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vi

This is to certify that the
dissertation entitled

THE EFFECTS OF MIGRAINE HEADACHE AND PHYSICAL
ACTIVITY ON COGNITIVE FUNCTION

presented by

Marguerite Theresa Moore

has been accepted towards fulﬁllment
of the requirements for the

PhD. degree in Kinesiology

 

 

”W W
a Major Pryfessor’s Signature ' '
ﬁ— 20 '09

Date

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THE EFFECTS OF MIGRAINE HEADACHE AND PHYSICAL ACTIVITY
ON COGNITIVE FUNCTION

By

Marguerite Theresa Moore

A DISSERTION

Submitted to
Michigan State University
in partial fulﬁllment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY
Kinesiology

2009

 

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THE EFFECTS OF MIGRAINE HEADACHE AND PHYSICAL ACTIVITY ON
COGNITIVE FUNCTION MEASURED BY IMPACT

ABSTRACT
By
Marguerite Theresa Moore

Migraine headaches are a common and often debilitating neurological disorder
affecting between 18-25% of the female population and 6-13% of the male population.
There has been no universal agreement on the long or short-term effects of chronic
migraine headaches on neurocognitive function or on the cognitive recovery patterns
following a migraine. Research has also been inconclusive on the effects physical activity
may have on the intensity and frequency of migraine attacks. The purpose of this study
was to investigate the effects of physical activity on neurocognitive function and recovery
patterns in collegiate students who incur a migraine headache compared to collegiate
students who do not incur a migraine.

One hundred twenty-two (122) individuals completed baseline testing with 44
migraineurs incurring a migraine and completing all testing. They were matched to 44
non-migraine controls for sex, education level and age. A pre-test / post-test design was
used with the following independent variables: migraine status, physical activity, testing
occasion sex, exercise, sleep, and diagnosis status. The dependent variables were the four
composite scores of ImPACT (verbal memory composite score, visual memory
composite score, reaction time composite score, and motor processing speed), level of
pain, and impact of headache scores. Descriptive statistics and several analyses using
MANOVAs, AN OVAs and t-tests which were performed with the alpha level set a priori

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Repeated measures one-way AN OVA revealed declines in neurocognitive
function of migraineurs in verbal memory (p=.045), visual memory (p=.041), and
reaction time (p< .001) at 24 hours. When compared to non-migraine controls MANOVA
tests revealed a main effect for group x time for visual memory (p=.036), motor
processing speed (p=.044) and reaction time (p=.002) composite scores. Post hoc
Univariate ANOVAs revealed that migraineurs experienced the largest declines between
baseline and 24 hours with verbal memory (p=.005), visual memory (p=.001) motor
processing speed (p=.003) and reaction time (p=.002) worse than controls. Reaction time
(p=.028) and motor processing speed (p=.022) remained impaired at 48 hours, and motor
processing speed (p=.009) was signiﬁcantly impaired at 7 days. Physical activity levels
did not signiﬁcantly affect neurocognitive function in migraine or non-migraine groups
(p—values range 0.232-0.933). Females reported higher pain levels than males (p=.028).
Sleep, exercise, and type of medication did not signiﬁcantly affect neurocognitive
function scores in migraineurs. Physical activity levels signiﬁcantly decreased the HIT
(Headache Impact Test) overall scores (p=.020) with results approaching signiﬁcance in
both migraineurs (p=.080) and non-migraineurs (p=.094).

Conclusively, migraineurs neurocognitive function is affected in the postdromal
phase of migraine, with cognitive decline reversible within a few days of onset. Physical
activity had no impact on neurocognitive function scores; however, collegiate students
who performed physical activity rated their HIT scores lower than those not physically
active. Further research is warranted to determine the degree of cognitive deﬁcits the

general population may incur after a migraine, and ways to minimize postdromal effects.

Copyright by
Marguerite Moore
2009

ACKNOWLEDGEMENTS

First and foremost, I need to thank my family. My husband, who has seen me
through the frustration, gave me unending encouragement and support and pushed me to
complete each step to the best of my abilities. I want to thank my kids, who have given
up much of their mommy summer time and have gone with me on many “study trips”
both downstate and around the area to collect data. And, of course my mom who has
spent hours taking care of my kids, often on short notice when someone had a migraine
or some other “emergency” came up. My family, both extended and immediate has
supported my educational process through its entirety and I sincerely appreciate all of the
comments of support from aunts and uncles, cousins, brothers and sisters and my parents.
Thank you for listening to me on countless occasions reason my way through and
supporting my decisions.

Secondly, I need to thank my committee. Tracey, you are amazing, quick to
respond and question, and the ﬁrst to give your support and honesty. Your quick
responses and corrections made this process so much easier than it could have been,
along with your support and friendship. Dr. Pfeiffer, Dr. Norris, Dr. Branta and Dr.
Dummer, thank you for your support and assistance in pointing out my strengths and
weaknesses to make this research the best it could be, and helping me to become a better
writer. Thank you to Dr. Jensen who has helped me over the last few months to complete
and understand my statistics. You never tired of my countless questions and have

supported and mentored me throughout.

 

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I would like to say a big thank you to the faculty and staff at both MSU and NMU
who have helped me many times with questions and supportive comments and
suggestions. You all have helped to shape my decisions and grow as both an individual
and as a researcher.

A thank you needs to be offered to my friends both at MSU and in Marquette.
Thank you for your support and guidance through these last few years. Thank you for not
allowing me to give up! A thank you also to my students, I have learned through you how
to be a better person, better educator and advisor. I need to say a big thank you to my
volunteers, both migraineurs and controls. Without your dedication to research, the
completion of this paper would not have been possible.

So many people have helped me and supported me through these last six years,
through the move, both kids, and to a new full time position. Thank you all for everything
you have done for me and my family. I never could have completed this with out the
support of my community of family and ﬁiends. I am so lucky to have such a wonderful

foundation of support.

Vi

TABLE OF CONTENTS

LIST OF TABLES ............................................................................................................. xi
LIST OF FIGURES ......................................................................................................... xiii
CHAPTER 1 ....................................................................................................................... 1
Introduction ......................................................................................................................... 1
Overview of the Problem ................................................................................................ 1
Signiﬁcance of the Problem ............................................................................................ 7
Statement of the Problem ................................................................................................ 9
Need for Study ................................................................................................................ 9
Hypotheses and Research Questions ............................................................................ 10
Primary Hypotheses. ................................................................................................. 10
Effects of Testing Occasion on Neurocognitive Function ............................................ 10
Effects of Migraine Status on Neurocognitive Function .............................................. 1 1
Effects of Physical Activity by Testing Occasion on Neurocognitive Function .......... 11
Exploratory Hypotheses ............................................................................................ 12
Exploratory Research Questions ............................................................................... 13
Assumptions, Limitations and Delimitations ................................................................ 13
Assumptions of the Study. ........................................................................................ 13
Limitations of the Study ............................................................................................ 14
Delimitations of the Study. ....................................................................................... 14
Operational Deﬁnitions ................................................................................................. 15
Deﬁnitions ..................................................................................................................... 17.
CHAPTER 2 ..................................................................................................................... 21
Literature Review .............................................................................................................. 21
Migraine Symptoms and Management ......................................................................... 21
Migraine without Aura. ............................................................................................. 22
Migraine with Aura. .................................................................................................. 23
Associated Syndromes for Migraine Headache ............................................................ 25
Migraine Prodromal Phase ........................................................................................ 27
Migraine Postdromal Phase. ..................................................................................... 28
Migraine Treatment. ................................................................................................. 29

vii

Pathology of Migraine. ............................................................................................. 3]

