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Received: 25 May 2018 Revised: 1 August 2018 Accepted: 10 August 2018 DOI: 10.1111/ane.13014
ORIGINAL ARTICLE
Multimorbidity in patients with chronic migraine and medication overuse headache Domenico D’Amico1 | Emanuela Sansone1 | Licia Grazzi1 | Ambra M. Giovannetti2 | Matilde Leonardi3 | Silvia Schiavolin3 | Alberto Raggi3 1 Neuroalgology Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
Abstract
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Objectives: Patients with chronic migraine (CM) display a considerable amount of
Unit of Neuroepidemiology, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
3 Neurology, Public Health and Disability Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
Correspondence Alberto Raggi, Neurology, Public Health and Disability Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy. Email:
[email protected]
comorbidities, particularly psychiatric and cardiovascular, and the presence of multiple comorbidities, that is, the so-c alled multimorbidity, is a risk factor for migraine chronification or maintenance of CM. Our aim was to address the rate and impact of multimorbidity in patients with CM and medication overuse headache (MOH). Materials & Methods: In a sample of patients with CM attending a structured withdrawal for coexisting MOH, we defined multimorbidity as the presence of two or more conditions in addition to CM-MOH. We compared patients with and without multimorbidity for demographic and clinical variables, quality of life, and disability; we also tested whether patients with multimorbidity had higher likelihood to attend emergency room, relapse into CM, and require further withdrawal treatments by 12 months. Results: One hundred and ninety-four patients were enrolled as follows: 61% had at least one comorbidity, the most common being mental (34%), circulatory (18%), and endocrine conditions (13%); 32% were multimorbidity cases. Patients with multimorbidity had higher headaches frequency, older age, lower education and lower employment rates, higher disability and lower QoL. They were more frequently opioids/barbiturates overusers and were more likely to attend ER (OR: 2.36), relapse into CM (OR: 2.19), and undergo another withdrawal (OR: 2.75) by 12 months after discharge, after controlling for age, gender, years of education, and headache frequency. Conclusions: Recognizing multimorbidity in patients with CM-MOH is important to enhance the management of these complex patients, who are at risk of polypharmacy and increased health care utilization. KEYWORDS
comorbidity, disability, medication overuse headache, multimorbidity, quality of life, relapse rate, withdrawal
Acta Neurol Scand. 2018;1–8.
wileyonlinelibrary.com/journal/ane © 2018 John Wiley & Sons A/S. | 1 Published by John Wiley & Sons Ltd
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D’AMICO et al.
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1 | I NTRO D U C TI O N
CM retrieved from clinical studies include sleep disorders, obesity,
Multimorbidity, that is, the situation in which multiple comorbid-
and allergic rhinitis,14-18 depression, anxiety, post-t raumatic stress
ities present in a single patient, is associated with higher rates
disorder, and personality disorders.12,19,20
cardiovascular conditions, epilepsy, chronic pain disorders, asthma
of mortality, polypharmacy, increased health care utilization, in1-3
In sum, patients with CM display a considerable amount of co-
A review
morbidities, the most common being psychiatric and cardiovascular
comprising data from 70 million people showed that female gen-
conditions, which may be regarded as risk factors for chronification.
der, age, lower education, and socio-e conomic status are the most
However, these studies addressed a limited set of comorbidities and
important determinants of multimorbidity.4 There is no consensus
did not make explicit whether MOH was present. Moreover, the im-
on the definition of multimorbidity, and two definitions are cur-
pact of multimorbidity on QoL and disability, as well as on failure/
creased disability, and reduced quality of life (QoL).
rently of use: joint presence of two or more, or of three or more
success of withdrawal treatments in patients with CM-MOH, has not
conditions.4,5
been systematically addressed.
