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Cephalalgia 30(12) 15021508 ! International Headache Society 2010 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0333102409359710 cep.sagepub.com
Mode of occurrence of traumatic head injuries in male patients with cluster headache or migraine: Is there a connection with lifestyle?
Giorgio Lambru, Paola Castellini, Gian Camillo Manzoni and Paola Torelli
Abstract Introduction: Our study objective was to investigate the mode of occurrence of traumatic head injury in episodic cluster headache and migraine patients. Methods: We conducted a retrospective study on 400 male patients, 200 with cluster headache (cases) and 200 with migraine (controls). We investigated the frequency and mode of occurrence of traumatic head injury and some lifestyle habits. Results: The number of traumatic head injuries was significantly higher in cases than in controls (adjusted odds ratio [OR] 2.0; 95% confidence interval [CI] 1.52.8). Cases were more often responsible for the head traumas (adjusted OR 2.6; 95% CI 1.34.9) and reported a significantly higher proportion of injuries during scuffles or brawls (OR 6.5; 95% CI 2.914.8). Compared with other cluster headache patients, cases responsible for traumatic head injuries were more frequently heavy alcohol (p .000), heavy tobacco (p .03) and heavy coffee consumers (p .003). Conclusions: Cluster headache patients (a) had traumatic head injuries more frequently than migraineurs; and (b) were more often responsible for them, perhaps due to particular behaviours related to their lifestyles. Keywords cluster headache, traumatic head injury, post-traumatic headache, lifestyle
Date received: 13 November 2009; accepted: 3 December 2009
Introduction
Cluster headache (CH) is a severe, debilitating headache that occurs in about one to three people per 1000 of the general population (1,2). Several authors have suggested a relation between traumatic head injury (THI) and CH (36), but the nature of this relation is still unclear (7). A few case reports indicate a causal relationship between THI and CH, suggesting that functional or organic alterations of intra- or extracranial nervous structures may predispose to CH onset (8). An alternative hypothesis is that CH suerers develop distinctive lifestyles (9), perhaps as a result of peculiar personality traits: males with episodic CH seem to be more anxiety-prone, less successfully socialised and with more hostile attitudes toward others than controls (1012). The high rate of THI may then
represent only an epiphenomenon of these individuals behaviour, which includes the tendency to overindulge in non-essential consumption habits such as cigarette smoking and heavy alcohol and coee consumption (4,13). To dene the behaviour of episodic CH male patients with respect to THI, we evaluated the frequency and clinical features of THIs, how they occurred and whether the patients themselves were responsible for the situation in which they occurred.
University of Parma, Italy. Corresponding author: Giorgio Lambru, Headache Centre, Department of Neurology, University of Parma, c/o Ospedale Maggiore, via Gramsci 14, 43100 Parma, Italy Email: iorz@libero.it
Lambru et al. We also investigated such patient habits as cigarette smoking and alcohol and coee consumption.
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accident that induced THI or for inicting THI. Based on the most common THI causes described in the literature (15), we recognised ve categories for THI etiology: road accidents, household accidents, workplace accidents, sports accidents and other accidents which included all those causes that did not fall within those four categories. For THI from road accidents, we also recorded the type of vehicle (car, motorcycle, bicycle) and whether the patient was driving. For CH patients who had responsibility in causing their THI, we compared personal habits with those of other CH patients. In particular, we evaluated: (a) alcohol consumption, measured in alcohol units per day (16) (mild drinkers, <4 units/day; moderate drinkers, 48 units/day; heavy drinkers, >8 units/day); (b) cigarette smoking, measured in number of cigarettes per day (mild smokers, 115 cigarettes/day; moderate smokers, 1624 cigarettes/day; heavy smokers, >25 cigarettes/day) (17); and (3) coee consumption, measured as cups of coee per day (mild drinkers, 13 cups/day; moderate drinkers, 36 cups/day; heavy drinkers, >6 cups/day). By this comparison among CH patients, we tried to nd out whether there was a behavioural pattern suggesting a possible association between responsibility for THI and the tendency to overindulge in non-essential consumption habits.