Differential Diagnosis for Migraine Headache ............................................................. 34
Headache Attributed to Rhinosinusitis. .................................................................... 34
Cluster Headache. ..................................................................................................... 35
Tension-Type Headache. .......................................................................................... 36
Headaches Associated with Substances or their Withdrawal. .................................. 37
Medication-Overuse Headache. ................................................................................ 37

Epidemiology of Migraine ............................................................................................ 4O
Prevalence and Demographics of Migraine Headaches ............................................ 41
Prevalence and Incidence of the Diagnosis of Migraine. ......................................... 42
Burden of Migraine. .................................................................................................. 44

Neurocognitive Function of Migraine Patients. ............................................................ 46
Migraine is not Associated with Long- Term Cognitive Decline. ............................ 47
Reversible Cognitive Decline. .................................................................................. 49
Migraine is Associated with Long-Tenn Cognitive Decline. ................................... 50

Physical Activity and Migraine. ................................................................................... 52
Migraine and Exercise Physiology. .......................................................................... 53
Physical Activity Deﬁned. ........................................................................................ 54
Physical Activity and Neurocognitive Function. ...................................................... 55

Instrument Validity ....................................................................................................... 57
Headache Impact Test (HIT). ................................................................................... 57
Behavior Risk Factor Surveillance System ............................................................... 58
[mediate Post-Concussion Assessment and Cognitive Testing (ImPACT). .......... 5 8

Summary of the Literature ............................................................................................ 63

CHAPTER 3 ..................................................................................................................... 65
Methods ............................................................................................................................. 65

Experimental Design ..................................................................................................... 65

Research Participants .................................................................................................... 66
Sample Size Estimate ................................................................................................ 68

Instrumentation ............................................................................................................. 69
Headache Impact Test (HIT). ................................................................................... 69
Migraine History Questionnaire. .............................................................................. 69
Physical Activity Questionnaire. .............................................................................. 70
24 Hours Questionnaire. ........................................................................................... 7O

viii

 

 

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Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT). .......... 71

Reliability and Validity of thACT. ........................................................................ 74
Procedures ..................................................................................................................... 75
Baseline Evaluation. ................................................................................................. 75
Post-tests Evaluation. ................................................................................................ 76
Data Analysis ................................................................................................................ 77
Hypotheses 1, 2, and 3. ............................................................................................. 77
Exploratory Hypotheses. ........................................................................................... 77
Research Questions. .................................................................................................. 78
Threats to Validity and Study Limitations .................................................................... 79
Threats to Internal Validity. ...................................................................................... 79
Threats to External Validity. ..................................................................................... 82
Limitations of the Study ............................................................................................ 83
CHAPTER 4 ..................................................................................................................... 84
Results ............................................................................................................................... 84
Demographic Data ........................................................................................................ 84
Hypothesis Data ............................................................................................................ 89
Results: Effects of Testing Occasion on Neurocognitive Function among the
Migraine Group ......................................................................................................... 89
Results: Effects of Testing Occasion on Neurocognitive Function among the Non-
Migraine Group ......................................................................................................... 93
Results: Effects of Migraine Status on Neurocognitive Function ............................ 95
Results: Effects of Physical Activity by Testing Occasion on Neurocognitive Function
..................................................................................................................................... 104
Exploratory Hypotheses .......................................................................................... 106
Results: Exploratory Research Questions ............................................................... 108
CHAPTER 5 ................................................................................................................... 1 11
Discussion ....................................................................................................................... 111
Discussion of Results .................................................................................................. 1 l 1
Effect of Time on Neurocognitive Function Scores ............................................... 11 1
Effect of Migraine Status on Neurocognitive Function Scores .............................. 117
Effect of Physical Activity Status on Neurocognitive Function Scores ................. 118
Additional Hypotheses and Research Questions .................................................... 120
Limitations .................................................................................................................. 124

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Conclusions ................................................................................................................. 1 24

Recommendations for Future Research ...................................................................... 126
APPENDIXES A-E ........................................................................................................ 128
HEADACHE IMPACT TEST ........................................................................................ 130
INFORMED CONSENT ................................................................................................ 133
MIGRAINE HISTORY QUESTIONAIRRE ................................................................. 136
PHYSICAL ACTIVITY QUESTIONAIRRE ................................................................ 140
24 HOUR QUESTIONAIRRE ....................................................................................... 143
WORKS CITED ............................................................................................................. 146

 

 

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LIST OF TABLES

Table 1: Aura Symptoms .................................................................................................. 17
Table 2: Primary Headache Classiﬁcation Criteria .......................................................... 38
Table 3: Secondary Headache Classiﬁcation Criteria ...................................................... 40
Table 4: Approximate Classiﬁcation Ranges for Index Scores-University Women ........ 62
Table 5: Approximate Classiﬁcation Ranges for Index Scores- University Men ............ 63
Table 6: Sample Size Estimates ........................................................................................ 68
Table 7: Demographic Data of Migraine and Physical Activity Groups .......................... 86

Table 8: Hours of Sleep, Total Symptoms, and ImPACT Neurocognitive Composite
Scores for Migraine and Physical Activity Groups .......................................................... 87

Table 9: Means and Standard Deviations for ImPACT CompOsite Scores for Migraine
Group ................................................................................................................................ 90

Table 10: One-way AN OVAs for Migraine Group x Time for Neurocognitive Composite
Scores ................................................................................................................................ 91

Table 11: Pairwise Comparisons for Migraine Group Verbal Memory Composite Scores

........................................................................................................................................... 91
Table 12: Pairwise Comparisons for Migraine Group for Visual Memory Composite
Scores ................................................................................................................................ 92
Table 13: Pairwise Comparisons for Migraine Group for Reaction Time Composite
Scores ................................................................................................................................ 92

Table 14: Means and Standard Deviations for ImPACT Composite Scores for the Non-
migraine Group ................................................................................................................. 94

Table 15: One-way AN OVAs for Non-migraine Group x Time for Neurocognitive
Composite Scores .............................................................................................................. 94

Table 16: Pairwise Comparisons for Non-migraine Group for Motor Processing Speed
Composite Scores .............................................................................................................. 95

Table 17: Repeated Measures MANOVAs for Group x Time for Neurocognitive
Composite Scores .............................................................................................................. 97

 

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Table 18: Univariate ANOVA for Group Differences at Baseline for Neurocognitive
Composite Scores .............................................................................................................. 97

Table 19: Univariate AN OVA for Group Differences at 24 hours for Neurocognitive
Composite Scores .............................................................................................................. 98

Table 20: Univariate AN OVA for Group Differences at 48 hours for Neurocognitive
Composite Scores .............................................................................................................. 98

Table 21: Univariate AN OVA for Group Differences at 7 days for Neurocognitive
Composite Scores .............................................................................................................. 99

