman-Guendler   2  , Juliane Prieto Mercante  2,4  , Marcelo Rodrigues Masruha  2,3  , Domingos Sávio Vieira  2,3  , Mario Fernando Prieto Peres 1,2,3 Abstract – Background: Migraine is a hroni neuroogia disease with seera trigger fators, inuding dietary, hormona and enironmenta fators. Purpose: To anayse preipitating fators in a sampe of migraine patients. Method: Two hundred onseutie migraine patients were interiewed about possibe trigger fators for migraine attaks. Results: Most patients showed at east one dietary trigger, fasting was the most frequent one, foowed by aoho and hooate. Hormona fators appeared in 53% , being the pre-menstrua period the most frequent trigger. Physia atiities aused migraine in 13%, sexua atiities in 2.5% and 64% reported emotiona stress a trigger fator. 81% reated some seep probem as a trigger fator. Regarding enironmenta fators, smes were reported by 36.5%. Conclusion: Trigger fators are frequent in migraine patients, its aoidane may derease headahe frequeny and aso improe patients’ quaity of ife.KEY WORDS: migraine, trigger fators. fatores desencadeantes de enxaqueca Resumo – Introdução: A enxaquea é uma doença neuroógia rônia que apresenta diersos desenadeantes omo fatores aimentares, hormonais e ambientais. Objetivo: Anaisar os fatores desenadeantes em uma amostra de paientes om enxaquea. Método: Duzentos paientes om diagnóstio de enxaquea foram questionados sobre fatores que pudessem desenadear suas rises. Resultados: 83,5% apresentaram agum fator aimentar, jejum foi o fator mais freqüente, seguido de áoo e hooate. Dos fatores hormonais, o período pré-menstrua foi o mais freqüente. Atiidade físia ausou enxaqueas em 13%, atiidade sexua em 2,5%, estresse em 64% e 81% reataram o sono omo fator desenadeante. Em reação aos fatores ambientais, odores foram desenadeantes em 36,5%. Conclusão: Os fatores desenadeantes são freqüentes em enxaquea e a sua deteção dee ser pormenorizada para que se reduza a freqüênia de rises e mehore a quaidade de ida do paiente.PAlAvRAS-cHAvE: enxaquea, fatores desenadeantes. 1 liga de cefaéia da Faudade de Mediina do ABc, São Bernardo SP, Brazi; 2 Instituto Israeita de Ensino e Pesquisa Abert Einstein, São Pauo SP, Brazi; 3 Neuroiênias, Uniersidade Federa de São Pauo, São Pauo SP, Brazi; 4 AMBAN, Instituto de Psiquiatria da FMUSP, São Pauo SP, Brazi.Reeied 4 Otober 2007, reeied in na form 6 June 2008. Aepted 23 June 2008. Dr. Mário F. Prieto Peres – Rua Joaquim Eugênio de Lima 881 / 708 - 01403-001 São Paulo SP - Brasil. E-mail: marioperes@yahoo.com Migraine is a hroni debiitating neuroogia ondi-tion with seera trigger fators. It usuay begins in hid-hood or adoesene and an remain with the patient for the whoe ife. It is more ommon in women than men, its preaene is 12% of the genera popuation, affeting 18% to 20% of women, ourring mainy during their produ-tie and reprodutie phases (20 to 50 years od). There-fore, migraine has a signiant soioeonomi impat and in patients quaity of ife 1 . Migraine is a ompex disor-der with seera pathopsysioogia mehanisms inoed, suh as hypothaami dysfuntion shown by a hronobi-oogi dysreguation, and a possibe hyperdopaminergi state 2 . A ariety of externa and interna fators hae been demonstrated to preipitate migraine attaks. Trigger fators are important in migraine management sine their aoidane may resut in a better ontro of the disorder. Seera studies are onsistent with stress, ak of seep, and fasting being the most ommon trig-ger fators 3,4 , but some other fators suh as inuding a-oho intake, exessie affeine onsumption, and hor-mona fators in women are aso reognized. In spite of its importane, itte is known about migraine trigger fa-tors in our soiety. The aim of this study was to make an anaysis of the pre-ipitating fators in a sampe of Braziian migraine patients. MeThod We studied 200 migraine patients diagnosed aording to  Arq Neuropsiquiatr 2008;66(3-A) 495 Migraine: trigger fatorsFukui et a. the Internationa cassiation of Headahe Disorders 5 . One hundred and sixty two women and thirty eight men were spe-iay asked about presene or absene of possibe trigger fa-tors for their migraine attaks. A pre-determined ist of trigger fators inuding: dietary (hooate, sausage, saami, monosodium gutamate, heese, mik, aspartame, aoho, red wine, white wine, offee, soft drink, itri fruits, ieream and nuts), fasting, hormona fa-tors (menstruation, pre