Data analysis
We performed our statistical analysis using Students t-test for mean comparison and the Chi-square test. For each variable, we calculated the crude odds ratio (OR) and, when applicable, we used the Mantel-Haenszel method to estimate the adjusted odds ratio (AOR) for confounding factors (cigarette smoking and alcohol consumption). For each OR, we calculated the corresponding 95% condence interval (CI); 95% CIs for AORs were estimated by the Miettinen method. We calculated p values using the two-tailed test (a .05). For data analysis, we used the Statistical Package for the Social Sciences software (version 15) (SPSS, Chicago, IL, USA).
Results
Mean age at the rst visit to our centre was 36.6 9.8 years for cases and 36.7 9.9 years for controls. Mean age at headache onset was 24.4 8.9 years (range, 866) for cases and 23.5 8.7 years (range, 665) for controls. The main THI characteristics for cases and controls are shown in Table 1. A positive history of THI was reported by a signicantly higher number of cases than by controls (38.5% vs. 23.0%; OR 2.1, 95% CI 1.72.6; AOR 2, 95% CI 1.52.8; p .019). The dierence between the
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Table 1. Traumatic head injury characteristics in cluster headache cases and in migraine without aura controls CH No. (%) of THI patients No. (%) of THI patients with loss of consciousness No. (%) of THI patients without loss of consciousness Patients with >1 THI Mean age at first THI No. of patients with THI preceding/following headache onset Mean latency between first THI and headache onset in cases with THI preceding headache onset (years) Total no. of THIs No. (%) of THIs with loss of consciousness No. (%) of THIs without loss of consciousness 77 (38.5) 22 (11.0) 55 (27.5) 26 (13.0) 18.7 11.7 57/20 (N 77) 11.0 7.9 MO 46 (23.0) 11 (5.5) 35 (17.5) 12 (6.0) 17.9 10.1 34/12 (N 46) 8 8.5 Crude OR (95% CI) 2.1 (1.72.6) n.s. n.s. 2.3 (1.73.2) AOR (95% CI) 2.0 (1.52.8) 2.3 (1.34.2)
61 13 (21.3) 48 (78.7)
n.s. n.s.
CH cluster headache; MO migraine without aura; OR odds ratio; AOR adjusted odds ratio; CI confidence interval; THI traumatic head injury; n.s. not significant.
two groups was observed also for those with multiple THIs (OR 2.3; 95% CI 1.73.2; AOR: 2.3; 95% CI 1.34.2; p .04). The number of THIs was also higher in cases than in controls. The mean latency between the rst THI and headache onset in cases with THI preceding CH headache onset was 11 years 7.9 (Table 1). In both study groups, about one-half of THIs occurred during a road accident (Table 2), with no signicant dierences in number between patients who were driving and patients who were not: the number of patients who suered THI during a road accident was 38 for cases and 27 for controls; of these, 33 cases (86.8%) and 20 controls (74.1%) were driving at the time of the accident. A signicantly higher number of cases than of controls suered their THI during a scue or a brawl (OR 6.5, 95% CI 2.914.8; p < .05) (Table 2). In 57.4% of THIs (N 62), cases themselves were responsible for the accident that caused the injury, compared with only 34.4% (N 21) of controls (OR 2.6; 95% CI 1.34.9; p .007). The number of CH patients who were responsible for at least one THI (45/77, 58.4%) was also signicantly higher than that of controls (16/46, 34.8%) (OR 2, 95% CI 1.34.9; AOR 2.8, 95% CI 1.64.9; p .02). Table 3 reports the number of THIs for which cases and controls were responsible, grouped according to the dierent accident categories. CH patients had a signicantly higher number of THIs than controls during scues and brawls (OR: 3.4; 95% CI: 2.225.9). A comparison of non-essential habits between cases and controls showed dierences in cigarette smoking and alcohol consumption. More CH patients (N 150, 75%) than controls (N 89, 44.5%; p .000) smoked;
Table 2. Traumatic head injury etiology in cluster headache cases and in migraine without aura controls CH MO OR (95% CI)
THI no. (%) THI no. (%) Road accident Sports accident Household accident Scuffle/brawl* Workplace accident Other Missing data Total no. (%) 50 14 13 12 8 7 4 108 (46.3) (13.0) (12.0) (11.1) (7.4) (6.5) (3.7) (100) 33 12 3 1 5 5 2 61 (54.1) (19.7) (4.9) (1.6) (8.2) (8.2) (3.3) (100) n.s. n.s. n.s. 6.5 (2.914.8) n.s. n.s.
