Le bâillement, du réflexe à la pathologie
Le bâillement : de l'éthologie à la médecine clinique
Le bâillement : phylogenèse, éthologie, nosogénie
 Le bâillement : un comportement universel
La parakinésie brachiale oscitante
Yawning: its cycle, its role
Warum gähnen wir ?
Fetal yawning assessed by 3D and 4D sonography
Le bâillement foetal
Le bâillement, du réflexe à la pathologie
Le bâillement : de l'éthologie à la médecine clinique
Le bâillement : phylogenèse, éthologie, nosogénie
 Le bâillement : un comportement universel
La parakinésie brachiale oscitante
Yawning: its cycle, its role
Warum gähnen wir ?
Fetal yawning assessed by 3D and 4D sonography
Le bâillement foetal

mystery of yawning 





mise à jour du
30 décembre 2015
Premonitory symptoms in migraine:
A cross-sectional study in 2714 persons
Laurell K, Artto V, Bendtsen L, Hagen K, Häggström J, Linde M, Söderström L, Tronvik E, Wessman M, Zwart JA, Kallela M.
Department of Pharmacology and Clinical Neuroscience
Umea University Hospital, Sweden


Yawning and migraine
To describe the frequency and number of premonitory symptoms (PS) in migraine, the co-occurrence of different PS, and their association with migraine-related factors.
In this cross-sectional study, a validated questionnaire was sent to Finnish migraine families between 2002 and 2013 to obtain data on 14 predefined PS, migraine diagnoses, demographic factors, and migraine characteristics. The estimated response rate was 80%.
Out of 2714 persons, 2223 were diagnosed with migraine. Among these, 77% reported PS, with a mean number of 3.0 symptoms compared to 30% (p<0.001) and 0.5 symptoms (p<0.001) among 491 persons with non-migraine headaches. Yawning was the most commonly reported symptom (34%) among migraineurs. Females reported PS more frequently than males (81 versus 64%, p<_0.001) and experienced a higher number of different symptoms (mean 3.3 versus 1.8, p<0.001). All measures of migraine severity were associated with a higher burden of PS. Light and sound sensitivity showed the highest co-occurrence (kappa_=0.51, 95% CI 0.47-0.55). In a generalized linear model, age, gender, higher frequency, duration and intensity of headache, reduced working capacity, most aura symptoms, and associated symptoms of the headache phase were significantly associated with an increased in the number of PS.
PS are experienced by a majority of migraineurs. More severe migraine is associated with a higher burden of PS. Since the material was not entirely representative of the general population of migraineurs, caution should be exercised in generalizing the results.

