Factors and Clinical Management

Transcription

1 Migraine and Cognitive Impairment: Risk Factors and Clinical Management Elizabeth K. Seng, Ph.D. Assistant Professor Ferkauf Graduate School of Psychology Saul R. Korey Department of Neurology Montefiore Headache Center

2 Disclosures Research Funding Sources NIH/NINDS (1K23NS PI: Seng) International Headache Academy (PI: Seng) Consultant GlaxoSmithKline

3 Objectives Define cognitive impairment Understand the state of the evidence regarding ictal and interictal cognitive impairment Understand tools and strategies for identifying and managing cognitive impairment in clinical practice

4 Cognitive Impairment and Migraine Cognitive Impairment: Difficulty with attention, processing speed, visuospatial or perceptual skills, verbal skills, or executive functioning that impacts everyday tasks. Perceived Ictal Cognitive Impairment Perceived Interictal Cognitive Impairment Observed Ictal Cognitive Impairment Observed Interictal Cognitive Impairment

5 Perceived Ictal Cognitive Impairment Transient ictal cognitive impairment reported commonly in migraine Verbal and executive complaints more common in migraine than TTH, and higher ictally than interictally 1 Observed reversible ictal changes in cognitive impairment Strongest evidence for difficulties with executive function 1 Gil Gouveia, 2016

6 Observed Ictal Cognitive Impairment The impact of pain on cognition Pain broadly interferes with information processing, impacting processing speed, attention, and higher-order cognitive processes Observed reversible ictal changes in cognitive impairment Executive functioning Sensory disturbances Executive Functions Task oriented abilities Processing Speed & Basic Attention

7 Clinical Considerations of Ictal Cognitive Impairment Acute medication adherence and migraine-management g decision-making Migraine involves considerable in-the-moment decision-making 1,2 Support patient decision-making prior to migraine attacks Make every effort to reduce attack frequency 1 Seng & Holroyd, 2012; 2 Peters et al, 2003

8 Perceived Interictal Cognitive Impairment People with migraine commonly describe interictal cognitive impairment 1 Recent clinic-based sample described difficulties with concentration (37%), reasoning (25%) and thinking (23%) 2 People with migraine describe interictal cognitive impairment as highly disabling Recent clinic-based study found participants perceived cognitive impairment to be the second most disabling ictal migraine symptom (second to pain) 3 1 Suhr & Seng, 2011; 2 Gil Gouveia, et al, 2016; 3 Gil Gouveia et al, 2015

9 Potential Mechanisms of Interictal Cognitive Impairment Migraine appears to result in structural changes in the brain Increased risk of stroke, possibly dementia Increased risk of deep white matter lesions Preventive medications may have side effects that disrupt cognitive functioning Topirimate may have negative impact on attention Sommer, Mitchell & Wroolie, 2013

10 But what about observed interictal cognitive impairment? Consistent evidence for impaired sensory processing interictally 1 Some studies demonstrate weak or mixed neuropsychological deficits in migraine compared to healthy controls 2 Processing Speed and Attention Executive Functioning: Sustained Attention, Working Memory and Inhibition Aura may be associated with poorer interictal i t performance on cognitive tasks However, higher quality studies typical fail to observe interictal cognitive deficits Further, studies that include a tension-type headache or other pain control suggest that any observed attention or executive function problem may be related to pain overall, rather than migraine specifically 1,4 1 Titlic et al, 2015; 2 Suhr & Seng, 2011; 3 Gil Gouveia et al, 2015; 4 Gil Gouveia et al, 2012

11 Interictal Cognitive Exertion? Neuropsychological py tests are only valid when adequate effort is put forth by the patient Both formal and embedded measures assess effort Long, boring measures that appear challenging, but are in actuality relatively easy Require sustained attention Occasionally labeled measures of malingering Cognitive exertion is a perceived migraine trigger Fear of cognitive exertion could contribute to poor effort Reduce validity of responding disproportionately among people with headache Paucity of studies have included d effort measures

12 Cogniphobia Fear of head pain due to cognitive exertion, leading to avoidance of cognitive exertion Cognitive Exertion Head Pain Avoid Poor Quality of Life Reduced activities Stress Response Engage gg Stress Response Physiologic Arousal Worry Martinelli et al, 1999; Suhr & Spickard, 2012; Klepper et al, 2015

13 Measuring Cogniphobia Cogniphobia Scale Primary Headache Disorders 15 items I will stop concentrating as soon as I sense headache pain coming on. I worry that when I have to think or concentrate too hard, that I will bring on a headache PCA One component retained (eigenvalue = 9.54) 54.05% variance in scores Excellent internal consistency ( = 0.94) Seng & Klepper, under review

14 Cogniphobia and Disability Variable Correlation P-value Aura 1 headache in past 1 mo. with visual changes Yes 41 (52.56%) No 37 (47.44%) 44%) Psychiatric Symptoms Anxiety (GAD-7) 3.73 (4.05) 0.35 Depression (PHQ-9) 5.51 (4.99) 0.24 Disability Migraine-Related i Disability (64.03) (MIDAS) Klepper, et al, in preparation

15 Cogniphobia and Cognitive Impairment Klepper, et al, in preparation

16 Clinical Implications Assess whether patients notice interictal cognitive impairment Note how this impairment impacts the patient s quality of life, particularly related to role functioning Note any avoidance of cognitively demanding activities Assess objective cognitive impairment MOCA or SLUMS (VA); avoid MMSE Be sure to provide in standardized manner; avoid nice guy effect Refer for neuropsychological evaluation if interictal cognitive p y g g impairment present on screen OR perceived interictal impairment appears to be impacting quality of life May be able to catch and intervene with early declines Remember, failure of measures of effort could occur for numerous reasons in this population

17 Future Directions MUCH more work needs to be done! Validity of assessment of cognitive functioning Neuropsychological investigations in migraine should include formal and embedded measures of effort Investigations should consider the full range of possible cognitive impairment, rather than focusing on the top of the pyramid Control Investigations into both ictal and interictal cognitive impairment in migraine should include TTH and healthy controls Subgroups Aura should always be evaluated, as this subgroup appears to be particularly important Does cognitive exertion precipitate migraines? Is this a rational fear for at least some people with migraine?

18 Acknowledgements Yeshiva University Jaclyn Klepper, M.A. Roee Holtzer, Ph.D. Northwell Health (LIJ/Northshore) Noah Rosen, M.D. Paul Mattis, Ph.D. Montefiore Headache Center Richard Lipton, M.D. Jelena Pavlovic, M.D. Dawn Buse, Ph.D. Matthew Robbins, M.D. Sarah Vollbracht, M.D. Ohio University Julie Suhr, Ph.D.

19 Thank you! Elizabeth K. Seng, Ph.D. Research Assistant Professor Ferkauf Graduate School of Psychology Saul R. Korey Department of Neurology 1165 Morris Park Ave Bronx, NY