Table 22: Repeated Measures AN OVA for Neurocognitive Function Composite Scores

for Migraine x PA Status x Time .................................................................................... 105
Table 23: Repeated Measures AN OVA for Non-Migraine x PA Status x Time for
Neurocognitive Function Scores ..................................................................................... 105
Table 24: T-test for Pain level at 24 hours x Sex or Diagnosis Status ............................ 107
Table 25: Means and Standard Deviations for Migraine Group and PA Status for HIT
Scores .............................................................................................................................. 108
Table 26: Two-way AN OVA for Migraine Group x PA Status ..................................... 108

Table 27: Means and Stande Deviations for Migraine Group x Type of Medication . 109

Table 28: Means and Standard Deviations for Neurocognitive Function and Hours of
Sleep since Migraine ....................................................................................................... 110

Table 29: ANOVA for Hours of Sleep since Migraine for Neurocognitive Function... 110

LIST OF FIGURES

Figure 1. Means for Group x Time for Verbal Memory Composite Scores ............... 100
Figure 2. Means for Group x Time for Visual Memory Composite Scores. . . . . .. . . . . l 01
Figure 3. Means for Group x Time for Motor Processing Speed Scores ................... 102
Figure 4. Means for Group x Time for Reaction Time Composite Scores ................. 103

 

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CHAPTER 1

Introduction

Overview of the Problem

Migraine headaches are a common and often debilitating neurological disorder
affecting between 18-25% of the female population and 6-13% of the male population
(Lipton, Scher, Kolodner, Liberman, Steiner, & Stewart, 2002; Lipton, Diamond, Reed,
Diamond, & Stewart, 2001; Launer, Terwindt, & Ferrari, 1999; Lipton, Stewart,
Celentano, & Reed, 1992). There has been no universal agreement on the long or short-
terrn effects of chronic migraine headaches on neurocognitive function or on the
cognitive recovery patterns following a migraine. Individuals suffering from migraine
headaches report lower visual processing speed (Wray, Mijovic-Prele, & Kosslyn, 1995),
verbal ability (Waldie, Hausmann, Milne, & Poulton, 2002), and decreased reaction time
(Zeitlin & Oddy, 1984). Researchers suggest migraine headaches may produce structural
and functional brain dysfunctions (Elkind & Scher, 2005; Swartz & Kern, 2004; Kruit, et
al., 2004). Speciﬁcally, MRI studies on migraine subjects suggest asymptomatic
subcortical (Swartz & Kern, 2004) and deep white matter changes (Swartz & Kern, 2004;
Kruit, et al., 2004), and abnormalities in the cerebellar region of the posterior circulation
(Swartz & Kern, 2004). Research has also been inconclusive on the effects physical
activity may have on the intensity and frequency of migraine attacks. Physical activity
either exacerbates or diminishes a migraine headache (Folkins & Sirne, 1981; Rooke,
1968; Lambert & Bumet, 1985). To date, no research (to my knowledge) has examined

the effect(s) physical activity and migraines have on neurocognitive function.

Migraine headaches affect individuals differently and are associated with a variety
of symptoms. Classiﬁcations have been developed to differentiate “migraine without
aura,” often called the common migraine, and, “migraine with aura,” often called classic
or classical migraine. Aura commonly manifests as visual disturbance, verbal difﬁculties,
and sensory disturbances. Migraine headaches may occur only on one side of the head,
with pulsating or throbbing pain. The quantity/quality of pain either stops or limits the
individual performance of daily activities (Society I. H., 2005). In addition, patients
suffer from nausea or vomiting, photophobia or phonophobia. Aura classically manifests
as visual disturbances, sensory disturbances, or as difﬁculty with speech (Society I. H.,
2005).

College students are subject to many of the common triggers for migraine
headaches in their daily lives. Students studying for tests often skip meals, study through
the night, under sleep or oversleep, or suffer from post-crisis letdown when they cram
prior to exams. Many female college students use oral contraceptives. Oral contraceptives
worsen migraine headaches in some patients, but are also used to moderate migraines in
others (Granella, Sances, Pucci, Nappi, Ghiotto, & Nappi, 2000). The general onset age
for migraines is during and following the pubertal years, often putting college students
early in the disorders course. Migraineurs with a shorter onset history are often unaware
of what triggers their migraines and consequently suffer needlessly. Most triggers are
inconsistent and are associated with migraine on one occasion but not on another
(Robbins, 1993). This makes it more difficult for many patients to begin a preventative

program because they cannot determine their personal migraine triggers.

Migraine headaches have a prodromal phase and a postdromal phase. The phase
of the migraine occurring prior to the main migraine attack is referred to as the prodromal
phase. This warning phase can be operative eight to 48 hours prior to an attack. It often
manifests as common signs of discomfort, such as dizziness or cervical neck pain, and
can go unnoticed by the migraineurs (Waelkens, 1985). Triggers associated with
migraine headache include stress, anxiety, fatigue, post-crisis letdown (the stress relief
following a crisis), depression, irregular sleep patterns (under or oversleeping),
menstruation, ovulation, physical and intellectual effort, environmental factors (exposure
to heat or cold), weather changes, missing meals and oral contraceptives (Turner,
Molgaard, Gardner, Rothrock, & Stang, 1995). Edibles such as cheese, chocolate, and
alcohol are also known triggers for migraines (Robbins, 1993; Wacogne, Lacoste,
Guillibert, Hugues, & Le Jeunne, 2003; Puri, et al., 2006). A large percentage of
migraineurs are unable to identify their triggers, making it idiopathic in nature.

Postdrome phase refers to the phase of the migraine after the main migraine
attack. The average postdrome phase lasts 25.2 hours. The quality and breadth of
postdromal symptoms suggest involvement of the whole brain, speciﬁcally the frontal
lobe and hypothalamus areas (Blau, 1991). Postdrome symptoms may be used to
diagnose migraine in the absence of aura. Blau (1991) reported on the most common
symptoms in a group of 40 migraineurs who completed a questionnaire on the day
following their most recent attack. These symptoms were physical and mental tiredness,
impaired concentration, subdued or depressed mood, and reduced physical activities.
Many migraineurs experience low-grade headaches or a feeling of “hangover” during this

phase (Kelman, 2005b). The postdrome phase has a signiﬁcant effect on a college student

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with migraines. While the severe headache may be gone, lesser, but still debilitating,
symptoms continue and are not commonly recognized by teachers, parents and even the
student. Anecdotal evidence suggests students feel they do not perform to their potential
and report lower grades on tests, quizzes and other modes of testing following a migraine
attack. Difﬁculties arise in determining duration of time from completion of the attack
due to the postdromal phase. Therefore, most studies determine time from initiation or
start of the migraine. Overall, the postdromal phase has a signiﬁcant impact on the
individual’s level of daily activities the day following a migraine headache.

Scientiﬁc evidence conﬁrms health beneﬁts are seen with moderate-intensity
physical activity (U .S. Department of Health and Human Services, Public Health Service,
Centers for Disease Control and Prevention, National Center for Chronic Disease
Prevention and Health Promotion, Division of Nutrition and Physical Activity, 1999).
The US. Department of Health and Human Services deﬁnes how physical activity
recommendations are met as moderate-intensity for at least 150 min per week, or
vigorous-intensity for at least 75 min per week, together with muscle strengthening
activities on two or more days of the week. Moderate physical activity is deﬁned as some
increase in breathing or heart rate, while vigorous physical activity is deﬁned as a large
increase in breathing or heart rate where conversation is difﬁcult or broken (U .S.
Department of Health and Human Services, 2008). Previous research has examined
physical activity relating to cardiovascular ﬁtness.

