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Original Paper

Eur Neurol 2010;64:134139

DOI: 10.1159/000316656

Association between Body Mass Indexand Migraine

Jos F. Tllez-Zentenoa Dave Rishi Pahwaa Lizbeth Hernandez-Ronquilloa

Guillermo Garca-Ramosb Antonio Velzquezc

aDivision of Neurology, Department of Medicine, Royal University Hospital, University of Saskatchewan,

Saskatoon, Sask., Canada; bDepartment of Neurology and Psychiatry, and cBlood Bank, National Institute of

Medical Sciences and Nutrition Salvador Zubirn, Mexico City, Mexico

ly significant. No association was found between the disabil-

ity and severity of migraine and BMI. Conclusions:This study

did not find associations between severity or disability of mi-

graine and BMI. Copyright 2010 S. Karger AG, Basel

Background

Migraine and obesity are highly prevalent disorders inthe general population. The prevalence of migraine rang-es from 5 to 35% in females and from 3 to 20% in males[1]. The highest rates have been found in North-America,Latin-America and Europe compared with Africa andAsia [1]. Migraine is a public health concern with a sig-nificant impact on the individual and society. Some stud-ies have shown that obesity is comorbid with a number of

chronic pain syndromes, including fibromyalgia, backand neck pain. Little is known about the influence ofbaseline weight status on the prevalence, severity, anddisability of episodic migraine. Migraine and obesitymay be linked from a biochemical perspective [2, 3]. It hasbeen demonstrated that obesity is a pro-inflammatorystate; adipocytes can secrete a variety of cytokines, in-cluding IL-6 and tumor necrosis factor, which are cyto-

Key Words

Overweight Migraine Body mass index Aura

Abstract

Objective: To explore the prevalence of overweight andobesity in patients with migraine. Background: Previous

studies support the concept that obesity is an exacerbating

factor for migraine. Also, some studies have found an in-

creased frequency of obesity and overweight in migraine

patients compared to the normal population. Methods:We

studied 1,371 patients with migraine and 612 controls. The

migraine population was matched by gender with a healthy

control group. Results:Mean age of patients with migraine

was 38.0813.3 years and in the controls it was 34.8812.1

years. The percentage of females in both groups was similar

(migraine 81.6% vs. control 83.3%, p = 0.40). The distribution

of body mass index (BMI) in migraine patients and controlswas as follows: underweight patients (BMI !18.5) 3.1% mi-

graine versus controls 1.5%; normal (BMI 18.524.9) 44.8%

migraine versus controls 47.1%; overweight (BMI 2529.9)

38.3% migraine versus controls 33.7%; obese (BMI 3034.5)

10.3% migraine versus controls 13.6%; morbidly obese (BMI

35) 3.4% migraine versus controls 4.2%. Overweight and

obesity in migraine patients versus controls were statistical-

Received: April 21, 2010

Accepted: J une 7, 2010

Published online: July 22, 2010

Jos F. Tllez-Zenteno, MD, PhDDivision of Neurology, Department of Medicine, Royal University HospitalSaskatoon, SK S7N 0W8 (Canada)

Tel. +1 306 966 8011, Fax +1 306 966 8008, E-Mail jft084 @ mail.usask.ca

2010 S. Karger AG, Basel00143022/10/06430134$26.00/0

Accessible online at:www.karger.com/ene


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Body Mass Index in Migraine Eur Neurol 2010;64:134139 135

kines that promote inflammation [2, 3]. On the otherhand, migraine is associated with neurovascular inflam-mation involving the same cytokines [4].

The relationship between overweight, and migraineand headache in general has been the focus of clinical re-search in recent years. Some studies have shown that gen-

eral obesity or total body obesity, which is estimated withthe body mass index (BMI), has been shown to be relatedto headache disorders in several epidemiological studies.However, there is a considerable uncertainty about thenature of the obesity/headache relationship and whetherit is specific to migraine, or chronic daily headache, orheadache in general [2]. The uncertainty is caused by in-consistent observations between studies. Some studieshave demonstrated that obesity in patients with migraine(PWM) is associated with aura, high frequency of mi-graines, greater severity and with an increased frequencyof photophobia and phonophobia [5, 6]. On the other

hand, other studies have not found any association be-tween obesity and migraine and its characteristics [7].The most consistent information reports a potential as-sociation between frequent headache in patients withoverweight and chronic daily headache [8]. Finally, somestudies have not demonstrated that obesity is more fre-quent in PWM than in the general population [5, 7].

