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Migraine and Stress: An Internet administered Multimodal Behavioral Treatment Intervention
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Internal Medicine.
2011 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Migraine is a disabling neurological disorder with high prevalence, the clinical manifestations of which are highly dependent on stress.

The overall theme of the present thesis was to address aspects of stress in migraine. A multimodal behavioral treatment (MBT) program was developed specifically designed for migraine and focusing on stress as a trigger and an intervention was performed using this Internet-administered program. Migraine symptoms were followed via an Internet administered diary and questionnaires were answered at regular intervals during the 11-month study period.

The thesis is based on four papers: In Paper I, life events and current stress, personality traits, and gender were studied cross-sectionally in 106 women and 44 men with migraine, who suffered at least two attacks a month at inclusion. Paper II describes a randomized controlled trial of the MBT program performed on 58 women and 25 men recruited from participants of the study described in Paper I. In the MBT study participants were randomized into one control group and two MBT groups, one of which received hand massage as part of the treatment. In Paper III, complete migraine drug use and changes in use and in drug efficacy during the MBT program were studied. In Paper IV, the salivary cortisol levels of MBT participants were evaluated as a biological stress marker.

The MBT program proved effective in decreasing migraine headache; it was feasible and there was low attrition. Moreover, MBT resulted in decreased migraine drug use and increased drug efficacy, but had no discernible effects on salivary cortisol profiles. No effect of hand massage on migraine headache frequency was seen. Personality trait profiling revealed high scores for the neuroticism factor. Stress susceptibility was the single most aberrant personality trait and correlated highly with the reported level of current stress and with experienced negative life events.

Gender differences included higher scores for women on trait anxiety, negative life events, depressive mood, anxiety, tension type headache, use of triptans, and efficacy of analgesics, whereas men displayed higher use of analgesics.

In conclusion, the efficacy and low attrition associated with the present MBT program appears promising and timely with regard to the development of better and more accessible migraine treatment. Stress susceptibility, gender, negative life events and psychosomatic comorbidity are important factors to consider in relation to the care of persons with migraine.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis , 2011. , 73 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 695
Keyword [en]
Awakening Cortisol Response, Cognitive Behavioral Treatment, Gender, Hand Massage, Internet, Life Events, Migraine, Multimodal, Personality, Salivary Cortisol, Stress, Stress Marker, Stress Susceptibility
National Category
Neurology
Research subject
Neurology
Identifiers
URN: urn:nbn:se:uu:diva-158079ISBN: 978-91-554-8139-1 (print)OAI: oai:DiVA.org:uu-158079DiVA: diva2:437780
Public defence
2011-10-14, Rosénsalen ingång 95, Barnsjukhuset, Akademiska sjukhuset, Uppsala, 09:15 (Swedish)
Opponent
Supervisors
Available from: 2011-09-23 Created: 2011-08-30 Last updated: 2011-11-03Bibliographically approved
List of papers
1. Stress in migraine: personality-dependent vulnerability, life events, and gender are of significance
Open this publication in new window or tab >>Stress in migraine: personality-dependent vulnerability, life events, and gender are of significance
2011 (English)In: Upsala Journal of Medical Sciences, ISSN 0300-9734, E-ISSN 2000-1967, Vol. 116, no 3, 187-199 p.Article in journal (Refereed) Published
Abstract [en]

Background and aim. The individual's experiences of stress as well as constitutional factors, including high neuroticism and female gender, are known determinants for migraine. The present aim was to further elucidate factors of personality and stress, including life events, in relation to gender in migraine. Methods. A cross-sectional study was performed on 150 persons, 106 women and 44 men, suffering from at least two migraine attacks a month. All obtained a doctor-defined migraine diagnosis based on a structured face-to-face interview concerning their health situation and current and prior stress. All of them also answered validated questionnaires regarding personality traits (SSP), life events, and perceived ongoing stress. Results. The personality trait inventory showed high mean scores for stress susceptibility and low mean scores for aggressiveness and adventure seeking, both for women and for men, as well as high mean scores for psychic and somatic anxiety in women. Stress susceptibility, the overall most deviant trait, correlated strikingly with current level of stress in both sexes. In women, stress susceptibility also correlated strongly with experiences of negative life events. Tension-type headache, anxiety, and depression were approximately twice as prevalent in women compared to men. Conclusions. The present study confirms previous research, showing that stress is an important factor in migraine. Stress susceptibility, life events, and concomitant psychosomatic illnesses should be considered important when evaluating individuals with migraine, and gender aspects need to be taken into account.