There is contemporaneous but conﬂicting research on the relationship between
physical activity and migraine. Stress, or post-crisis letdown, is a known trigger for

migraine, while mild to moderate physical activity is known to diminish stress (Turner,

 

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Molgaard, Gardner, Rothrock, & Stang, 1995). Logically, exercise is frequently promoted
as a method of migraine management (Folkins & Sime, 1981). Some individuals use
vigorous exercise successfully to abort a migraine headache at the ﬁrst signs of onset
(Darling, 1991 ). Conversely, exertional exercise without proper warm-up can be a trigger
for migraine headaches (Lambert & Bumet, 1985; Rooke, 1968).

The relationship between migraine and exercise has been explored by researchers.
Data indicate pain intensity and frequency of migraines decrease after a regular exercise
program was initiated (Lockett & Campbell, 1991; deeoglu, Akboyraz, Soyuer, &
Ersoy, 2003). The results of these studies strongly suggest an ongoing exercise program
is essential for decreased migraine frequency. However, previous researchers stopped
short of examining neurocognitive function of migraineurs meeting physical activity
recommendations and those not meeting physical activity recommendations in a
collegiate population.

Several studies examined cognitive function and migraine headaches; however,
research is inconclusive whether migraine headaches lead to cognitive dysﬁmction over
time (Jelicic, van Boxtel, Houx, & Jolles, 2000; Magnusson & Becker, 2003; Gaist, etal.,
2005; Launer, Terwindt, & Ferrari, 1999; Waldie, Hausmann, Milne, & Poulton, 2002).
Direct comparison can be difficult due to the methodological problems of selection bias
(convenience sample or hospital sample) and small sample size (Hooker & Raskin, 1986;
Leijdekkers, Goudswaard, Menges, & Oriebeke, 1990; Le Pira, Zappala, Giuffrida, Lo
Bartola, Morana, & Lanaia, 2000; Le Pira, etal., 2004; Haverkamp, Honscheid, &
Miiller-Sinik, 2002; Zeitlin & Oddy, 1984). Consequently, it is difﬁcult to determine the

long-term effects of migraine headache on cognitive function.

 

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A number of studies found migraine is not associated with cognitive decline
(Lipton et al, 2002; Hu, Markson, Lipton, Stewart, & Berger, 1999; Schreiber,
Hutchinson, Webster, Ames, Richardson, & Powers, 2004; Bell, Primeau, Sweet, &
Loftland, 1999). A Danish twin study concluded that lifetime diagnosis of migraine
health was not associated with cognitive deﬁcits, which is an epidemiological gold
standard (Gaist, et al., 2005). Similarly, Haverkamp and colleagues found children with
migraines and their unaffected sibling also reported no cognitive dysfunctions differences
(Haverkamp, Honscheid, & Muller-Sinik, 2002). However, subjects are often recruited
from a local migraine group, which may contribute to reporting bias. Prior research has
focused on long-term cognitive ﬁmction following a migraine; however, very few studies
have examined short-term cognitive function and the recovery pattern following a
migraine headache in a collegiate population.

Research has found a reversible cognitive decline in the recovery pattern
following migraine headache (Meyer, Thomby, Crawford, & Rauch, 2000). A reversible
cognitive decline is deﬁned as a cognitive decline during the headache interval which
completely subsides during a measured period after the individual is headache free.
Meyer and colleagues (2000) found a reversible cognitive decline 30 hours after recovery
from headache and nocturnal sleep. This is after the postdrome phase is complete in most
individuals. Cognitive decline can also be reversed by migraine medication. Speciﬁcally,
two prescription drug studies utilizing surnatriptan (injection and nasal spray) determined
cognitive dysﬁmction was reversible 15 minutes after medication administration (Farmer,
Cady, Bleiberg, & Reeves, 2000; Farmer, etal., 2001). A limitation to these studies was

not monitoring the subjects beyond 45 minutes. In both studies, cognitive function

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(simple reaction time, sustained attention/ concentration, working memory, visual-spatial
processing) and alertness/fatigue were adversely affected during a migraine headache.
However, results of these studies may be skewed by the lack of a comparison to a control
group as well as small sample size.

Migraine studies have reported long-term or permanent cognitive decline in
information processing, reaction time, verbal ability and visual processing (Hooker &
Raskin, 1986; Zeitlin & Oddy, 1984; Waldie, Hausmann, Milne, & Poulton, 2002; Wray,
Mijovic-Prele, & Kosslyn, 1995). Hooker and Raskin tested 29 migraineurs who
exhibited poorer free recall of semantic material and diminished ability to discriminate
forms and analyze spatial relationships in the tactile modality. Five subjects reported not
feeling as “bright” since migraines started. Zeitlin and Oddy’s 19 nrigraineurs, recruited
through a migraine clinic, showed consistently poorer performance on a series of memory
and information-processing tests. While many studies found long-term neurocognitive
deﬁcits in migraineurs, the two primary limitations of these studies are the lack of a
control group and the use of diagnosed migraine patients only. Furthermore, no previous
research speciﬁed college-aged patients or examined short-term recovery patterns from
migraine headaches compared to a control group. Conclusively, it is relevant and
signiﬁcant to determine whether neurocognitive effects of a migraine resolve in a short

period of time in a college population.

Significance of the Problem
Migraine headaches are an episodic and progressive disorder affecting a
signiﬁcant portion of the population, more than asthma and diabetes combined (Lipton et

al, 2002; Lipton et a1, 2001; Launer, Terwindt, & Ferrari, 1999; Lipton, Stewart,

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Celentano, & Reed, 1992). During a migraine attack, progression is seen in aura
development (if present) and intensity of pain, with prodromal and postdromal symptoms
typically leaving migraineurs performing at a decreased capacity for up to one week
surrounding a migraine attack. With frequent attacks, migraine is a direct cost to the
individual and the economy as a whole. From a collective perspective, direct and indirect
costs relating to migraine headaches are estimated at 13 billion dollars, impacting society
in many venues, including work productivity, absenteeism and social functioning (Lipton
et al, 2001). Ninety one percent (91%) of individuals who suffered from migraine
headaches reported ﬁmctional impairment, with 53% of respondents indicating their
headaches cause severe impairment or require bed rest. Another 51% reported a reduction
in their school or work productivity of at least 50% during a migraine episode (Lipton et
al, 2001 ). With the average migraineur experiencing one migraine per month, and 25%
debilitated by at least two episodes per month, how does this affect college students with
migraine headaches (Launer, Terwindt, & Ferrari, 1999)? It is widely held that lost time
due to migraine headaches is the result of short-term effects. However, few studies have
examined the relationship between migraine headache and short-term cognitive function.
College students are expected to be ready on a daily basis for pop quizzes, tests or
practical skills tests. Students may study for months for a licensure, board or certiﬁcation
test where the outcome determines their future standing and status in their profession or
job. From ages 18-28 the prevalence of migraine increases yearly, and the life of the
college student is ﬁill of migraine triggers, making it important to determine if migraines

affect cognitive function following an attack.