Migraine is the most common neurological disease and is characterized by intermittent headache accompanied by nausea, vomiting, photophobia, and phonophobia (1). The premonitory symptoms (PS) of migraine are defined forewarning of a migraine attack by 2-48 hours, occurring before the aura in migraine with aura and before the onset of pain in migraine without aura,'' with fatigue, elation, depression, unusual hunger, and craving for certain foods given as examples (1). However, various PS and timespans have been used in previous studies (2-8).
The pathophysiologic basis to the PS is incompletely understood, but the involvement of hypothalamic and dopaminergic mechanisms has been suggested (9,10). Recently, glyceryl trinitrate has been used to provoke migraine-like attacks as well as PS, allowing them to be studied directly, which might increase our insight into the pathophysiology of migraine (11,12).
Previous studies have reported that between 8% and 87% of adult migraineurs (4-7) and 67% of child migraineurs (8) experience PS. Varying study populations and definitions of PS might have contributed to the wide range of reported frequencies.
In a prospective study, it was shown that, in migraineurs with PS, the onset of headache attacks can be pre- dicted several hours in advance (3). Early treatment guided by PS might be beneficial (13,14). Our objectives were to determine the frequency and number of PS among persons from Finnish migraine families, to explore the co-occurrence of different PS, and to examine the association between PS and age, gender, and migraine characteristics.
This study is, to date, the largest study of PS, including altogether 2714 persons with headache. The frequency of PS of 77% among migraineurs in this material is within the previously reported range of 8-87% (4-7), comparable to the frequency found in 100 persons seek- ing a general practitioner for migraine headache (84%) (5) and 374 migraine patients from a neurology out- patient clinic (87%) (7), but higher than in a study of 484 migraineurs in the general population (8%) (4) and 893 at a tertiary care clinic (33%) (6). Among the 137 persons below 18 years of age, the frequency of PS was 71%, which is in line with a previous report of 67% in 103 pediatric-adolescent migraine patients (8). The mean number of different PS per person of 3.0 out of a possible 14 is similar to a previously reported mean of 3.2 symptoms out of 12 (7).
The most commonly reported individual symptoms in the present study, namely yawning, mood changes, lethargy, neck symptoms, and light sensitivity, have all previously been shown to be frequent, with some vari- ation between studies (3,5-8).
As expected, PS were more than twice as common in migraine headaches as in non-migraine headaches. Persons with MwA reported PS significantly more often and experienced a higher number of PS compared to those with MwoA, which has not been reported pre- viously (4,5,7,8). The differences were much larger between the subtypes of MwA, with hemiplegic migraine having by far the highest frequency and number of PS. This is in agreement with hemiplegic migraine being at the very end of the spectrum of migraine severity.
Sound and light sensitivity showed the highest co-occurrence, which might represent a common origin, as both symptoms are aspects of sensory hypersensitivity. Yawning showed a high co-occurrence with several other symptoms; for instance, lethargy, craving, and mood changes. In a previous study exploring co-occurrences of PS, associations between these symptoms were not as strong as those between depression and irritability, concentration problems, and fatigue (7).
All measures of severity (frequency, duration, inten- sity, working capacity, attacks requiring bed rest, and presence of associated symptoms) were related to a higher burden of PS. This is in accordance with clinical impressions and previous findings that severe pain is associated with a higher number of PS than mild-moderate pain (5) and that those who experience PS have a longer duration of headache and more nausea (i.e. more is more in migraine) (6). These factors also significantly and greatly affected the PS as predictors in the regression analyses. An unpredicted exception was that scintillating scotoma was associated with a lesser burden of PS.
In this material, a relatively large number of participants reported a typical headache duration of less than 4 hours. This may be due to the large number of children (in whom a shorter duration is more common) (16), the effects of successful treatment, or the uncertainty of self-reported time estimates. In addition, the ICHD criteria for MwA do not include a minimum duration (1).
The number of PS differed across age groups and age was a significant predictor in both regression analyses. Previously, in smaller studies, age has not been asso- ciated with PS (5,7,8).
As in this study, females have been associated with a higher number of PS previously (7), while there have been no gender differences in other studies (4-6,8). In the generalized linear model, females reported a 16% higher number of PS. Females have a higher prevalence of migraine and more severe migraines than males (17), thus our findings might be explained by a stronger migraine phenotype in females.
Strengths of the study include the vast material, the large pediatric-adolescent subset, and ample information on other characteristics of the migraines.
In terms of the limitations of the study, firstly, the material did not represent the general population because the questionnaire was only distributed to migraine patients and their relatives. While the study population did consist of persons from a wide range of ages with both genders being well represented, our sampling strategy caused the material to be skewed towards those with a larger hereditary burden and more severe migraine, which was shown in that MwA was more common than MwoA and in that hemiplegic migraine was considerably more prevalent than expected, at approximately one-tenth of all migraineurs compared to an estimated 1 in 10,000 in the general population (18).
However, this allowed us to study the relationship between PS and measurements of migraine severity across their entire range.
Secondly, retrospective questions have the drawback of potential recall bias and lack the prospective recordings of the frequency and temporal aspects of the symptoms. We did not determine the frequency of the symptoms we considered to be PS during headache-free intervals, which is more readily done with a prospective approach, and this might have led to an overestimation of their rate, as several such symptoms have been shown also to be common outside the migraine attack (5).
Furthermore, all of the PS in the study were prede- fined, which could result in a lower reported frequency than with open questions in which participants are able to add their other observed symptoms. For instance, ''face changes'', which in a previous report was the most common individual PS among children, was not included (8). However, open questions might have introduced unspecific symptoms and been unfavorable for determining co-occurrences.
In conclusion, PS are experienced by a majority of migraineurs, more commonly in females. A higher burden of PS is associated with a more severe migraine. Thus, further understanding of the pathophysiology of the premonitory phase is desired to enable the development of specific therapy for this early phase of migraine that might alleviate the subsequent attack.
Clinical implications
. Increased knowledge of the occurrence of premonitory symptoms (PS) could help in understanding the pathophysiologic basis of migraine.
. Among 2223 individuals with migraine, 77% reported PS.
. More severe migraine was associated with a higher burden of PS.
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