Prevalence of trigeminocervical convergence mechanisms in episodic and chronic migraine

Abstract

Background: Migraine pain location and trigeminocervical convergence have limited diagnostic value and have usually been assessed using non-standard verbal descriptors in a small number of centers. Objective: To use non-verbal descriptors of migraine pain location to determine the prevalence of trigeminocervical convergence mechanisms in patients with episodic and chronic migraine. In addition, we explored the factors associated with the presence of convergence. Methods: A multicenter study was carried out. The explicit pain location was explored by asking subjects to indicate, on an electronic form, three points on the anterolateral side and three points on the posterolateral side of the head and neck that represented the common locations of their migraine pain. We evaluated associations of the pain pattern with demographic and psychological features, comorbidities, lifestyle and other headache characteristics. Results: 97 episodic and 113 chronic migraine patients were included. Convergence was present in 116 migraineurs (55%) who indicated dominance of pain in the posterior cervical region. This site was more often involved in the chronic migraine group (21 vs. 33%; p=0.034). The number of migrainous/altered sensitivity symptoms (OR=1.39; 95%CI 1.14–1.71) was associated with convergence independently of the chronification status. In this symptom group, there were statistical associations between convergence and vomiting (p=0.045), tactile allodynia (p<0.001), nuchal rigidity (p<0.001) and movement allodynia (p=0.031). Conclusions: Trigeminocervical convergence is common in migraineurs and, in practice, it might be found frequently in chronic migraineurs. Some features commonly found in this group, such as altered sensitivity symptoms, are associated with this phenomenon.

RESUMO

Antecedentes: A localização da dor da migrânea e a convergência trigeminocervical têm valor diagnóstico limitado geralmente sendo avaliadas por meio de descritores verbais não padronizados em um pequeno número de centros. Objetivo: Usar descritores não verbais da localização da dor migranosa para determinar a prevalência de mecanismos de convergência trigeminocervical em pacientes com migrânea episódica e crônica. Além disso, exploramos os fatores associados à presença de convergência. Métodos: Um estudo multicêntrico foi realizado. A localização explícita da dor foi explorada solicitando aos migranosos que indicassem, em um formulário eletrônico, três pontos no lado anterolateral e três pontos no lado posterolateral da cabeça e pescoço representando a localização comum de sua dor migranosa. Avaliamos a associação do padrão de dor com características demográficas e psicológicas, comorbidades, estilo de vida e outras características da cefaleia. Resultados: 97 pacientes com migrânea episódica e 113 com migrânea crônica foram incluídos. A convergência esteve presente em 116 migranosos (55%) que indicaram um predomínio da dor na região cervical posterior. Este local estava mais frequentemente envolvido no grupo migrânea crônica (21 vs. 33%; p=0,034). O número de sintomas de migrânea/sensibilidade alterada (OR=1,39; IC95% 1,14–1,71) foi associado à convergência independentemente do estado de cronificação. Nesse grupo de sintomas, houve associações entre convergência e vômito (p=0,045), alodinia tátil (p<0,001), rigidez de nuca (p<0,001) e alodinia ao movimento (p=0,0031). Conclusões: A convergência trigeminocervical é comum em pacientes com migrânea e, na prática, podemos encontrá-la com frequência em pacientes com migrânea crônica. Algumas características comumente encontradas nesse grupo, como sintomas de sensibilidade alterada, estão associadas a esse fenômeno.

Keywords:

Headache - Migraine Disorders - Neck Pain

Palavras-chave:

Cefaleia - Transtornos de Enxaqueca - Cervicalgia

Authors’ contributions:

All authors contributed equally to this work.

Support

This study was financed in part by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior – Brazil (CAPES) – Finance Code 001 (grant number 88887.465414/2019-00). This work was sponsored by Allergan (grant number PG-2020-10985). The funders had no role in the study design, data collection and analysis, decision to publish or preparation of the manuscript.