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Researchers have produced inconsistent results on long-term cognitive ﬁrnction
following a migraine headache and the effect(s) of physical activity on migraines. From
individuals who suffer exertional migraines to those that ward off migraines through
physical activity, no research study has captured the effects of physical activity under an
observational approach. Furthermore, no prior research examined the effects of migraine
and physical activity on cognitive function within 24-hour, 48-hour, and one-week
intervals after a migraine and compared the data to a control group. Finally, prior
research did not contrast neurocognitive function following a migraine headache with an

individual’s baseline neurocognitive test scores.

Statement of the Problem
The purpose of this study was to investigate the effects of physical activity on
neurocognitive function and recovery patterns in collegiate students who incur a migraine

headache compared to collegiate students who do not incur migraines.

Need for Study

The postdromal phase of migraine has yielded inadequate results for the public in
general and suffering migraineurs speciﬁcally. This phase of the migraine affects
migraineurs signiﬁcantly post migraine and may last for days. Little and limited research
has explored the neurocognitive deﬁcits following a migraine, and no prior research
determined whether physical activity has any effect on migraine and neurocognitive

function. The hypotheses and research questions of this study are listed below.

Hypotheses and Research Questions

Primary Hypotheses.

The primary focus of this study is neurocognitive function as it relates to migraine
headaches and individuals who meet or do not meet physical activity recommendations.
The independent variables were:

A. migraine status migraine (M), non-migraine (NM)
B. physical activity met physical activity recommendations PA

did not meet physical activity recommendations (N PA)
C. testing occasion baseline (B), 24 hours (24h), 48 hours (48h), and one week (7d)
The dependent variables were neurological function deﬁned as the four composite scores
of ImPACT. The four composite scores of ImPACT are verbal memory composite score,
visual memory composite score, reaction time composite score, and processing speed
composite score. The ImPACT composite scores were collectively referred to as
neurocognitive function. All subjects in this study were college students between the ages

of 18 and 28. Speciﬁc hypotheses include:

Effects of Testing Occasion on Neurocognitive Function

Hla. Baseline neurocognitive function scores will be higher than 24 hours post-
rnigraine scores for mi grainous college students.

Hlb. Neurocognitive function scores at 24 hours will be lower than 48 hours post-
migraine scores for migrainous college students.

ch. Neurocognitive ﬁmction scores at 48 hours will be lower than 7 days post-

migraine scores for migrainous college students.

10

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Neurocognitive function scores at baseline will exhibit no difference than 7 days
post-migraine scores for migrainous college students.

Neurocognitive ﬁanction scores at baseline will exhibit no difference than 24
hours, 48 hours or 7 days post-baseline scores for non-migrainous college

students.

Effects of Migraine Status on Neurocognitive Function

112a.

H2b.

H2d.

The nrigraineurs and non-migraineurs will exhibit no difference in neurocognitive
function at baseline.

The rrrigraineurs will exhibit lower neurocognitive function scores than the non-
rrrigraineurs at 24 hours post-migraine.

The migraineurs will exhibit lower neurocognitive function scores than non-
migraineurs at 48 hours post-migraine.

The migraineurs will exhibit lower neurocognitive function scores than the non-

migraineurs at 7 days post-migraine.

Effects of Physical Activity by Testing Occasion on Neurocognitive Function

H3a.

H3b.

H3c.

H3d.

Physically active migraineurs will exhibit no difference in neurocognitive
function scores than non-physically active migraineurs at baseline.

Physically active migraineurs will exhibit higher neurocognitive function scores
than non-physically active migraineurs at 24 hours.

Physically active migraineurs will exhibit higher neurocognitive function scores
than non-physically active migraineurs at 48 hours.

Physically active migraineurs will exhibit no difference on neurocognitive
function scores than non-physically active migraineurs at 7 days.

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H3c. Physically active non-migraineurs will exhibit no difference in neurocognitive

function scores than non-physically active non-migraineurs at any testing interval.

Exploratory Hypotheses
The purpose of the exploratory hypotheses was to examine the relationships
between additional variables collected throughout the study. The independent variables
were:
A. migraine status migraine (M) and non-migraine (NM])
B. sex female and male
C. diagnosis status physician diagnosed (PD) and self-diagnosed (SD)
D. testing occasion 24 hours only
E. physical activity met physical activity recommendations (PA)
did not meet physical activity recommendations (N PA).
The dependant variables are level of pain and impact of headache scores.
The Headache Impact Test (HIT) score was referred to as impact of headache scores.
H4. Female migraineurs will rate their pain higher than male migraineurs at 24 hours
post-migraine.
H5. Physician diagnosed migraineurs will rate their pain higher than self-diagnosed
migraineurs at 24 hours post-migraine.
H6a. Physically active individuals will score lower than non-physically active
individuals on their impact of headache score.
H6b. Physically active migraineurs will score lower than non-physically active

migraineurs on their impact of headache scores.

12

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Physically active non-migraineurs will score lower than non-physically active

non-migraineurs on their impact of headache scores.

Exploratory Research Questions

The purpose of the exploratory research questions was to examine the relationship

between additional variables previously not researched in the literature. The independent

variables were migraine status (migraine only), exercise (yes and no), and sleep (none, a

little to 4 hours, 4-8 hours, more than 8 hours). The dependant variables were pain, and

the four composite scores of ImPACT. The four composite scores of ImPACT are verbal

memory composite score, visual memory composite score, reaction time composite score,

and processing speed composite score, which were referred to as neurocognitive function.

RQ 7.

RQ 8.

RQ 9.

Is there a difference in pain reported at 24 hours post-rnigraine for college
students who use prescription medications, over-the-counter medications, or no
medications for their migraine headaches?

Is there a difference in pain reported at 24 hours post-migraine for college
students who did or did not exercise during the 24 hours immediately following
onset of a migraine headache?

Is there a difference in neurocognitive function at 24 hours post-migraine for
college students who did or did not sleep during hours immediately following

onset of a migraine headache?

Assumptions, Limitations and Delimitations

Assumptions of the Study.

13

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The assumptions of this study included: the subjects answered all questions
honestly, were aware of a physician diagnosis of migraine, that they physician diagnosis
was correct, and that tried their hardest on all occasions when taking the ImPACT test.
Another assumption of the study was that the subjects were honest about the onset of
their migraines and contacted the investigator in a timely manner following migraine

onset.

Limitations of the Study.

A limitation of this study was related to the participant population. The
population of the Upper Peninsula of Michigan is not ethnically diverse, making the
sample primarily Caucasian. Generalizing the results to the broader population was
difﬁcult, although results may be generalized to a similar population of college-aged
individuals 18 to 28 years of age. Sex representation was not equal due to the prevalence

of migraines in females, occurring at a rate three times that of males.

Delimitations of the Study.

One of the delirnitations of the study was that the 24 hour questionnaire asked
about the past 24 hours of their migraine headache, which may not capture prodromal
symptoms. Another delimitation of the study was that the research focused on ImPACT’s
ability to detect neurocognitive function following a migraine, but the subjects were not
administered any other tests to establish neurocognitive function. A ﬁnal delimitation was
that subjects offered subjective information throughout the study, which was not veriﬁed

with a physician.

14

Operational Deﬁnitions

Exercise. Bodily exertion for the sake of developing and maintaining physical
ﬁtness (www.nlm.nih.gov/medlineplus/mplusdictionary.html). For the purpose of this
study, exertion is measured in minutes over a one-week period and determined whether it
is moderate-intensity or vigorous-intensity physical activity.