Poor consideration has been given to multimorbidity in headache
The aims of this paper were as follows: (a) to assess the rate of
disorders. Results from a population study addressing multimorbid-
multimorbidity in a sample of patients with CM-MOH and describe
ity (defined as the joint presence of two or more disease), in people
their comorbidity profile; (b) to address whether patients with mul-
aged >55 showed that 70% of migraine cases had multimorbidity,
timorbidity show different clinical and demographic aspects, and
with an average of 2.62 conditions: The most common were hyper-
whether the impact of CM-MOH is more burdensome; (c) to address
tension, back/neck disorders and arthritis, and age was associated
whether multimorbidity influence the outcome in terms of rates of
with higher multimorbidity rates.6 On the contrary, to the best of our
attendance to emergency room (ER) for headache, rates of relapse
knowledge, no studies on multimorbidity pattern have been carried
into CM and need for another withdrawal treatment over 12 months
out on patients with chronic migraine (CM).
following discharge from a structured withdrawal treatment. Our
Chronic migraine is a negative evolution of migraine course
hypothesis was that multimorbidity may be a common phenomenon
characterized by daily or nearly-daily headaches and is frequently
among this group of patients and that it might be associated with
associated with medication overuse headache (MOH).7 When CM is
worse disease course.
associated with MOH and to other conditions structured withdrawal of overused medications is useful to detoxify patients, stop the chronic course of headaches and improve responsiveness to acute
2 | M ATE R I A L S & M E TH O DS
and prophylactic drugs.8,9 Moreover, withdrawal was shown to impact on two of the most common comorbidities of CM, that is, de-
This study is based on a sample of 194 adult patients with CM-
pression and anxiety. In fact, the study of Bendtsen and colleagues
MOH, according to ICHD 3-b eta criteria. 6 All patients had mi-
showed that the prevalence of anxiety and depression was reduced
graine as primary headache (ie, no cases of tension-t ype) and were
by 50.7% and by 27.1%, respectively, at 6 months from withdrawal.10
consecutively recruited on a voluntary basis at the Headache
However, structured withdrawal is a costly procedure, and prelimi-
Centre of the Neurological Institute C. Besta of Milan, a third-level
nary evidence shows that a brief intervention for MOH patients—
center, between June 2011 and December 2012 on occasion of
that did not received prophylaxis and were managed in primary care
a structured withdrawal program. 21 The program included intra-
only—was effective in the short term to reduce headache days per
venous hydration and steroids and-or antiemetics, education on
month by 7.1, and to achieve 50% reduction on baseline headache in 11
the correct use of medications and promotion of healthy habits:
35% of patients : The authors concluded that this intervention may
engaging in moderate physical activity (ie, 90 minutes of aerobic
be preliminary to structured withdrawal and may be attempted in
exercise per week), remaining well hydrated, consuming three
selected patients before referral.
meals per day, and maintaining a regular sleep/wake pattern with
The presence of comorbidities is among the most relevant
at least 7-8 hours of sleep per night. 22 The study was approved by
risk factors for the onset and maintenance of CM.12 Large epi-
the institute’s ethical committee (DIS.CHRONIC protocol, No.16;
demiological studies showed that patients with CM display more
08/06/2011), and each patient signed an informed consent form
comorbidities than episodic migraineurs. Cheng and colleagues
prior to data collection. Patients were interviewed on the second
retrospectively analyzed the Taiwan National Health Insurance
or third day of treatment, that is, when clinical evaluation was
Research Database and found that CM cases had more comorbidi-
completed and blood or radiological examination results were
ties compared to episodic migraineurs, particularly hyperlipidemia,
available.
asthma, depression, bipolar disorder, and anxiety disorders.13
Frequency of headaches, defined as days with headache, and av-
Similarly, Buse and colleagues observed higher comorbidity rates
erage pain intensity were referred to the previous 3 months, QoL was
for allergies, arthritis, chronic bronchitis, and chronic obstruc-
measured with the Migraine-Specific Quality-of-Life Questionnaire
tive pulmonary disease among patients with CM compared to
Version 2.1 (MSQ ), 23 disability with the WHO-Disability Assessment
episodic migraineurs that participated to the American Migraine
Schedule, 2nd version (WHODAS 2.0)24 and symptoms of depres-
14
Prevalence and Prevention (AMPP) study.
Other comorbidities of
sion with the Beck Depression Inventory-second version (BDI-II), 25
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D’AMICO et al.
with score ≥14 indicating the presence of depressive symptoms. The
which the amount of comorbidities was
