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mise à jour du
24 septembre 2006
Cephalalgia
2006;26(10):1209-1213
Migraine
The prevalence of premonitory symptoms in migraine:
a questionnaire study in 461 patients
Schoonman GG, Evers DJ, Terwindt GM, van Dijk JG, Ferrari MD.
Department of Neurology, Leiden University Medical Centre
the Netherlands

Chat-logomini

 
Yawning and migraine
 
Migraine attacks are often preceded by premonitory symptoms. Prevalence rates of migraine patients reporting one or more premonitory symptoms show considerable variability and rates range between 12% and 79%. Sources of variability might be differences in study population or research design. Using a questionnaire, we retrospectively studied the prevalence of 12 predefined premonitory symptoms in a clinic-based population. Of 461 migraine patients, 374 (81%) responded. At least one premonitory symptom was reported by 86.9% and 71.1% reported two or more. The most frequently reported premonitory symptoms were fatigue (46.5%), phonophobia (36.4%) and yawning (35.8%). The mean number of premonitory symptoms per person was 3.2 (+/- 2.5). Women reported 3.3 premonitory symptoms compared with 2.5 symptoms in men (P = 0.01). Age, education, migraine subtype (with or without aura) and mean attack frequency had no effect on the mean number of symptoms per individual. In conclusion, premonitory symptoms are frequently reported by migraine patients. Sensitivity and specificity of premonitory symptoms for migraine need to be assessed using prospective methods.
 
Introduction
Migraine is a severe paroxysmal neurovascular disorder and considered a major cause of disability by the World Health Organization. The primary cause of a migraine attack is unknown but probably lies within the central nervous system. Prior to the start of the headache phase several non-headache symptoms (often called premonitory symptoms) are reported by migraine patients, such as changes in mood, behaviour and sensory perception. In a selected population migraine patients were able to predict an upcoming migraine attack well before the start of the headache phase. Prevalence rates of patients reporting one or more premonitory symptoms range between 12% (5) and 79%. One source of variability in prevalence rate might be differences in study population. In population-based studies rates range from 12% in migraine patients without aura to 18% in migraine patients with aura, whereas in clinic-based studies prevalence rates range from 33% to 79%. Other sources of variability might be differences in study design, such as preselection of patients or unclear definitions of premonitory symptoms.
 
In this study we assessed the prevalence of 12 frequently reported premonitory symptoms using a questionnaire in a large unselected clinic-based population and only symptoms preceding two or more out of three attacks were considered a premonitory symptom.
migraine
Discussion
The proportion of migraine patients reporting premonitory symptoms was high: 86.9% of patients reported at least one symptom. This high prevalence rate is comparable to one previous clinic-based study, where the rate was 79% (6), but in contrast to two other studies, where rates were about 33%. Variability in rates might be explained by differences in study design such as preselection of patients or differences in symptoms that are included in the questionnaire. Furthermore, the study of Amery was conducted before the introduction of the IHS migraine criteria. Another source of variability might be the studied population. For example, prevalence rates in population-based studies have shown to be as low as 12%. It may be that patients identified in a population-based setting are not informed about premonitory symptoms in migraine and therefore are less aware of these symptoms. Fatigue was the most common premonitory symptom and the order of reported symptoms is comparable to a previous study in a selected population. In our study the percentage of patients presenting with aura was high. Patients with aura are more likely to consult a neurologist than those without aura and this differencemight be increased due to the fact that all patients in the Netherlands see their general practioner first in case of complaints. However, no significant differences in premonitory symptoms were seen between migraine subtypes.
 
Females reported more premonitory symptoms than males. An overlap between premonitory symptoms and premenstrual syndrome may explain this difference. Furthermore, more females reported craving and nausea as premonitory symptoms compared with males. This is an interesting finding since craving for chocolate and sweets is more common in females than in males. Nausea is also more frequently reported in females than in males inacute myocardial infarction and after anaesthesia. The physiological basis for this gender difference is not clear. Besides gender differences, cooccurrence of premonitory symptoms within one subject was studied. The strongest associations were found between depression and symptoms such as irritability, concentration problems and fatigue. Cooccurrence of these mood symptoms might not be a coincidence, since they are all part of the DSM IV criteria for dysthymic disorder and major depression.
 