Impact of headaches. The impact an individual experiences related to their
headaches in their daily lives. This may include sleep quality, level of pain, length of
post-dromal features, and frequency of migraine.

Migraine. A migraine is a headache satisfying the following criteria. The
migraine may or may not occur with aura. The headache has at least two of the following
characteristics: 1) unilateral location, 2) pulsating quality, 3) moderate or severe pain
intensity, or 4) aggravation by or causing avoidance of routine physical activity. During
the headache, at least one of the following is present: 1) nausea and/or vomiting, or 2)
photophobia and/or phonophobia.

Neurocognitiveﬁmction. For the purpose of this study, the ImPACT composite
scores were collectively referred to as neurocognitive function. The four composite
scores of ImPACT are verbal memory composite score, visual memory composite score,
reaction time composite score, and processing speed composite score.

Onset of a migraine. The onset of the migraine is the time (hour) the individual
starts to develop either headache symptoms or any aura they recognize as the start of a

migraine headache.

15

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Over-the-counter medications. Any medication utilized by an individual and is
recognized by the American Medical Association as a medication to treat migraine
headaches which is available without a physician prescription.

Pain. A state of physical, emotional, or mental lack of well-being or physical,
emotional, or mental uneasiness ranging from mild discomfort or dull distress to acute,
often unbearable agony. It may be generalized or localized, and is the consequence of
being injured or hurt physically or mentally or of some derangement of or lack of
equilibrium in the physical or mental functions (as through disease). It usually produces a
reaction of wanting to avoid, escape, or destroy the causative factor and its effects
(National Institute of Health Dictionary through Med-Line).

Physical Activity. Moderate-intensity physical activity or vigorous-intensity
physical activity, self reported and measured over a one-week span in minutes.

Physician diagnosis. An individual who has obtained a migraine diagnosis by a
physician. Individuals self-report their physician diagnosis.

Prescription medication. Any medication prescribed to the individual speciﬁcally
intended to treat migraine headache acute symptoms or any medications utilized to
prevent migraines.

Self-diagnosis. Any individual who meets IHS criteria for migraine with aura,
migraine without aura, or menstrual migraine, and has not been diagnosed formally by a
physician.

Testing occasion. A testing occasion is the time frame an individual completes
any surveys and one of the four ImPACT tests (baseline, 24h, 48h, and 7d) post-migraine.

Sleep. The natural periodic suspension of consciousness during which the powers

16

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of the body are restored (National Institute of Health Dictionary through Med-Line).

Definitions

Aura. Occurs prior to a migraine headache. Auras may be in the form of visual

disturbances, unilateral paresthesias (pins and needles feeling) and/or numbness,

unilateral weakness, or aphasia or unclassiﬁable speech difﬁculty. Visual disturbances

may be in the form of loss of vision, seeing stars, zigzag lines or sparkles (Society I. H.,

2005).

Adila and Sanchez (1988) described aura symptoms as consisting of any of the

following listed in Table 1:

 

 

Table 1: Aura Symptoms

Aura Symptom Explanation of symptom

Anomia Forgetting the name of things

Difﬁculty speaking Diffrculty forming words/ knowing the
right word

Depersonalization Feeling as if another person

Seeing the world as strange Seeing the world as strange

Macropsia Increase of apparent object size

Micropsia Decrease of apparent object size

Simultaneous agnosia
Automatic behavior

Inability to understand language
Olfactory hallucinations
Achromatopsia

Chromatopsia

Only the full or partial object is recognized

Disassociating from a task, performing
tasks automatically

Difﬁculty comprehending the words and
their meanings

A hallucinations involving the sense of
smell

Disappearance of colors

Modiﬁcation of object colors

 

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Palinopsia

Pelopsia

Gustatory hallucinations
Alexia

Acalculia

Telopsia

Transient global amnesia

Hemisomatognosia

Visual perseveration- reports seeing ﬁgures
or images repeatedly

The object seems to become larger and
approach the patient

A hallucination involving the sense of taste
Inability to read

Calculation disturbance

Objects seem small and far away

A passing episode of short-term memory
loss without other signs or symptoms of

neurological involvement

Unilateral misperception of one’s own
body

Cognition. A term referring to the mental processes involved in gaining

knowledge and comprehension, including thinking, knowing, remembering, judging, and

problem solving. Cognition involves higher-level functions of the brain and encompasses

language, imagination, perception, and planning.

ImPA CT. Immediate post-concussion assessment and cognitive testing (ImPACT)

is a computer-based program used to assess neurocognitive function and migraine

symptoms.

Incidence. The number of new cases of a speciﬁc disease occurring during a

Speciﬁed period of time, divided by the population at risk for developing the disease.

These do not include already diagnosed cases.

tin

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Migraine without aura. An individual who has experienced at least 5 headache
attacks lasting 4-72 hours (untreated or unsuccessfully treated) with at least two of the
following characteristics:

(1) Headache is only on one side of the head

(2) Pulses or throbs

(3) It is of moderate to severe intensity (stops you or limits you in performing

daily activities) or

(4) The pain is aggravated by walking stairs or similar routine activities.
In addition, at least one of the following accompanies the headache attack:

(1) Nausea or vomiting or

(2) Photophobia or phonophobia (Society I. H., 2005).

Migraine with aura. An individual who has had at least two attacks with at least
three of the following four characteristics:

(1) One or more fully reversible aura symptoms

(2) At least one aura symptom develops gradually over 4 minutes, or two or more

symptoms occur in succession

(3) No single aura symptom lasting more than 60 minutes, or

(4) Headache interval follows aura within 60 minutes (Society I. H., 2005).

Motor processing speed. It is a measurement of the speed that an individual
completes a speciﬁed task in units of time.

Phonophobia. The fear of sound. Individuals with phonophobia during migraine

may desire to be in a quiet room, and state that sounds increase the intensity of their

migraine.

19

Photophobia. The fear of light. Individuals with photophobia during migraine
may desire to be in a dark room, and state that light increases the intensity of their
migraine.

Physically active. Moderate-intensity physical activity for at least 150 minutes per
week or vigorous-intensity physical activity for at least 75 minutes per week. For the
purpose of this study, individuals meeting this deﬁnition of physically active (PA) are in
the PA group, and individuals not meeting this deﬁnition of physically activity are in a
not physically active (NPA) group.

Prevalence. The number of affected persons present in the population at a speciﬁc
time divided by the number of persons in the population at that time.

Reaction Time. The measurement of the time it takes to recognize and respond to
a designated response.

Tinnitus. Ringing in the ears.

Verbal Memory. A measurement of reaction time to the recognition of words
previously viewed by the individual.

Visual Memory. A measurement of reaction time to the recognition of symbols

previously viewed by the individual.

20

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CHAPTER 2
Literature Review

The purpose of this study was to investigate the effects of physical activity on
neurocognitive function and recovery patterns in collegiate students who incur a migraine
headache compared to collegiate students who do not incur migraines. In order to gain
insights from previous research conducted on migraine headaches, this review of
literature is divided into eight major sections: (a) Migraine symptoms and management, '
(b) pathology of migraine; (c) differential diagnosis for migraine headache; (d)
epidemiology of migraine; (e) neurocognitive function of migraine patients; (f) physical

activity and migraine; (g) instrument validity; and (h) summary of the literature.