We report a large population-based study investigat-ing (1) the influence of BMI on the prevalence of episod-ic migraine, and (2) the influence of BMI on migraineclinical features, including headache frequency, pain se-verity, disability, and associated symptoms.

Methods

Methods and Sample DesignThis is a cross-sectional study performed in two large teaching

hospitals in Mexico City (National Institute of Medical Sciencesand Nutrition, and National Institute of Neurology and Neuro-surgery) and affiliated hospitals. The Inst itutional Review Boardsof both institutions approved the research protocol. The investi-gation was carried out in accordance with the latest version of theDeclaration of Helsinki.

Migraine PatientsAdult PWM were identified from the outpatient neurologyclinic of the previously mentioned hospitals. After their clinic ap-pointment, PWM were approached and asked to voluntarily par-ticipate in the study. Informed consent of participants was ob-tained before interviews and measures. A trained physician con-ducted a standardized diagnostic interview adhering to thecriteria of the International Headache Society (IHS), evaluatingthe presence of headache and its subtypes in the previous year.The headache test contains 51 questions and classifies headache

into the seven subtypes accepted by the IHS. This test assesses thetype and frequency of headache, medications and it includes abrief neurological exam to rule out secondary causes. It has beenpreviously validated in the Mexican population [911]. None ofthe patients were evaluated during a migraine episode.

Control Groups

The control group was a group of healthy people attending theblood donor bank of the National Institute of Medical Sciencesand Nutrition on the days of the migraine case recruitment. Thesecontrols participated voluntarily, had a general examination andanswered a standardized questionnaire to rule out other relevantmedical conditions. None of the controls had migraine and wereattending the clinic for clinical reasons, and al l were determinedto be healthy. The process of headache ascertainment was per-formed with the same questionnaires as in PWM.

Headache-Related Disability and Frequency of HeadachesWe used the migraine disability assessment (MIDAS) ques-

tionnaire to evaluate headache-related disability [12]. The MIDASscore was classified into four grades of severity: (I) scoring 05(minimal or infrequent disability) these migraine sufferers tendto have little or no treatment needs; (II) scoring 610 (mild or in-frequent disability) these migraine sufferers tend to have mod-erate treatment needs; (III) scoring 1120 (moderate disability);(IV) scoring 21 and more (severe disability) grade III and IVmigraine sufferers have high disability and tend to have urgenttreatment needs [12]. Frequency of headaches was ascribed tothree groups: mild = patients had migraines at least 6 times a yearor every other month, moderate = monthly headaches, and se-

vere = weekly headaches.

Body Mass IndexBMI was calculated according to the following formula:

BMI = weight (kg)/height (m)2. We defined five categories basedon BMI: underweight (!18.5), normal weight (18.524.9), over-

weight (2529.9), obese (3034.9), and morbidly obese (135).

AnalysisWe used descriptive statistics to assess frequencies and distri-

butions. As appropriate, proportions were compared with either2 test or Fishers exact test. All analyses were performed usingSPSS version 17 (SPSS Inc., Chicago, Ill., USA).

Results

General Characteristics of the CohortOur sample consists of 1,985 subjects. 1,371 (70%) were

PWM and 612 (30%) were healthy blood donors (HBD)matched by gender. In the migraine group 1,122 (81.6%)patients were females and in the HBD group 509 patients(83.3%) (p = 0.36). The height was 159.6 80.09 cm inHBD versus 160.3 8 0.82 cm in PWM (p = 0.15), theweight was 66.4813.0 kg in HBD versus 64.7813.3 kgin PWM. Finally, BMI was 25.3 84.4 in PWM versus25.884.4 in HBD (table 1).