CH cluster headache; MO migraine without aura; OR odds ratio; CI confidence interval; THI traumatic head injury; n.s. not significant. *The adjusted OR for the scuffle/brawl variable was not calculated because the number of subjects was too small.
they were also more frequently moderate or heavy smokers (Table 4). In addition, only 17 (11.3%) patients who were smokers in the CH group had quit smoking, compared with 36 (40.5%) in the migraine group; the dierence was statistically signicant (p .000). Mean age at cessation of tobacco use was older (34.0 years 7.9) among former smokers with CH than former smokers with migraine (30.0 years 9.3), while mean age at initiation of tobacco use was comparable in the two groups (16.3 years 3.3 for CH patients vs. 16.7 years 3.6 for MO patients). Again, more CH patients than controls drank alcohol (149 vs. 113, 74.5% vs. 56.5%, p .000); in this case, too, they were more frequently moderate (p .002) or heavy (p .03) drinkers. No signicant
Lambru et al. dierences were observed for coee consumption between the two groups (Table 4). When we investigated the association between patients responsibility for THI and non-essential
Table 3. Responsibility for mode of occurrence of traumatic head injuries in cluster headache cases and migraine without aura controls CH MO Crude OR (95% CI) n.s. n.s. n.s. 3.4 (2.225.9) n.s. n.s. 2.6 (1.34.9)
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personal habits, we found that 26.7% of cases responsible for al least one THI (N 12/45) were heavy alcohol drinkers, 44.4% (N 20/45) were heavy smokers and 22.2% (N 10/45) were heavy coee drinkers. The dierence in behaviour from that of the other CH patients in the case group was statistically signicant: of the latter, only 5.1% (N 8/155; OR 7.2; 95% CI 2.918.2; p .000) were heavy alcohol drinkers, 26.5% (N 41/155; OR 2.2, 95% CI 1.63.1; p 0.03) were heavy smokers, and 5.8% (N 9/155; OR 5; 95%, CI 3.18.1; p .003) were heavy coee drinkers (Table 4).
THI no. (%) THI no. (%) Road accident Sports accident Household accident Scuffle/brawl Workplace accident Other Total 37 7 5 9 4 (59.7) (11.3) (8.0) (14.5) (6.5) 62 (100) 13 4 2 1 (61.9) (19.0) (9.5) (4.8) 1 (4.8) 21 (100)
Discussion
The purpose of our study was to describe THI occurrence and causal responsibility in a clinical population of CH compared to MO male patients. To our knowledge, no similar study has ever been published in the literature. The study was conducted on two homogeneous groups matched by age at headache onset, type of job
CH cluster headache; MO migraine without aura; OR odds ratio; CI confidence interval; THI traumatic head injury; n.s. not significant.