Migraine Symptoms and Management

Migraine headaches are documented throughout history. Hippocrates described
the visual aura and the relief of the headache by vomiting (Unger, 2005) in 500 AD.
Important historical ﬁgures like Charles Darwin, Thomas Jefferson, and Robert E. Lee
among many others, consistently reported the recurrent disability from headaches.
Jefferson reportedly did not meet with Congress for one month following a terrible bout
with a chronic migraine (Unger, 2005).

Historical remedies have varied from binding an orange half or applying black
plaster to the temple (and allowing either the orange half or the plaster to drop off in
time), to sleep and solitude (Loder, 2002). Traditional practices culminated with the more

modern technique of sumatriptan, a nasal spray that can be administrated within minutes

21

of a migraine attack (Farmer, et al. 2001). Despite historical documentation and the
accumulated knowledge of migraine through centuries, migraines are still somewhat a
mystery because of their varying presentation of signs and symptoms.

Migraine headaches affect each individual differently and are associated with a
myriad of symptoms. Different classiﬁcations have been identiﬁed to differentiate
“migraine without aura,” often called the common migraine, and “migraine with aura,”
often called a classic or classical migraine. In 1988 the Headache Classiﬁcation
Committee of the International Headache Society (IHS) issued the ﬁrst “Classiﬁcation
and diagnostic criteria for headache disorders, cranial neuralgias and facial pain.” These
diagnostic criteria allowed physicians to diagnosis each patient based on a consistent
criteria with consistent language. (Society H. C., 1988) An update was issued in 2004
(Society H. C.-C., 2004) and the frrst revision was published the following year (Society
I. H., 2005) (See table 5 and 6). This section discusses migraine without aura, migraine
with aura, associated syndromes to migraine headache, the migraine postdrome and

predrome phases, prevention and treatment, and the pathology of rrrigrainous attacks.

Migraine without Aura.

Migraine without aura is often referred to as common migraine or hemicrania
simplex. The diagnostic criteria includes at least ﬁve attacks lasting 4-72 hours when
untreated or unsuccessfully treated, and at least two of the following four characteristics:
(a) unilateral location; (b) pulsating quality (throbbing or varying with the heartbeat); (c)
moderate or severe intensity; or (d) aggravation by or causing avoidance of routine
physical activity (i.e. walking or climbing stairs). During the headache the patient must

have at least one of the following: (e) nausea and/or vomiting; and/or (f) photophobia

22

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and/or phonophobia. Migraine without aura must not be attributed to any other disorder
such as: head trauma, vascular disorders, non-vascular intracranial disorders, substance
abuse or withdrawal, non-cephalic infection, metabolic disorders or disorder of the facial
or cranial structures (Society I. H., 2005). Individuals meeting the criteria, but who have
had fewer than ﬁve attacks may be coded probable migraine without aura. Observing the
more stringent guidelines, these individual were not included in this study. New
guidelines for two new entities, pure menstrual migraine and menstrual-related migraine,
were released in the 2005 edition of the IHS criteria. They were included in the migraine

without aura group for the purpose of this study.

Migraine with Aura.

Migraine with aura is also referred to as ophthalmic, hemiparesthetic, hemiplegic,
aphasic, classic or classical migraine, complicated migraine and migraine accompagnée.
It is described as idiopathic, with reoccurring symptoms localized to the cerebral cortex
or brain stem gradually developing over 5- 20 minutes and lasting less than 60 minutes.
This is typically followed by headache, nausea and/or photophobia within an hour of aura
symptoms. The headache usually lasts 4—72 hours. To diagnose a migraine with aura the
patient must exhibit at least two attacks with at least one of the following three criteria,
not including motor weakness: (a) fully reversible visual symptoms including positive
features (e.g. ﬂickering lights, spots or lines) and/or negative features (i.e. loss of vision);
(b) fully reversible visual sensory symptoms including positive features (i.e. pins and
needles) and/or negative features (i.e. numbness); or (0) fully reversible dysphasic
speech disturbance. The migraineurs must also experience at least two of the following to

meet diagnostic criteria for typical aura with migraine headache: (a) homonymous visual

23

symptoms, and/or unilateral sensory symptoms; (b) at least one aura symptom develops
gradually over 3 ﬁve minutes and/or different aura symptoms occur in succession over 2
ﬁve minutes; and (c) each symptom lasts 3 ﬁve minutes and g 60 minutes. Migraine with
aura must also not be attributed to any other disorder (Society I. H., 2005).

For the purpose of this study, all individuals meeting migraine with or without
aura criteria, including all of the following: typical aura with migraine headache, typical
aura with non-migraine headache (aura, but headache does not meet migraine criteria),
familial hemiplegic migraine (migraine must occur in ﬁrst or second degree relative and
include motor weakness) or sporadic hemiplegic migraine (motor weakness, but no
incidence in ﬁrst or second degree relative with motor weakness), were included. In
addition, basilar-type migraine (migraine with aura clearly originating from the brainstem
(e. g. dysarthria [slow, slurred speech], vertigo, tinnitus [ringing in the ears], hypacusia
[impairment of hearing], diplopia [double vision], ataxia, decreased level of conscious)
and/or both hemispheres simultaneously affected, but no motor weakness), and retinal
migraine (repeated attacks of monocular visual disturbance, including scintillations,
scotomata or blindness, associated with migraine headache) were included in the
migraine group.

The most common form of migraine with aura displays one or more of the
following symptoms: visual disturbances, unilateral paresthesias (pins and needles
feeling) and/or numbness, unilateral weakness, aphasia or unclassiﬁable speech
difficulty. Visual disturbances are the most common symptoms reported during a
migraine headache (Society I. H., 2005). Visual disturbances may be in the form of loss

of vision, seeing stars, zigzag lines or sparkles. It often presents as a zigzag ﬁgure near a

24

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point of ﬁxation that spreads left or right leaving a trail in its wake. During typical
migraine headache aura symptoms such as sensory, motor or cognitive dysftmction
usually disappears after 10-15 minutes (Ardila & Sanchez, 1988). Ardila and Sanchez
(1988) described aura symptoms as any of the following: Anomia (forgetting the name
of things), difﬁculty speaking, depersonalization (feeling as if another person), seeing the
world as strange, macropsia and micropsia (increase or decrease of apparent object size),
simultaneous agnosia (when only the full or partial object is recognized), automatic
behavior, inability to understand language, olfactory hallucinations, achromatopsia
(disappearance of colors), Chromatopsia (modiﬁcation of object colors), palinopsia
(visual perseveration— reports seeing ﬁgures or images repeatedly), pelopsia (the object
seems to become larger and approach the patient), gustatory hallucinations, alexia
(inability to read), acalculia (calculation disturbance), telopsia (objects seem small and
far away), transient global amnesia, or hemisomatognosia (unilateral misperception of

one’s own body).

Associated Syndromes for Migraine Headache

Migraine headache has been associated with fatigue, stress, and other life events
in chronic migraine patients. Fatigue is a symptom of depression and migraine, and both
are co-morbid with chronic fatigue syndrome. Peres, Zuerman, Young and Silberstein
(2002) reported 84.1% of chronic migraine patients in their study suffered from fatigue
with 66.7% meeting the CDC criteria for chronic fatigue syndrome (Peres, Zukerman,
Young, & Silberstien, 2002). This fatigue may be due to a decrease in quality of sleep
(Seidel, et al., 2009) leading to daytime fatigue and decreases in productivity and

function. Decreases in quality of sleep as well as altering patterns of sleep may lead to a

25

vicious cycle of sleep deprivation causing decreases in both cognitive and psychomotor
function (Scott, McNaughton, & Polman, 2006).

