Sunday, September 30, 2018

Pediatric migraine and obesity

As in adults, headache and obesity are highly common in the pediatric population, with conservative estimates indicating a prevalence of 17.1% and 18.5%, respectively.  Both have been linked with substantial morbidity, functional impairment, and cost, and a growing body of research suggests important associations between the 2 conditions, including frequent comorbidity and potentially overlapping risk factors, pathophysiologic mechanisms, and treatment implications.

In research published in 2010 (n=5847), risk for migraine was found to be 60% greater in overweight or obese adolescents, and a 2008 study of 273 children showed a greater prevalence of episodic migraine in those with vs without obesity (8.9% vs 2.5%, respectively).  Another investigation of 124 children found a higher migraine frequency in those with obesity compared with normal-weight or overweight children.

While the mechanisms underlying the association between migraine and obesity have yet to be elucidated, it is “likely to be multifactorial, related on both central and peripheral pathways regulating feeding and adipose tissue function, that overlap with pathways implicated in migraine pathophysiology, as well as lifestyle and environmental factors,” wrote the authors of a 2017 systematic review.6 Shared factors may include “inflammatory mediators such as the calcitonin gene-related protein, neurotransmitters such as serotonin, peptides such as orexin, and adipocytokines such as adiponectin and leptin [which] play a role both in feeding and migraine physiopathology and could explain the common pathogenesis.”

Determinants of pediatric obesity include poor nutritional habits, low physical activity, urban residence, socioeconomic status, and female gender.  Key strategies to address childhood obesity include healthy eating habits such as increased consumption of produce and fiber, eating breakfast and avoiding frequent snacking, and limiting intake of nutrient-poor foods; physical activity, ideally for 60 minutes per day at a moderate to vigorous level of intensity, and less sedentary time in general; and education of parents regarding these health-promoting behaviors and the nutritional needs of their children.

In addition, depression and anxiety have been found to affect eating behavior as well as headache frequency and disability, highlighting the need for adequate screening and referral to mental health treatment if indicated.

To learn more about the connection between migraine and obesity in pediatric patients, Neurology Advisor spoke with Lauren Doyle Strauss, DO, FAHS, assistant professor of pediatric neurology at Wake Forest University Baptist Medical Center.

Neurology Advisor: What is known about the link between migraine and obesity in children, including lifestyle factors that have an impact on this risk?

Dr Strauss: This is a very important concern that warrants attention, as rates of pediatric obesity are rising in the United States. Studies in adults have shown that obesity is not only associated with an increased risk for having migraine, but is also a known risk factor for conversion to chronic migraine. There was a large meta-analysis published in 2017, which included 288,981 participants age 18 to 98 years, that showed a 27% increased risk for migraine in obese people even when adjusted by sex and age, compared with subjects with normal weight.

Overall, data in children do support an association between pediatric obesity and headache disorders in general, but more research is needed to confirm the association specifically with pediatric migraine. We know that pediatric obesity is associated with obesity in adulthood. Addressing young-onset obesity at an early age is important due to the multiple associated health concerns that can [persist or emerge] over subsequent years.

Neurology Advisor:  What are the treatment implications for clinicians, including the role of exercise?

Dr Strauss: There are multiple implications for clinical practice and whether weight reduction will reduce the number of headaches. Many of our daily preventive medications used in the management of migraine and other headaches can be associated with weight gain, and as a result, medication choices may be limited by obesity. Topiramate, the only daily medication with [US Food and Drug Administration] approval for migraine in adolescents, can be associated with decreased appetite or weight loss. However, in the recent multicenter [National Institutes of Health]-funded CHAMP study led by Andrew Hershey, MD, PhD, and Scott Powers, PhD, both of Cincinnati Children's, topiramate did not fare as well as placebo and was associated with more side effects compared with amitriptyline.10 Topiramate may be contraindicated in the obese population, as it can interact with metformin, which is often used to treat common obesity-associated health conditions such as polycystic ovary syndrome or insulin resistance.

There are various weight loss approaches that are being studied in pediatric patients, including the role for exercise, dietary recommendations, and surgical options. In 2013, there was an Italian multicenter study of obese adolescents ([body mass index] ≥97th percentile) with migraine who were 14 to 18 years old, that examined how weight loss can affect headache outcomes.11 Participants were treated in a multidisciplinary program including dietary education, physical exercise, and behavioral therapy. Weight reduction was shown over 1 year and was significantly associated with a reduction in headache frequency and intensity.

Another study by Dr Hershey showed a positive correlation between change in [body mass index] and reduction in headache frequency.  However, these studies included behavioral therapy interventions or the elimination of foods that may also trigger migraines.

Increasing physical exercise is often recommended to overweight and obese patients as a weight-loss tool and maintenance strategy, but exercise in patients with migraine has several considerations. There is some evidence that yoga and tai chi may be particularly helpful for patients with migraine.   On the other hand, exercise can also be a trigger for some patients with migraine.

Neurology Advisor: What should be the focus of future research in this area?

Dr Strauss: More research is needed to investigate whether obesity is a risk factor for conversion from episodic to chronic migraine in pediatric patients. The overall association between obesity and migraine is likely multifactorial, and more research exploring mechanisms involving obesity-related bioactive substances and the role of the hypothalamus may help us better understand migraine pathophysiology. This understanding may lead to potential new behavioral therapies, interventions, or targeted treatments for migraine.

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