抑郁是偏头痛进展的危险因素

伦敦——欧洲头痛与偏头痛信托基金国际大会上公布的有关美国偏头痛患病率与预防(AMPP)研究的分析显示，发作性偏头痛患者的抑郁症状是偏头痛从发作性进展至慢性的独立危险因素。

AMPP研究是一项目前仍在进行中的纵向人群研究，纳入24,000例重度头痛成人患者，2004~2009年间每年对患者进行1次调查。此项分析纳入的是2005年和2006年调查发现符合发作性偏头痛标准的13,500例患者。发作性偏头痛定义为过去3个月每个月的偏头痛发作天数平均≤14天，慢性偏头痛定义为每个月的偏头痛发作天数平均≥15天。在2005年队列和2006年队列中，分别有2.4%和2.2%的患者的偏头痛在下一年从发作性转变成慢性。

该分析对多个因素(皮肤异常性疼痛、医生诊断焦虑症、头痛程度、头痛频率、偏头痛症状评分、抗抑郁药使用情况、头痛驱动的药物过度使用、年龄、性别、体重指数、收入和医保状况)进行校正后发现，抑郁和药物(曲坦类和/或阿片类)过度使用是偏头痛从发作性转变至慢性的最强烈预测因素。合并抑郁的发作性偏头痛患者在下一年进展至慢性偏头痛的校正后风险是无抑郁的发作性偏头痛患者的1.65倍。

此外，在抑郁严重程度与从发作性偏头痛进展至慢性偏头痛的风险之间观察到量效关系。1,400例合并中度抑郁[患者健康问卷-9(PHQ-9)评分10~14分]的发作性偏头痛患者在下一年进展至慢性偏头痛的校正后风险是10,898例无抑郁或合并轻度抑郁的发作性偏头痛患者(在此作为对照组)的1.77倍，656例合并较重度抑郁(PHQ-9评分15~19分)的患者的该风险是对照组的2.35倍，420例PHQ-9评分20~27分的患者的该风险是对照组的2.53倍。

研究者表示，既往研究发现抑郁与偏头痛常并存，且两者之间存在双向关系，即偏头痛是新发抑郁的危险因素，抑郁也是新发偏头痛的危险因素。此外，既往研究还发现慢性偏头痛可反向转变为发作性偏头痛，每年约1/4的慢性偏头痛患者发生此类反向转变。未来研究有必要探讨以下问题，即对慢性偏头痛患者进行有效的抗抑郁治疗是否可促进慢性偏头痛反向转变至发作性偏头痛，以及对发作性偏头痛患者进行抗抑郁治疗是否可降低转变至慢性偏头痛的风险。

AMPP研究获Ortho-McNeil Neurologics公司资助。此项分析获Allergan公司资助。研究者声明是NeurogesX和Depomed公司的顾问。

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By: BRUCE JANCIN, Internal Medicine News Digital Network

LONDON – Depression in patients with episodic migraine is an independent risk factor for transformation of their headache pattern into far more burdensome chronic migraine, according to data from the landmark American Migraine Prevalence and Prevention study. 

"The study indicates that we need to look for depression in patients with episodic migraine or chronic migraine. We need to take it seriously and address this issue with patients – make the referral to a psychiatrist or treat them yourself if you’re comfortable with that. And the depression should be addressed as a problem separate from the headaches," Dr. Sait Ashina said at the European Headache and Migraine Trust International Congress.

AMPP study participants who had episodic migraine and depression were 1.65-fold more likely to progress to chronic migraine within the next year than were nondepressed participants who had episodic migraine, in an analysis extensively adjusted for potential confounding variables, reported Dr. Ashina of Albert Einstein School of Medicine, New York. 

Moreover, a dose-response relationship was evident between depression severity and risk of progression from episodic to chronic migraine. That is, the nearly 1,400 AMPP participants with episodic migraine and moderate depression as defined by a Patient Health Questionnaire–9 (PHQ-9) score of 10-14 out of a maximum possible 27 had an adjusted 1.77-fold greater risk of converting to chronic migraine within the next year than did the 10,898 episodic migraine sufferers with no or mild depression, while the 656 with moderately severe depression as evidenced by a PHQ-9 score of 15-19 had a 2.35-fold increased risk, and the 420 individuals with a PHQ-9 score of 20-27 were at 2.53-fold increased risk. 

The AMPP study is an ongoing longitudinal, population-based study in which 24,000 adults with severe headache were surveyed annually during 2004-2009. Dr. Ashina’s analysis involved nearly 13,500 participants who met criteria for episodic migraine in the 2005 or 2006 surveys. Transformation from episodic to chronic migraine within the next year occurred in 2.4% of the 2005 cohort and 2.2% of the 2006 group. Episodic migraine was defined in standard fashion as migraine headaches occurring on not more than 14 days per month averaged over the past 3 months, while chronic migraine entailed headaches on an average of 15 or more days per month. 

The depression/migraine chronification analysis was adjusted for cutaneous allodynia, physician diagnosis of an anxiety disorder, headache pain intensity, headache frequency, migraine symptom score, use of antidepressant medications, headache-driven medication overuse, age, sex, body mass index, income, and health insurance status. The two strongest predictors of migraine chronification in the multivariate analysis proved to be depression and medication overuse involving triptans and/or opioids. 

Dr. Ashina said that prior studies have established that depression and migraine are cotravelers, and that the relationship is bidirectional: That is, migraine is a risk factor for new-onset depression, and depression is a risk factor for new-onset migraine.

For example, one classic study conducted by some of the coinvestigators in Dr. Ashina’s current AMPP analysis showed a 2-year incidence of new-onset migraine of 9.3% in patients with major depression, compared with 2.9% in controls without major depression (odds ratio, 3.4). There also was a 2-year incidence of new-onset depression of 10.5% in migraineurs, compared with 2% in controls without migraine or other severe headache, for an odds ratio of 5.8 (Neurology 2003;60:1,308-12). 

And in a combined analysis of two other studies, the prevalence of depression as defined using the PHQ-9 was 9.2% in the general population, 17.2% in persons with episodic migraine, and 30.2% in those with chronic migraine. 

However, the relationship between depression and transformation of episodic to chronic migraine hasn’t previously been carefully looked at, which was the impetus for the AMPP analysis, he explained. 

Back transitions from chronic to episodic migraine are known to be common, occurring in roughly one-quarter of patients with chronic migraine per year. Whether effective treatment of depression in chronic migraine patients promotes back transition to episodic migraine, or for that matter, whether antidepressant therapy in patients with episodic migraine reduces the risk of transformation to chronic migraine, are unanswered questions – and priorities for further research, in Dr. Ashina’s view. 

At the international congress, Dr. Ashina received the prestigious Enrico Greppi Award from the Italian Society for the Study of Headaches for his research. 

The AMPP study is funded by a grant from Ortho-McNeil Neurologics. Dr. Ashina’s analysis received supplemental funding in the form of a research grant from Allergan. He reported having served as a consultant to NeurogesX and Depomed.

学科代码：神经病学 精神病学 麻醉与疼痛治疗　　　关键词：欧洲头痛与偏头痛信托基金国际大会 抑郁与偏头痛
来源： EGMN