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Tllez-Zenteno et al.Eur Neurol 2010;64:134139136

Patients with Migraine1,371 patients with headache fulfilled the criteria for

migraine according to the standardized questionnaire.Only patients with episodic migraine were included inthis study. Patients with chronic migraines were exclud-ed. The age at onset of migraine was 19.5 813.3 years,

725 patients (53%) had migraine with aura (MA) and 646(47%) had migraine without aura. The disability score(MIDAS) showed little or no disability in 192 patients(9.7%), mild disability in 138 (10.1%), moderate disabilityin 460 (33.6%), and severe disability in 581 (42.4%). Re-garding self-reported comorbidity ascertained in thisstudy, 74 patients had hypertension (9%), 2 Reynaud phe-nomenon (0.1%), 6 mitral valve prolapse (0.4%), 6 angina/myocardial infarction (0.4%), 3 stroke (0.2%), 17 epilepsy(1.2%), 32 vertigo (2.3%), 206 functional bowel disorder(15%), 20 asthma (1.5%), 126 allergies (9.2%), 250 depres-sion (18.3%), 25 mania (1.8%), 6 panic attacks (0.4%) and

188 anxiety (13.7%).

Body Mass Index in Patients with Migraine andControlsPWM had a higher proportion of overweight (38.3%)

compared with HBD (33.7%), p = 0.03. On the other hand,HBD had a higher proportion of obesity (13.6%) and mor-bid obesity (4.2%) than PWM (10.3 and 3.4%, respective-ly); only obesity was statistically significant. The presenceof underweight was more frequent in HBD than PWM(p = 0.03). The category of normal weight was similar inboth groups (table 2; fig. 1).

Disability of Migraine and Body Mass IndexThere was no correlation between the disability scores

and BMI. PWM and overweight were homogeneouslydistributed in all the weight categories and no statisticalassociation was identified. The same trend was seen inobese and morbidly obese PWM (table 3).

Severity of Migraine and Body Mass IndexThere was no correlation between the severity of mi-

graine and BMI. PWM were well distributed accordingto severity, and the different categories of weight had no

significant differences (table 4).

Migraine with Aura and Body Mass IndexWe did not find any correlation between the pre-

sence of MA and BMI in PWM. The distribution ofweight was similar between patients with and withoutMA (table 5).

Table 1.General characteristics of the sample

Variable PWM(n = 1,371)

HBD(n = 612)

p value

Age 38.0813.3 34.87812.17 0.00Gender, female 1,125 (81.6%) 509 (83.3%) 0.40Height 160.380.08 159.680.093 0.07Weight 64.7813.3 66.3813.05 0.01

BMI 25.38

4.46 25.88

4.46 0.02

PWM = Patients with migraine; HBD = healthy blood donors.

Table 2.Comparison of BMI between PWM and HBD

Weight category PWM HBD p value

Underweight (n = 52) 43 (3.1) 9 (1.5) 0.03Normal (n = 903) 615 (44.8) 288 (47.1) 0.3Overweight (n = 732) 526 (38.3) 206 (33.7) 0.03Obesity (n = 224) 141 (10.3) 83 (13.6) 0.01Morbid obesity (n = 73) 47 (3.4) 26 (4.2) 0.3

Total 1,371 612

Underweight (35). Numbers inparentheses denote percentages.

PWM = Patients with migraine; HBD = healthy blood donors.

0

Underweight

Migraine

5

10

15

20

25

30

35

40

45

50

%

Blood donors

Nor mal O ver wei ght

Weight category

Obesity Morbid obesity

Fig. 1. BMI distribution in PWM and HBD. No difference was

seen between groups in any of the categories.


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Tllez-Zenteno et al.Eur Neurol 2010;64:134139138

HBD, but obesity and morbid obesity was more frequentin HBD than PWM. Other observations, such as in thestudy by Mattson et al. [7] in a Swedish population, sup-port the findings of our study, where obesity was not

more frequent in PWM compared with the general popu-lation.

A review of 11 epidemiological studies by Keith et al.[13] concluded that obesity was associated with an in-creased likelihood of headache or severe headache. Al-though this analysis showed a possible association, theincluded studies had different methods of ascertainmentof headache and the used controls were different, whichmakes them difficult to compare. An important method-ological aspect in our study that validates and strength-ens our observation is the type of controls. While Bigal etal. [5] used subjects from the general population without

any formal screen, we used subjects recruited in a bloodbank with a formal assessment to corroborate that theywere healthy. In addition, these subjects were paired withPWM by gender, which is usually the main confounderin a disease like migraine, which is more prevalent in fe-males. Another consideration in our study is the inclu-sion of patients with nonchronic migraine, consideringthat some studies in the past have linked obesity mainlywith chronic daily headache [8, 14].

