Wednesday, June 26, 2013

CPAP Improves Migraine Burden in Patients With Sleep Apnea

BARCELONA, Spain — For migraine sufferers with obstructive sleep apnea (OSA), continuous positive airway pressure (CPAP) treatment can decrease the frequency of migraine attacks, their duration, and intensity. In addition, medication use and lost days from work were reduced, a study shows.

Presenting results here at the 23rd Meeting of the European Neurological Society (ENS), Hildegard Hidalgo, MD, from the Department of Neurology at Kamillus-Klinik in Asbach, Germany, said that 25% of patients with OSA also have migraines and that the frequency of OSA in patients with migraine is similar to that in the general population: about 12% in migraine without aura and about 7% in migraine with aura.

Migraine may be triggered by several factors, including foods, hormonal status, drugs, psychological state, sleep deficit or excess, sensory input, and environmental conditions, including altitude and hypoxia. In this prospective study, the researchers investigated the possible role of hypoxia during sleep and the long-term effects of CPAP therapy on migraine.

They screened 314 potential participants with OSA. Inclusion criteria were an apnea-hypopnea index (AHI) greater than 15 or greater than 5 with clinical symptoms (excessive daytime sleepiness, nonrefreshing sleep, sleep fragmentation, nocturia, decreased concentration, memory loss, or morning headaches), and a diagnosis of migraine according to International Classification of Headache Disorders, second edition, criteria. Additional inclusion criteria were being free of migraine prophylactic medications, oxygen therapy, or other central nervous system medications, and not having any other neurologic or psychiatric disorders. In-hospital video polysomnography was performed.

Of the 314 potential participants, 41 (13.1%) were included in the study, with an average age of 48.9 years and mean body mass index 30 ± 6.1 kg/m2 (20 women). They had a mean Epworth Sleepiness Scale score of 9.8 ± 4.8 and a mean AHI of 27.4 ± 25.4 episodes/hour at baseline. Twenty-one had migraine with aura, 19 had migraine without aura, and 1 had chronic migraine.

Thirty patients (73.2%) accepted CPAP therapy, with data on 24 at 1 year and on 18 at 2 years. Two patients dropped out because they did not accept CPAP long term, 3 were nonadherent (CPAP use <90%), and 7 were not accessible.

Improved Sleep Measures and Migraine Burden
Compared with baseline, polysomnography showed significant improvements at 1 year in AHI, mean duration of sleep-related breathing disorders, oxygen desaturation index (all P < .001), arousal index (P < .002), slow wave sleep (P = .031), and other measures. CPAP therapy significantly reduced migraine measures and disease burden.

Table. Migraine Measures and Disease Burden With CPAP
 
Migraine Measures At Diagnosis (n = 41) 1 Year (n = 24) 2 Years (n = 18)
Frequency of attacks (d/wk) 1.2 0.2 0.1
Attack duration (h) 22 3 3
Intensity 2.7 0.8 0.3
Burden of disease      
Medication intake (units/wk) 2.2 0.3 <0.1
Inability to work (d/mo) 1.2 0.3 0.3
Lost free days (d/mo) 2.1 0.4 0

Dr. Hidalgo concluded that CPAP is an effective therapy for both OSA and migraine in patients with both conditions. It improved nocturnal oxygen saturation, stabilized sleep, and increased slow wave sleep as a proportion of total sleep time. It also reduced the burden of migraine, so she recommended that symptoms of OSA should be considered in migraineurs.

A Single Treatment
Session moderator Pierre Maquet, MD, PhD, professor of neurology at the University of Li├Ęge in Belgium, who was not involved in the study, commented to Medscape Medical News that the study is interesting, especially because at least migraine with aura is recognized as a risk factor for stroke, as is apnea, "so it's nice to see that there is some way to treat both with a single treatment."

However, he pointed out that the study suffers from a lack of a control population, such as participants possibly receiving low-pressure CPAP as a sham treatment or periods of the night in which the CPAP is turned off. "So they can't assess which is the proportion of the effect which is due to the treatment and what's the proportion that is just due to placebo effect, he said.

He noted that the mere fact of having contact with patients over 2 years might explain part of the effect. "The more you see patients, the better they get," he said. A better experiment, he explained, may be a randomized, placebo-controlled, crossover study.

Nonetheless, Dr. Maquet said it makes sense that CPAP could aid migraines. Although no one knows the causes of migraines, they may involve a failure of energy metabolism in the neurons, so hypoxia could induce disruption of metabolism.

The study was not commercially funded. Dr. Hidalgo and Dr. Maquet have disclosed no relevant financial relationships.
23rd Meeting of the European Neurological Society (ENS). Abstract O314. Presented June 10, 2013.

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