STOWE, VT—Obesity is comorbid with episodic and chronic migraine, particularly among persons of reproductive age, according to epidemiologic studies presented at the Headache Cooperative of New England’s 24th Annual Headache Symposium. The data suggest that the risk of migraine increases with increasing weight gain and that the risk that episodic headache will transform into chronic daily headache is higher in obese patients.

The association between obesity and headache has generated heightened research interest recently, in large part because obesity is potentially modifiable and because obesity has nearly become epidemic. Results from recent studies of the association between migraine and obesity have implications for current and future therapies, including the recognition of a novel migraine biomarker such as adiponectin, said B. Lee Peterlin, DO, Associate Professor of Neurology and Director of Headache Research at the Johns Hopkins School of Medicine in Baltimore.

“What we know from the epidemiologic data is that migraine is comorbid with obesity,” Dr. Peterlin continued. “There is potential for many obesity-related proteins, including adiponectin, to be novel migraine biomarkers and drug targets. While there are data suggesting that physical activity and bariatric surgery may modulate migraine frequency, the existing data don’t currently support any particular diets specifically for migraine. And because many migraine preventatives can modulate weight, they should be chosen with the patient’s body composition in mind.”

Evidence Is Limited for Most Therapeutic Options
Clinicians can take various steps to help reduce headache frequency in their obese patients, according to Dr. Peterlin, who cited several small retrospective studies of bariatric surgery in obese individuals with episodic migraine. “All of the studies … have not been controlled, and they have relatively small numbers,” she said. “But so far, these studies suggest that there is a 50% to 75% reduction [in headache frequency] in people who have bariatric surgery for obesity reasons and who happen to also have episodic migraine.” This reduction in headache frequency may persist for as long as six months.

Data on the effect of diet on migraine are less encouraging. Studies to date have been either negative or methodologically flawed. “I tell my patients [that] we do not really know the diet that is most beneficial to migraine, but to avoid foods that they have identified as triggers, such as meats with nitrates and nitrites, pending future studies,” said Dr. Peterlin.

Recent trials have compared the efficacy of a high omega-3 and low omega-6 diet versus a low omega-6 diet. “The high omega-3 and low omega-6 diet is the most exciting diet for patients with headache,” said Dr. Peterlin. “However, it was just [studied in patients with] chronic daily headache and not episodic headache … but the research is ongoing and it’s something to keep our eye on for the future.”

Exercise May Reduce Risk of Headache
The data on migraine and exercise are more robust, said Dr. Peterlin. Epidemiologic findings suggest that lack of exercise—defined as less than three hours of exercise per month for adults—is associated with a 20% increased risk of headache in adults and an approximately 50% increased risk in adolescents. Clinical data about the effect of frequent aerobic exercise—alone or in combination with diet—indicate a decreased risk of headache.

The migraine and exercise studies focused predominantly on women who exercised for 40 to 50 minutes at a time and from two to three times per week. The study participants had much less aerobic exercise than the American Heart Association recommends, noted Dr. Peterlin. Although the organization recommends exercising at least five days per week, “as long as your patients can get in approximately two to three days per week for anywhere from 30 to 50 minutes, that may be enough to help headaches,” said Dr. Peterlin.

Two medications intended to prevent migraine result in weight gain rather than weight loss. “When I want to use a tricyclic antidepressant, I prefer protriptyline over amitriptyline or nortriptyline in someone who is overweight or obese,” said Dr. Peterlin. “Likewise, I think everybody is familiar with topiramate, an antiepileptic drug, being more weight-neutral or associated with weight loss.”

Ictal Adiponectin Levels May Correlate With Pain Severity
Adiponectin is a potential biomarker for migraine, and Dr. Peterlin and her colleagues are investigating whether ictal adiponectin levels correlate with pain severity and treatment response in episodic migraineurs. Although larger confirmatory studies are needed for baseline pain states and ictal evaluations before adiponectin can be identified as a migraine biomarker, the early findings are “exciting,” said Dr. Peterlin.

The total amount of adiponectin declined among treatment responders and increased or remained stable among nonresponders. These trends did not change as more patients enrolled in the study. “However, additional considerations with larger population samples will be needed, and further consideration for differences in regards to obesity status will need to be considered,” said Dr. Peterlin. “In addition, the population that we studied to do the ictal evaluation was all women.... This next paper will include a few men, but it won’t be enough to truly see sex differences.”

—Fred Balzac

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