Table 4. Non-essential consumption habits in cluster headache cases and migraine without aura controls No. CH patients responsible for THI (%) 2 12 20 34 11 45 17 10 12 39 6 45 22 10 10 42 3 45 (4.4) (26.7) (44.4) (75.6) (24.4) (100) (37.8) (22.2) (26.7) (86.7) (13.3) (100) (48.9) (22.2) (22.2) (93.3) (6.7) (100) *No. other CH patients (%) 14 61 41 116 39 155 72 30 8 110 45 155 87 44 9 140 15 155 (9.0) (39.4) (26.5) (74.9) (25.1) (100) (46.5) (19.4) (5.1) (71.0) (29.0) (100) (56.1) (28.4) (5.8) (90.3) (9.7) (100)
No. CH patients (%) Tobacco intake Mild Moderate Heavy Total smokers Non-smokers Total Alcohol intake Mild Moderate Heavy Total drinkers Non-drinkers Total Coffee intake Mild Moderate Heavy Total drinkers Non-drinkers Total 16 73 61 150 50 200 89 40 20 149 51 200 109 54 19 182 18 200 (8.0) (36.5) (30.5) (75.0) (25.0) (100) (44.5) (20.0) (10.0) (74.5) (25.5) (100) (54.5) (27.0) (9.5) (91.0) (9.0) (100)
No. MO patients (%) 49 21 19 89 111 200 88 17 8 113 87 200 125 37 9 171 29 200 (24.5) (10.5) (9.5) (44.5) (55.5) (100) (41.0) (5.5) (0.5) (56.5) (40.0) (100) (62.5) (18.5) (4.5) (85.5) (14.5) (100)
p value (>.05) .000 .000 .000 .000 .000 n.s. .002 .03 .000 .000 n.s. .05 n.s. n.s. n.s.
p value (>.05) n.s. n.s. .03 n.s. n.s. n.s. n.s. .000 .05 .05 n.s. n.s. .003 n.s. n.s.
CH cluster headache; MO migraine without aura; OR odds ratio; CI confidence interval; THI traumatic head injury; n.s. not significant. *Other CH patients includes CH subjects not responsible for THI and CH subjects without THI.
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(data not shown), and number of patients driving a vehicle when a road accident was involved. We found that CH patients were more likely to incur THI than MO controls. This nding corroborates evidence from an Italian cooperative study (5), which revealed a history of THI in 30.8% of CH patients (N 120) versus 15.8% of healthy controls (N 120) (OR 2.50, 95% CI 1.284.88) and conrmed the results obtained by Manzoni et al. in another Parma University Headache Centre case series in the late 1990s (6). The latency between head trauma and subsequent onset of CH makes a causal relation between the two occurrences rather unlikely, except for rare cases of post-traumatic CH (18). Our study indicates that CH patients exhibit distinctive THI-related features compared with MO controls, namely: (a) they are more likely to incur a THI; (b) they have a higher rate of multiple THIs; (c) they have a higher rate of THI incurred during scues or brawls; (d) they are more frequently responsible for their THI, especially when incurred during scues or brawls, and the number of THIs for which they are responsible is also higher; and (e) they are more frequently cigarette smokers and alcohol drinkers. We found that the number of heavy smokers and heavy alcohol and coee drinkers was signicantly higher among CH patients who were responsible for their THI than among the other CH patients. As CH male patients are more frequently responsible for their THI and they are more likely to engage in risky behaviour prone to THI than MO controls, it is reasonable to assume that the higher THI rate in these patients is a result of their behaviour, which could be correlated to their particular lifestyle. Literature data indicate that CH patients tend to indulge more in certain habits than do healthy subjects or patients with other types of primary headache (10,13,19): in a case series of 246 CH patients, Schu rks et al. reported that more than 80% were alcohol drinkers and 65.9% were smokers (20). Our results, too, show that CH patients are more inclined than controls to smoke cigarettes and drink alcohol. We also found that the rate of tobacco-use cessation in current smokers was higher in the migraine group than in the CH group. This nding might corroborate the hypothesis that in CH patients smoking could represent a personality-/ lifestyle-related phenomenon and not just a non-essential consumption habit; that would also be the reason why only a tiny proportion of them would quit smoking. In agreement with our hypotheses, Levi et al. suggested that addictive behaviour regarding cigarette smoking in CH patients might reect certain personality characteristics (21). To determine whether there is an association between responsibility for THI and lifestyle of CH patients, we compared CH patients