Publication History

Received: 17 March 2021

Accepted: 31 May 2021

Article published online:
06 February 2023

• References

• 1 Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders. 3rd. Cephalalgia. 2018. Jan;38(01) 1-211 https://doi.org/10.1177/0333102417738202
• 2 Kelman L. Migraine pain location: a tertiary care study of 1283 migraineurs. Headache 2005; Sep; 45 (08) 1038-1047 https://doi.org/10.1111/j.1526-4610.2005.05185.x
• 3 Fernández-de-Las-Peñas C, Falla D, Palacios-Ceña M, Fuensalida-Novo S, Arias-Buría JL, Schneebeli A. et al. Perceived pain extent is not associated with widespread pressure pain sensitivity, clinical features, related disability, anxiety, or depression in women with episodic migraine. Clin J Pain 2018; Mar; 34 (03) 217-221 https://doi.org/10.1097/AJP.20210095202100950537
• 4 Uthaikhup S, Barbero M, Falla D, Sremakaew M, Tanrprawate S, Nudsasarn A. Profiling the extent and location of pain in migraine and cervicogenic headache: a cross-sectional single-site observational study. Pain Med 2020; Dec; 21 (12) 3512-3521 https://doi.org/10.1093/pm/pnaa282
• 5 Piovesan EJ, Kowacs PA, Oshinsky ML. Convergence of cervical and trigeminal sensory afferents. Curr Pain Headache Rep 2003; Oct; 7 (05) 377-383 https://doi.org/10.1007/s11916-003-0037-x
• 6 Piovesan EJ, Kowacs PA, Tatsui CE, Lange MC, Ribas LC, Werneck LC. Referred pain after painful stimulation of the greater occipital nerve in humans: evidence of convergence of cervical afferences on trigeminal nuclei. Cephalalgia 2001; Mar; 21 (02) 107-109 https://doi.org/10.1046/j.1468-2982.2001.00166.x
• 7 Dilli E, Halker R, Vargas B, Hentz J, Radam T, Rogers R. et al. Occipital nerve block for the short-term preventive treatment of migraine: a randomized, double-blinded, placebo-controlled study. Cephalalgia 2015; Oct; 35 (11) 959-968 https://doi.org/10.1177/0333102414561872
• 8 Andreou AP, Edvinsson L. Mechanisms of migraine as a chronic evolutive condition. J Headache Pain 2019; Dec; 20 (01) 117-117 https://doi.org/10.1186/s10194-019-1066-0
• 9 Serrano D, Lipton RB, Scher AI, Reed ML, Stewart WBF, Adams AM. et al. Fluctuations in episodic and chronic migraine status over the course of 1 year: implications for diagnosis, treatment and clinical trial design. J Headache Pain 2017; Oct; 18 (01) 101-101 https://doi.org/10.1186/s10194-017-0787-1
• 10 Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy. 6th ed.. Philadelphia: Lippincott Williams & Wilkins; 2010
• 11 Karsan N, Bose P, Goadsby PJ. The Migraine Premonitory Phase. Continuum (Minneap Minn); 2018. Aug 24; (4, Headache) 996-1008 https://doi.org/10.1212/CON.20210095202100950624
• 12 Florencio LL, Chaves TC, Branisso LB, Gonçalves MC, Dach F, Speciali JG. et al. 12 item allodynia symptom checklist/Brasil: cross-cultural adaptation, internal consistency and reproducibility. Arq Neuro-Psiquiatr 2012; Nov; 70 (11) 852-856 https://doi.org/10.1590/S0004-282X2012001100006
• 13 Fragoso YD. MIDAS (Migraine Disability Assessment): a valuable tool for work-site identification of migraine in workers in Brazil. Sao Paulo Med J 2002; Jul; 120 (04) 118-121 https://doi.org/10.1590/S1516-31802002000400006
• 14 Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001; Sep; 16 (09) 606-613 https://doi.org/10.1046/j.1525-1497.2001.016009606.x
• 15 Spitzer RL, Kroenke K, Williams JBW, Löwe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med 2006; May; 166 (10) 1092-1097 https://doi.org/10.1001/archinte.166.10.1092
• 16 Giffin NJ, Ruggiero L, Lipton RB, Silberstein SD, Tvedskov JF, Olesen J. et al. Premonitory symptoms in migraine: an electronic diary study. Neurology 2003; Mar; 60 (06) 935-940 https://doi.org/10.1212/01.WNL.0000052998.58526.A9
• 17 Blau JN, MacGregor EA. Migraine and the neck. Headache 1994; Feb; 34 (02) 88-90 https://doi.org/10.1212/01.WNL.0000052998.58526.A9
• 18 de Queiroz LP, Rapoport AM, Sheftell FD. Clinical characteristics of migraine without aura. Arq Neuro-Psiquiatr 1998; Mar; 56 (01) 78-82 https://doi.org/10.1590/s0004-282x1998000100012
• 19 Ashina S, Bendtsen L, Lyngberg AC, Lipton RB, Hajiyeva N, Jensen R. Prevalence of neck pain in migraine and tension-type headache: a population study. Cephalalgia 2015; Mar; 35 (03) 211-219 https://doi.org/10.1177/0333102414535110
• 20 Calhoun AH, Ford S, Millen C, Finkel AG, Truong Y, Nie Y. The prevalence of neck pain in migraine. Headache 2010; Sep; 50 (08) 1273-1277 https://doi.org/10.1111/j.1526-4610.2009.01608.x
• 21 Lipton RB, Fanning KM, Buse DC, Martin VT, Reed ML, Manack Adams A. et al. Identifying natural subgroups of migraine based on comorbidity and concomitant condition profiles: results of the Chronic Migraine Epidemiology and Outcomes (CaMEO) study. Headache 2018; Jul; 58 (07) 933-947 https://doi.org/10.1111/head.13342
• 22 Calhoun AH, Ford S, Pruitt AP. Presence of neck pain may delay migraine treatment. Postgrad Med 2011; Mar; 123 (02) 163-168 https://doi.org/10.3810/pgm.2011.03.2274
• 23 Barón J, Ruiz M, Palacios-Ceña M, Madeleine P, Guerrero ÁL, Arendt-Nielsen L. et al. Differences in topographical pressure pain sensitivity maps of the scalp between patients with migraine and healthy controls. Headache 2017; Feb; 57 (02) 226-235 https://doi.org/10.1111/head.12984
• 24 Palacios-Ceña M, Lima Florencio L, Natália Ferracini G, Barón J, Guerrero ÁL, Ordás-Bandera C. et al. Women with chronic and episodic migraine exhibit similar widespread pressure pain sensitivity. Pain Med 2016; Nov; 17 (11) 2127-2133
• 25 Florencio LL, Giantomassi MCM, Carvalho GF, Gonçalves MC, Dach F, Fernández-de-Las-Peñas C. et al. Generalized pressure pain hypersensitivity in the cervical muscles in women with migraine. Pain Med 2015; Aug; 16 (08) 1629-1634 https://doi.org/10.1111/pme.12767