Keyword
Gender, life event, migraine, personality, stress
National Category
Public Health, Global Health, Social Medicine and Epidemiology Psychiatry
Identifiers
urn:nbn:se:uu:diva-156942 (URN)10.3109/03009734.2011.573883 (DOI)000292920200003 ()
Available from: 2011-08-20 Created: 2011-08-11 Last updated: 2017-12-08Bibliographically approved
2. Multimodal behavioral treatment of migraine: An Internet-administered, randomized, controlled trial
Open this publication in new window or tab >>Multimodal behavioral treatment of migraine: An Internet-administered, randomized, controlled trial
2011 (English)In: Upsala Journal of Medical Sciences, ISSN 0300-9734, E-ISSN 2000-1967, Vol. 116, no 3, 169-186 p.Article in journal (Refereed) Published
Abstract [en]

Introduction. Multimodal approaches in behavioral treatment have gained recent interest, with proven efficacy for migraine. The utility of the Internet has been demonstrated for behavioral treatment of headache disorders, but not specifically for migraine. The aim of the study was to develop and evaluate an Internet-based multimodal behavior treatment (MBT) program for migraine and to test hand massage treatment as an adjunct. Methods. Eighty-three adults, 58 women and 25 men, with at least two migraine attacks a month were recruited via advertisements. An MBT program aiming at improvements in life-style and stress coping was developed for this study and, together with a diary, adapted for use over the Internet. Participants were randomized to MBT with and without hand massage and to a control group, and were followed for 11 months. Questionnaires addressing issues of quality of life (PQ23) and depressive symptoms (MADRS-S) were used. Results. A 50%, or greater, reduction in migraine frequency was found in 40% and 42% of participants of the two groups receiving MBT (with and without hand massage, respectively), who statistically were significantly more improved than participants in the control group. No effect of hand massage was detected, and gender did not show any independent contribution to the effect in a multivariate analysis. Conclusions. MBT administered over the Internet appears feasible and effective in the treatment of migraine, but no effect of hand massage was found. For increased knowledge on long-term effects and the modes of action of the present MBT program, further studies are needed.

Keyword
Cognitive behavioral treatment, hand massage, Internet, migraine, multimodal, stress
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-156941 (URN)10.3109/03009734.2011.575963 (DOI)000292920200002 ()
Available from: 2011-08-20 Created: 2011-08-11 Last updated: 2017-12-08Bibliographically approved
3. The influence of multimodal behavioral treatment on theconsumption of acute migraine drugs: a randomized, controlled study
Open this publication in new window or tab >>The influence of multimodal behavioral treatment on theconsumption of acute migraine drugs: a randomized, controlled study
2012 (English)In: Cephalalgia, ISSN 0333-1024, E-ISSN 1468-2982, Vol. 32, no 4, 297-307 p.Article in journal (Other academic) Published
Abstract [en]

Objectives: To characterize overall drug use in migraine in conjunction with multimodal behavioral treatment.

Methods: 76 adults reporting at least two monthly migraine attacks underwent a randomized, controlled 24-week multimodal behavioral treatment intervention. Migraine drugs and symptoms were registered in an Internet-based diary.