There might also be an overlap between premonitory symptoms and trigger factors in migraine. A migraine trigger is any factor that on exposure or withdrawal leads to the development of a migraine attack, whereas premonitory symptoms are a consequence of an ongoing attack. For example, mental stress (either the acute episode or the relief period after an acute episode) is often considered a trigger factor in retrospective questionnaires. However, it is unclear whether migraine attacks can be triggered in an experimental provocation study. So, it could be that mental stress triggers a migraine attack or that patients perceive more mental stress because they are in the premonitory phase of a migraine attack. Future prospective diary studies or experimental studies are needed to address this question.
 
This study, as well as other retrospective studies assessing premonitory symptoms in migraine, has some limitations. First, the list of possible premonitory symptoms is based on previous studies (3, 4, 8) and may seem somewhat arbitrary. To be complete, a study should include a full exploration of all possible symptoms associated with a migraine attack. Second, non-responders may have introduced some bias. However, the response rate was 81% and there were no differences in age, sex or migraine subtype between responders and nonresponders (data not shown). Third, when should a symptom be classified as a premonitory symptom?
 
We excluded photophobia as a premonitory symptom, but it could be argued that phonophobia and nausea are actually part of the headache phase and therefore not premonitory symptoms. Furthermore, in this study we considered symptoms as premonitory if two-thirds of attacks were preceded by this particular symptom. In order to assess the sensitivity and specificity of individual premonitory symptoms for migraine attacks, possible premonitory symptoms and migraine attacks need preferably to be studied prospectively (4, 16). Also, the temporal relationship between possible premonitory symptoms, aura and the occurrence of headache needs to be assessed in a prospective design.
 
In conclusion, premonitory symptoms are frequently reported by migraine patients. Sensitivity and specificity of premonitory symptoms for migraine need to be assessed using prospective methods.
 
-Quintela E, Castillo J, Munoz P, Pascual J.Premonitory and resolution symptoms in migraine: a prospective study in 100 unselected patients.Cephalalgia. 2006;26(9):1051-1060.
 
Migraine : il y a des symptômes avant la crise chez plus de 80 % des patients
La migraine s'accompagne très souvent de symptômes autres que la céphalée avant, pendant et après la crise. Ceux qui précèdent la crise et qui sont à distinguer de l'aura elle-même, s'il y en a une, n'ont été que peu explorés dans les études cliniques. Or la valeur prédictive éventuelle de ces symptômes pourrait avoir des implications dans la prise en charge de la crise migraineuse.
 
Encore faut-il préciser la prévalence de ce type de manifestations « prémonitoires ». C'est ce à quoi s'est employée une équipe de Leiden (Pays Bas) qui a soumis 461 migraineux à un questionnaire leur demandant s'ils éprouvaient, avant la survenue de leur crise un ou plusieurs symptômes parmi douze pré-définis. Un peu plus de 80 % (374) des patients ont répondu, ce qui a permis de constater que 86,9 % d'entre eux rapportaient au moins une manifestation prémonitoire et 71,1 % deux ou plus. En fait, le nombre moyenne de symptômes prémonitoires par personne était de 3,2 +/-2,5 (3,3 chez les femmes et 2,5 chez les hommes), l'ensemble de ces chiffres témoignant d'une prévalence élevée.
 
Les symptômes les plus fréquemment signalés étaient la fatigue (46,5 % des sujets), puis la phonophobie (36,4 %) et les accès de bâillements (35,8 %). L'âge, le niveau d'éducation, non plus que le type de migraine avec ou sans aura n'ont semblé avoir d'influence sur le nombre de symptômes prémonitoires rapportés.
Ainsi une symptomatologie prodromique (à distinguer de l'aura) apparaît-t-elle très fréquente chez les sujets migraineux. Une étude plus ancienne avait montré que les sujets présentant ces manifestations prémonitoires étaient capables de prédire avec précision la survenue d'une crise de migraine.
 
Il faut néanmoins attendre des études prospectives pour établir la spécificité et la sensibilité de ces signes.
 
Il reste que sur un plan purement clinique, il est intéressant de s'enquérir auprès des patients de l'existence de tels prodromes, cette donnée étant susceptible d'influer sur la prise en charge globale de la maladie.