Winter et al. [6] explored the association of BMI withmigraine characteristics in 12,613 patients. This study re-ported that PWM with a BMI 135 had an increased risk

of high migraine frequency. Also Bigal et al. [5] reportedan association between BMI and the frequency of mi-graines. In their study, 5.8% of PWM with overweight,13.6% of PWM with obesity, and 20.7% of PWM withmorbid obesity had between 10 and 15 attacks per month.Our study did not show any association of disability andseverity of episodic migraine with BMI. We believe thatthe main explanation for our results is the exclusion of

patients with chronic headache, which is the group of pa-tients where a potential association between obesity andhigh frequency of headaches has been reported [5, 14, 15].

Some studies have described an association between

BMI and some clinical characteristics of PWM. Horev etal. [16] reported that the frequency of aura was more fre-quent in patients with overweight. The main observationof this study is controversial because of the reduced sam-ple size, lack of controls and the selection of the sample.In keeping with previous studies with stronger method-ology [6] than the study of Horev et al. [16], our study didnot find any association between the presence of aura andBMI. Winter et al. [6] reported that those PWM with aBMI 135 had an increased risk of photophobia and pho-nophobia. Our study in part confirms this association;there was a trend in some symptoms like nausea and pho-

tophobia to be more frequent in patients with overweight,and this was statistically significant (table 6).

MA is a primary headache disorder that affects about30% of migraine sufferers [17]. One of the most interest-ing findings in our study was the high frequency of MA.In the majority of studies performed in the general popu-lation, the frequency of MA varies from 15 to 30%. Weassume that this finding could be explained by a referencebias. Both institutions are national reference centers forcomplex neurological conditions and this could be thereason for the high prevalence of MA. On the other hand,the high frequency of accompanying symptoms in pa-

tients with aura is worth noting; this observation couldbe explained in the same way as the high frequency ofpatients with aura. It is possible that the most complicat-ed cases are referred to specialized centers in Mexico.This preponderance of patients with MA with more com-plications and more symptoms has been seen in studiesof epilepsy clinics and tertiary centers in other popula-tions [18].

Table 6.Correlation between migraine characteristics and BMI

Nausea p value Vomiting p value Photophobia p value Phonophobia p value

Underweight (n = 43) 35 (81.4) 0.10 29 (67.4) 0.54 36 (83.7) 0.16 35 (81.4) 0.99Normal (n = 614) 542 (88.1) 0.36 376 (61.1) 0.19 539 (87.6) 0.08 497 (80.8) 0.61Overweight (n = 525) 478 (91) 0.05 338 (64.4) 0.41 485 (92.4) 0.02 431 (82.1) 0.60

Obesity (n = 141) 123 (87.2) 0.48 85 (60.3) 0.47 132 (93.6) 0.13 115 (81.6) 0.95Morbid obesity (n = 47) 42 (89.4) 0.93 36 (76.65) 0.50 42 (89.4) 0.88 38 (80.9) 0.92

Underweight (35).Numbers in parentheses denote percentages.


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Body Mass Index in Migraine Eur Neurol 2010;64:134139 139

Our study had some strengths and limitations. Themain strength in our study is the ascertainment methodof migraine using the international criteria of the IHS.Another strength of our study is the ascertainment ofHBD, who were all screened to corroborate that they werehealthy. Previous studies used the general population as

controls, mainly in surveys, including populations thatcould have other comorbidities. Finally, the measure ofweight and height were standardized and done at thesame time as the inclusion of patients. Previous studiesused self-reported weight and height, which can causepotential differences [19]. A limitation of our study is thelack of inclusion of patients with chronic daily headache,which is the group where all the potential associationsbetween BMI and migraine have been reported. Ourstudy mainly includes patients with episodic migraine,

but not chronic migraine, and our results should be ap-plied fo this specific population. Another limitation is thepotential reference bias in our study. The high prevalenceof MA could indicate a potential reference bias, becausethe study was done mainly in two tertiary centers in Mex-ico City. Unfortunately, there are not many epidemiolog-

ical studies in Mexico [20] exploring different settings toexplain variability in the rate of MA, considering that themajority of studies have shown that the prevalence of MAranges from 10 to 15%.

Acknowledgments

Dr. Tllez-Zenteno receives grants from the Royal Univer-sity Hospital Foundation in Saskatoon and the University of Sas-katchewan.

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