menstrua period, after menstrua pe-riod, pregnany, menopause, ouation and hormona repae-ment), seep (oerseep, ak of seep, hanges in time of seep, weekend), stress (at work, at home and famiy, rying, onit, argument and aggressieness), exertiona atiities (physia, sex-ua, oughing, sneezing, to ift weight, eauation) and eniron-menta (aergy, poution, wind, rain, height, sun/arity, od weather, hot weather, hanges in the weather, igarette, air on-ditioning in the ar, home or work, odors of perfumes, food, fat, eanness produt and gasoine). The study was performed by media students at the liga de cefaeia of ABc Media Shoo under the superision of the senior author (MFPP) .It was approed by the Eti commit-ted in Researh of FMABc and registered under the number of 028/2007. resulTs Two hundred patients were anayzed, 162 women (81%) and 38 men (19%). The mean age of femae patients was 37.0 ± 11.14 and 40.7 ± 14.20 for mae, the tota aerage was 37.7. The most ommon group of trigger fators was di-etary triggers, in both women and men. In Tabe 1, it is de-sribed the main group of trigger fators and its distribu-tion aording to gender. Table 1. Trigger factors in migraine patients according to gender.  Femae%Mae%Tota%FatorsaarageFasting65.4355.2663.50Dietary64.8160.5364.004.70Hormona53.700.0043.500.95Seep75.9073.6075.502.30Atiities12.9026.3015.500.23Stress65.4063.1065.001.64Enironmenta74.0044.7068.503.18Minimum of 1 fator100100Minimum of 2 fators96.3092.10 Table 2. Number and percentage distribution of dietary trigger factors in migraine patients according to gender. Dietary fatorTotaFemaeMaen%n%n%chooate4120.503722.84410.53Sausage126.0095.5537.89Saami94.5074.3225.26Monosodium gutamate52.5053.0900cheese178.50159.2625.26Mik52.5053.0900Aspartame178.50148.6437.89Aoho6834.005332.721539.47Red wine*3919.503622.2237.89White wine2110.501811.1137.89Others4020.003119.13923.68coffee2914.502112.96821.05Soft drink31.5010.6225.26citri fruits84.0084.9400Ieream63.0042.4725.26Nuts31.5021.2312.63Minimun of 1 fator1286410564.812360.52Minimun of 2 fators7939.506540.121436.84Minimun of 3 fators4623.003726.84923.68Minimun 4 fators2814.002414.81410.53Minimun 4 fators168.00148.6425.265 Or more fators84.0063.7025.26 A the eements hae no signiant distribution with the exeption of red wine, that has the signiane of p < 0.05  Arq Neuropsiquiatr 2008;66(3-A)496 Migraine: trigger fatorsFukui et a. In Tabe 2, the dietary triggers are isted in detai. Fast-ing was the most frequent one, foowed by aoho, ho-oate, red wine and offee. Aoho intake in genera, ho-oate, red wine and offee were aso signiant. The resut of hi-square test showed that women had signianty more migraines trigger by red wine than men. In Tabe 3, stress is desribed. Work is the main ause of stress in pa-tients with migraine, being the rst for the women and men. Moreoer, other situations regarding daiy routine as famiy and home, suh as arguments between peope were aso seen as preipitating fators of migraine. Further-more, seep behaiour (oerseep or ak of seep) seems to hae an inuene in the migraine ourrene (Tabe 4).A the enironmenta fators are desribed in Tabe 5. The most frequent were sun/arity and igarette smok-ing. Regarding odors, pefume sme was the most frequent one, foowed by gasoine and onsidering air onditioning as a fator, the most important was ar air onditioning.Exertiona atiities were aso asked, being physia atiity the most frequent one.The minority (15.5%) pre-sented at east one exertiona trigger fator, 2.0% report-ed at east 2 fators and just 1.0% presented 3 or more fa-tors, being the aerage 0.23 fators. Athough ow in per-entages, exertiona triggers may be important due to its ominous srcin in seeted ases (Fig 1).One spei part of the study was dediated to hor-mona reated issues in women, menstruation, pregnany, menopause, ouation and hormona responses as a pre-ipitating fator in migraine. The eement pregnany was reported by one patient and menopause by none. Further-more, ouation and hormona repaement were ited by three patients eah. Therefore, the majority (54.32%) presented at east one hormona trigger fator, 19.14% re-ported at east 2 fators and just 0.62 % presented 3 or more fators (Fig 2).The e main trigger fators reported by the patients were fasting, foowed by stress and ak of seep (Fig 3). Then, other fators as sme and pre menstrua period were aso ited. discussion Trigger