Cephalalgia 30(12) responsible for their THI with the other CH patients in terms of the tendency to indulge in such habits as cigarette smoking and alcohol and coee consumption. The results of this comparison indicated that CH patients who caused themselves at least one THI were more frequently heavy smokers and heavy alcohol and coee drinkers. Our ndings support the hypothesis of a distinctive lifestyle for some CH patients, which is characterized not only by overindulging in some non-essential consumption habits, but also by the tendency to adopt certain kinds of behaviour, which lead to THI. Our hypothesis seems to be conrmed also by Sjo strand et al. who in a recent study of 23 families with 42 CH suerers and 41 non-aected rst- and/or second-degree relatives found a signicantly higher number of THI suerers, alcohol drinkers and coee drinkers among CH patients than controls. Other than a personality-/lifestyle-related phenomenon, these ndings might represent a gene-environment interaction in aected CH patients or a combination of these mechanisms (22). On the other hand, cigarette smoking is thought by some authors to have a prominent role in CH pathophysiology (23). However, it cannot be excluded that the high THI rate in CH patients is related to the psychoactive eect of their substance abuse. Literature data indicate that chronic as well as occasional heavy alcohol drinkers are more likely to incur traumatic injuries (24,25) and are more often involved in episodes of interpersonal violence, probably because of a reduction of their cognitive ability to assess risk and to make rational decisions (26). A few studies have demonstrated that cigarette smokers, too, tend to engage in more risky behaviour when they are driving vehicles and therefore are more prone to incur road accidents (27). Having adjusted the crude OR for these confounding factors, we can state that being a CH suerer is an independent factor for THI. Our study does have a few methodological limitations: (a) Data were gathered by evaluating THI retrospectively, so our ndings merely suggest an association between CH and THI; on the other hand, this approach enabled us to recruit a larger sample of CH patients than would otherwise be possible through a prospective study, given the low prevalence of CH in the general population (1,2). (b) There was a recall bias problem: patients with headache are more inclined to recall a past traumatic head injury as a way to nd an explanation for their headache. Probably, due to the extremely severe pain they suer, CH patients are more likely to remember previous head traumas than do migraine patients who experience a less severe headache. (c) Control subjects were not healthy individuals, but migraineurs; it cannot be excluded, then, that the dierences found were due to the fact that migraineurs are described by some authors as
Lambru et al. perfectionist, strict and inexible, and therefore have a lifestyle that makes them less prone to incur THI (28,29). Although not supported by statistical analysis, some observations allow us to assume that in terms of lifestyle, migraineurs do not appear to be dierent from the general population. When we compared the percentage of daily smokers and alcohol drinkers in migraine patients with data from the Italian general population, we didnt nd any remarkable dierence (17,30); moreover, no study in the literature has ever demonstrated that migraineurs suer fewer THIs than the general population or tend to be less violent. The choice of a clinical control group was dictated by practical reasons: the patient sample size was so large that it was not possible to establish a control group of healthy individuals. THI concern only moderate-to-severe injuries that had repercussions on the health condition of the injured individuals or led to emergency department admissions (31,32). By contrast, in our case series we considered all THIs, including those that did not require a medical visit. In conclusion, our study suggests that CH male subjects not only tend to overindulge in some non-essential consumption habits, but also are more prone to cause themselves THI compared with migraine patients. CH patients being prone to dangerous behaviours could be a consequence of their particular lifestyle, which could partly explain the association between CH and THI. To corroborate our results, further studies are needed to investigate the frequency and mode of occurrence of non-head traumas in CH patients versus non headache controls and to dene the personality prole of CH patients as a possible predisposing factor to their distinctive lifestyle. References
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