Results: During 4256 days of baseline registration, 859 drug doses were taken during 655 of the 856 days with migraine headache. Triptans and analgesics constituted 56.7 and 38.3 percent of all doses with efficacy ratios of 0.41, and 0.20, respectively. Men displayed significantly lower drug efficacy (p = 0.001) and used triptans significantly less (p < 0.001) and analgesics significantly more (p < 0.001) than women did. At the end of multimodal behavioral treatment, total drug consumption decreased by 22 percent (p = 0.021), corresponding to 27 percent fewer days with migraine headache. Drug efficacy increased during multimodal behavioral treatment from 0.30 to 0.52 (p < 0.001), mainly explained by an increased proportion of mild attacks which also was the attack category which displayed the largest increase in drug efficacy.

Conclusions: Triptans were the most used and efficient drugs. Multimodal behavioral treatment led to decreased and more efficient drug consumption. Men used triptans less frequently.

Keyword
Migraine, medication, multimodal behavioral treatment, gender, drug use, drug efficacy
National Category
Neurology
Research subject
Neurology
Identifiers
urn:nbn:se:uu:diva-157979 (URN)10.1177/0333102412437386 (DOI)000301518200006 ()
Available from: 2011-08-30 Created: 2011-08-29 Last updated: 2017-12-08Bibliographically approved
4. Evaluation of Salivary Cortisol in Adult Migraineurs Participating in an Internet-Administered Multimodal Behavioral Treatment Program:  
Open this publication in new window or tab >>Evaluation of Salivary Cortisol in Adult Migraineurs Participating in an Internet-Administered Multimodal Behavioral Treatment Program:  
2011 (English)Manuscript (preprint) (Other academic)
Abstract [en]

Objective: To evaluate salivary cortisol as a biological stress marker in migraine and how the different measurements used were affected during the course of a multimodal stress treatment program.

Methods: Saliva samples were collected at four predetermined time points of the day at inclusion, at mid-treatment, and at treatment conclusion during the course of a controlled Internet-administered multimodal behavioral treatment (MBT) intervention focusing on stress. Seventy-six participants (52 women/24 men) reporting at least two migraine attacks a month at inclusion were enrolled. The following four measurements of salivary cortisol as putative stress markers were used: aberrant Awakening Cortisol Response (ACR; < 50% or > 160% or < 2.5 nmol/L), low daytime profiles (all values <13 nmol/L), a low daytime value(s) (< 2.5 nmol/L; excluding the bedtime value), a high bedtime value (> 6 nmol/L), and a summarizing cortisol “index”. In a multivariate model these outcome measurements were compared to the following parameters: MBT treatment time, headache level, gender, stress susceptibility, negative life events, quality of life, depressive mood, physical activity, and body mass index − chosen as independent parameters related to stress.

Results: During the course of the MBT study the rate of aberrant relative ACR (< 50% or > 160%) was high with a range of 59 to 83 percent. No differences in aberrant cortisol profiles (ACR and low daytime profile) were detected as a function of: treatment (vs. control), degree of headache improvement, gender, or body mass index. With regard to single cortisol values (day- or bedtime), the number of high bedtime values increased and the number of low daytime values decreased significantly with time for participants in MBT when compared with controls, thus providing ambiguous data on change in stress responses as a function of the intervention. Low daytime profiles correlated with stress susceptibility. Experience of strongly negative life events during childhood and adolescence correlated with low daytime values and a higher cortisol “index”. However, the inverse relationship was found for strongly negative life events that had occurred during adulthood. Increased depressive mood according to MADRS-S scores was significantly associated with aberrant ACR.

Conclusions: The great variations in salivary cortisol profiles seen here demonstrate the complexity of cortisol regulation and, hence, underscore the difficulty of using measurements of salivary cortisol as stress markers in migraine. Although the intervention showed no consistent effect on cortisol levels, data need to be cautiously interpreted. Cortisol findings relating to stress susceptibility and life events during childhood/adolescence may be of particular interest for further study.

Publisher
50 p.
Keyword
Salivary cortisol, migraine, stress, behavioral treatment, stress marker, stress susceptibility, awakening cortisol response
National Category
Neurology
Research subject
Neurology
Identifiers
urn:nbn:se:uu:diva-158064 (URN)
Available from: 2011-08-30 Created: 2011-08-29 Last updated: 2013-06-12

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