fators are ery important for migraine pa- Table 3. Number and percentage distribution of stress as trigger factors in migraine patients according to gender. StressTotaFemaeMaen%n%n%Stress at12361.5010061.72360.50 Work10351.5081.0050.002257.89 Home7236.0062.0038.271026.31 Famiy199.5016.009.8837.89crying94.507.004.3225.26conit52.503.001.8525.26Argument94.507.004.3225.26Aggressieness10.500.00012.63Minimun of 1 fator12864.00104.0064.102463.10Minimun of 2 fators7035.0058.0035.801231.503 or more fators199.5017.0010.5025.26 Table 4. Number and percentage distribution of sleep as trigger factors in migraine patients according to gender. SeepTotaFemaeMaen%n%n%Oerseep8844.007143.831744.74lak of seep12361.509961.112463.16changes in time of seep6532.505634.5795.55Weekends73.5074.3200.00Minimun of 1 fator15175.5012375.922873.68Minimun of 2 fators8643.007143.831539.47 3 or more fators4422.003722.84718.42  Arq Neuropsiquiatr 2008;66(3-A) 497 Migraine: trigger fatorsFukui et a. Table 5. Number and percentage distribution of environmental as trigger factors in migraine patients according to  gender. EnironmentaTotaFemaeMaen%n%n%Aergy115.50116.7900Poution147116.7937.89Wind52.5042.4712.63Rain31.5010.6225.26Height4242.4700Sun / carity28142314.20513.16cod weather189159.2637.89Hot weather199.50138.02615.79changes in the weather73.5053.0925.26cigarette smoking22111911.7337.89Air onditioning of52264326.54923.68 ar2311.502012.3437.89 home136.50116.7925.26 work168127.41410.53Sme7135.506338.90821.10 perfume60305332.72718.42 food157.50138.0225.26 fat63.0053.0912.63 eanness produt2110.501811.1137.89 gasoine2211.002012.3425.26Minimun of 1 fator11658.0010061.731642.10Minimun of 2 fators7638.006540.121128.95Minimun of 3 fators4422.003823.45615.79Minimun of 4 fators2512.502213.5837.89Minimun of 5 fators168.00148.6425.265 or more fators115.595.5625.26 Fig 1. Number and percentage distribution of exertional activities as trigger factors in migraine pa-tients according to gender.  Arq Neuropsiquiatr 2008;66(3-A)498 Migraine: trigger fatorsFukui et a. tients, we oud obsere that a patients had at east one trigger fator and around of 95. 5% had at east 2 trigger fators. Therefore, studying its distribution and harater-istis in a Braziian popuation euidates what iniians wi fae in daiy pratie. Athough reeant to migraine management trigger fators hae neer been studied in a arge sampe of Braziian migraineurs. This study is to our knowedge the rst of a kind to assess this issue in our popuation.Anayzing as a group, our study indiated the most fre-quent preipitating fators reported by patients were di-etary (84.5%), seep (75. 5%), enironmenta (68. 5%), stress (65%), hormona fators (43.5%) and exertiona atiities (15. 5%). Eah group researhed was subdiided into se-era eements and the most ited trigger fators was fast-ing (63. 5%), stress (61. 5%), and ak of seep (61. 5%). A-ording to Spierings et a. 4 , stress/ tension was the most frequent trigger fator (84%), foowed by fasting (82%) and seepessness (74%). In different studies 6-8 , stress was reported as the most signiant fator (72.4 % by Sharff    et a. 8 and 62% by Robbins 7 ). These resuts, in addition to the ndings in our study, suggest that psyhoogia man-agement, dietary orientation and seep hygiene reom-mendations shoud be important for migraine patients.Fasting was the most ited aspet oera, foowed by aoho intake, hooate and affeine onsumption, whih is in aordane to the iterature onsuted 4,6,7 . In-terestingy, wine was signianty more ommon as a trig-ger in women than men, showing that women are more sensitie to red wine than men. Many reasons may be re-ated to this nding, suh as different drinking habits in women ompared to men, genetiay and/or hormona mediated suseptibiity.Hormona and geneti fators may expain this nd-ing. Dietary triggers may be oerrepresented in this study beause it was the rst to be asked in the ist of triggers, when we anayze the fators isoated, not grouped, we an see stress and seep probems as emerging aspets, with simiar perentages, and magnitude. Hormona fators are ery important as triggers in women, mainy the pre menstrua period (26%) and the Fig 2. Number and percentage distribution of hormonal factors in migraine.Fig 3. Number and percentage distribution of the more frequents trigger factors in migraine patients according to gender.
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