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April 22, 2014; 82 (16) Article

Reduction in perceived stress as a migraine trigger

Testing the “let-down headache” hypothesis

Richard B. Lipton, Dawn C. Buse, Charles B. Hall, Howard Tennen, Tiffani A. DeFreitas, Thomas M. Borkowski, Brian M. Grosberg, Sheryl R. Haut
First published March 26, 2014, DOI: https://doi.org/10.1212/WNL.0000000000000332
Richard B. Lipton
From the Saul B. Korey Department of Neurology (R.B.L., D.C.B., C.B.H., T.A.D., T.M.B., B.M.G., S.R.H.) and Department of Epidemiology and Population Health (R.B.L., C.B.H.), Albert Einstein College of Medicine, Bronx; Montefiore Headache Center (R.B.L., D.C.B., T.A.D., B.M.G.), Bronx, NY; and Department of Community Medicine (H.T.), University of Connecticut School of Medicine, Farmington, CT.
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Dawn C. Buse
From the Saul B. Korey Department of Neurology (R.B.L., D.C.B., C.B.H., T.A.D., T.M.B., B.M.G., S.R.H.) and Department of Epidemiology and Population Health (R.B.L., C.B.H.), Albert Einstein College of Medicine, Bronx; Montefiore Headache Center (R.B.L., D.C.B., T.A.D., B.M.G.), Bronx, NY; and Department of Community Medicine (H.T.), University of Connecticut School of Medicine, Farmington, CT.
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Charles B. Hall
From the Saul B. Korey Department of Neurology (R.B.L., D.C.B., C.B.H., T.A.D., T.M.B., B.M.G., S.R.H.) and Department of Epidemiology and Population Health (R.B.L., C.B.H.), Albert Einstein College of Medicine, Bronx; Montefiore Headache Center (R.B.L., D.C.B., T.A.D., B.M.G.), Bronx, NY; and Department of Community Medicine (H.T.), University of Connecticut School of Medicine, Farmington, CT.
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Howard Tennen
From the Saul B. Korey Department of Neurology (R.B.L., D.C.B., C.B.H., T.A.D., T.M.B., B.M.G., S.R.H.) and Department of Epidemiology and Population Health (R.B.L., C.B.H.), Albert Einstein College of Medicine, Bronx; Montefiore Headache Center (R.B.L., D.C.B., T.A.D., B.M.G.), Bronx, NY; and Department of Community Medicine (H.T.), University of Connecticut School of Medicine, Farmington, CT.
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Tiffani A. DeFreitas
From the Saul B. Korey Department of Neurology (R.B.L., D.C.B., C.B.H., T.A.D., T.M.B., B.M.G., S.R.H.) and Department of Epidemiology and Population Health (R.B.L., C.B.H.), Albert Einstein College of Medicine, Bronx; Montefiore Headache Center (R.B.L., D.C.B., T.A.D., B.M.G.), Bronx, NY; and Department of Community Medicine (H.T.), University of Connecticut School of Medicine, Farmington, CT.
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Thomas M. Borkowski
From the Saul B. Korey Department of Neurology (R.B.L., D.C.B., C.B.H., T.A.D., T.M.B., B.M.G., S.R.H.) and Department of Epidemiology and Population Health (R.B.L., C.B.H.), Albert Einstein College of Medicine, Bronx; Montefiore Headache Center (R.B.L., D.C.B., T.A.D., B.M.G.), Bronx, NY; and Department of Community Medicine (H.T.), University of Connecticut School of Medicine, Farmington, CT.
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Brian M. Grosberg
From the Saul B. Korey Department of Neurology (R.B.L., D.C.B., C.B.H., T.A.D., T.M.B., B.M.G., S.R.H.) and Department of Epidemiology and Population Health (R.B.L., C.B.H.), Albert Einstein College of Medicine, Bronx; Montefiore Headache Center (R.B.L., D.C.B., T.A.D., B.M.G.), Bronx, NY; and Department of Community Medicine (H.T.), University of Connecticut School of Medicine, Farmington, CT.
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Sheryl R. Haut
From the Saul B. Korey Department of Neurology (R.B.L., D.C.B., C.B.H., T.A.D., T.M.B., B.M.G., S.R.H.) and Department of Epidemiology and Population Health (R.B.L., C.B.H.), Albert Einstein College of Medicine, Bronx; Montefiore Headache Center (R.B.L., D.C.B., T.A.D., B.M.G.), Bronx, NY; and Department of Community Medicine (H.T.), University of Connecticut School of Medicine, Farmington, CT.
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Citation
Reduction in perceived stress as a migraine trigger
Testing the “let-down headache” hypothesis
Richard B. Lipton, Dawn C. Buse, Charles B. Hall, Howard Tennen, Tiffani A. DeFreitas, Thomas M. Borkowski, Brian M. Grosberg, Sheryl R. Haut
Neurology Apr 2014, 82 (16) 1395-1401; DOI: 10.1212/WNL.0000000000000332

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Abstract

Objective: To test whether level of perceived stress and reductions in levels of perceived stress (i.e., “let-down”) are associated with the onset of migraine attacks in persons with migraine.

Methods: Patients with migraine from a tertiary headache center were invited to participate in a 3-month electronic diary study. Participants entered data daily regarding migraine attack experience, subjective stress ratings, and other data. Stress was assessed using 2 measures: the Perceived Stress Scale and the Self-Reported Stress Scale. Logit-normal, random-effects models were used to estimate the odds ratio for migraine occurrence as a function of level of stress over several time frames.

Results: Of 22 enrolled participants, 17 (median age 43.8 years) completed >30 days of diaries, yielding 2,011 diary entries including 110 eligible migraine attacks (median 5 attacks per person). Level of stress was not generally associated with migraine occurrence. However, decline in stress from one evening diary to the next was associated with increased migraine onset over the subsequent 6, 12, and 18 hours, with odds ratios ranging from 1.5 to 1.9 (all p values < 0.05) for the Perceived Stress Scale. Decline in stress was associated with migraine onset after controlling for level of stress for all time points. Findings were similar using the Self-Reported Stress Scale.

Conclusions: Reduction in stress from one day to the next is associated with migraine onset the next day. Decline in stress may be a marker for an impending migraine attack and may create opportunities for preemptive pharmacologic or behavioral interventions.

GLOSSARY

GAD-7=
Generalized Anxiety Disorder–7 item;
OR=
odds ratio;
PHQ-9=
Patient Health Questionnaire–9 item;
PSS=
Perceived Stress Scale;
SRSS=
Self-Reported Stress Scale

Footnotes

  • Go to Neurology.org for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.

  • Editorial, page 1388

  • Supplemental data at Neurology.org

  • Received May 8, 2013.
  • Accepted in final form December 10, 2013.
  • © 2014 American Academy of Neurology
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