Life stress is another precursor to migraine headaches (W acogne, Lacoste,
Guillibert, Hugues, & Le Jeunne, 2003; Passchier, 1994). Many patients report puberty or
other stressful life events such as birth of a child, getting married, college-related
anxieties or a new job as precipitating migraine events (Wacogne et al., 2003). During
pregnancy, most individuals report a favorable impact on their rrrigraines (43% of
migraineurs with aura and 76 % of migraineurs without aura), while few report more
frequent and intense migraines (Granella, et al., 2000). Anxiety, depression and family
history of migraine were also associated with migraine headaches, with most attacks
beginning at the end of the night (early am) (Wacogne et al., 2003).

Migraine sufferers are characterized by more marked disabilities when coping
with pain, especially passive coping (Siniatchkin, Riabus, & Hasenbring, 1999). Two
research studies suggest increased headache intensity is associated with higher levels of
depression and emotional distress (Magnusson & Becker, 2003; Oedegaard, et al., 2006).
Other co-morbid diseases of migraine are hyper- or hypotension, Reynaud’s syndrome
(associated with vasoconstriction and reﬂexive vasodilatation of blood vessels to the
extremities), mitral valve prolapse, angina and stroke, epilepsy, positional vertigo, some
ﬁrnctional gastrointestinal disorders, asthma and allergies (Silberstein & Goadsby, 2002).
It is important to determine if an individual has an associated syndrome, or recently
experienced a life-changing event prior to his/her migraine attack, so physicians can

determine how to help prevent and best treat their rrrigraine attacks.

26

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Migraine Prodromal Phase.

The warning phase of the migraine (that may occur) which is up to 48 hours prior
to the main migraine attack is the prodromal phase. The most common signs of
discomfort such as dizziness and cervical neck pain are often unnoticed by the
migraineurs and accepted as normal (Waelkens, 1985). Migraine represents a genetic
component to headache with a lowered threshold of susceptibility to a variety of
headache triggers (Loder, 2002; McCrory, 2000). Triggers associated with migraine
headache consist of a myriad of factors that can include psychological symptoms (i.e.
stress, depression, anxiety), or physical symptoms (fatigue, intellectual effort, physical
effort). Migraines may also be related to bodily processes (menstruation, ovulation, sleep
patterns), or environmental changes (being overly hot or cold, weather pattern changes).
Migraines can be related to ingested substances such as oral contraceptives, nitrates,
cheese, chocolate or alcohol, or may be related to skipping meals (Robbins, 1993; Turner,
Molgaard, Gardner, Rothrock, & Stang, 1995; Wacogne et al., 2003; Puri, et al., 2006).
Triggers for migraine may cause a migraine one time, and on another occasion not trigger
a migraine headache (Robbins, 1993).

Triggers for migraine are routine in a college student’s activities of daily living.
The daily fare for a college student includes varying sleep patterns and stress related to a
job, class work, procrastination, and varying importance placed on each class and the
work related to that class. A single midterm may cause the average student to stay up all
night studying, feel stressed, or skip dinner in lieu of snacks such as chocolate. In the
aftermath of the exam, many mi graineurs will experience the postdromal phase of

migraine and later that evening a migraine headache.

27

Other triggers in college students may be varied. Many college students use oral
contraceptives, which have been found to worsen migraine headaches in many patients
(Granella et al., 2000). Migraineurs with a shorter history of migraine are often unaware
of what triggers their migraines and therefore suffer needlessly. While these triggers are
shown to precipitate migraines in migraineurs, one study reported similar triggers in non—
migraineurs prior to headache (Charbriat, Danchot, Michel, Joire, & Henry, 1998). The
most common triggers for both migraineurs and non-migraineurs were fatigue, and or
sleep, food, drinks, menstruation, heat/cold/weather and infections. A possible
explanation for this discrepancy may be due to genetic decreases in threshold levels
related to pain (Loder, 2002) resulting in a migraine headache in one individual while

another individual may exhibit a common headache.

Migraine Postdromal Phase.

The postdromal phase of the migraine occurs after the main migraine. These
symptoms are often used to diagnose migraine in the absence of aura. Patient’s rarely
spontaneously volunteer information about the postdromal phase of migraine unless
speciﬁcally asked by their physician. This may occur because the focus of the migraine is
on the most painful and unbearable portion, the headache phase. Common symptoms
reported in a group of 40 migraineurs that completed a questionnaire on the day after
their most recent attack included descriptions such as feeling listless, weary, and unable
to summon up energy, everything an effort, wooly headed, not thinking clearly, and
confused. The migraineurs reported the symptoms lasted anywhere from 2-27 hours
(mean 18). They also complained of reduced physical activities in the postdromal phase

that included descriptions of reduced activity in the following areas: walking, slower in

28

all actions, slow to turn head, unable to read, and impaired ﬁne motor coordination
(Blau, 1991). Another study of 827 migraineurs reported an average postdromal phase of
25.2 hours with 88% reporting postdromal periods of g 24 hours (category 18-24 hours)
with 68% of their subjects reporting postdromal symptoms. Many migraineurs experience
low-grade headaches or a feeling of fatigue and inability to concentrate similar to a
hangover from alcohol abuse that occurs in the postdromal phase (Kelman, 2005b).
Because not all individuals experience a postdromal phase it is difficult to classify when
the migraine ended, therefore most studies determine time since initiation or start of the
migraine. The scope of postdromal symptoms suggests involvement of the entire brain, in

particular, the frontal lobe and hypothalamic areas (Blau, 1991).

Migraine Treatment.

There are many different solutions in a comprehensive headache treatment plan
involving prevention, education, and pharmacotherapy. Educating the patient on
techniques of biofeedback, relaxation, life style regulations such as daily routines and
regular sleep patterns can decrease the intensity and frequency of each migrainous event.
In addition, patients can be educated on when to initiate pharmacotherapy during an
attack which can also decrease the intensity and frequency of a migraine headache
(Silberstein & Goadsby, 2002).

Migraine is an episodic and progressive disorder in which an individual with a
mild condition can progress into having frequent attacks that may change cognitive
processes in the brain (Silberstein & Goadsby, 2002). During a migraine attack, there is
progression in aura development (if present) and intensity of pain. Patients desire an

acute treatment that brings rapid, complete, and well-tolerated pain relief. Most

29

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individuals will utilize acute prevention pharmacotherapy, along with acute treatment if
they have attacks more than two to three days a week, have profound disability with each
attack, it is a recurring migraine that signiﬁcantly interferes with activities of daily living
despite acute treatment, or if co-morbid disease is present (Silberstein & Goadsby, 2002).
The American migraine study reported that 41% of patients used prescription drugs for
their migraine headaches (Lipton et al, 2001). The major medication groups utilized to
prevent migraine headaches are anti-convulsants, anti—depressants, and anti-
hypertensives. Literature suggest that efficacy of some drugs are ﬁrst noted at four weeks
and continues to increase for three months (Silberstein & Goadsby, 2002). During the
migraine, hyper excitability (i.e. photophobia, phonophobia) may respond faster than pain
to treatment (Linde, Mellberg, & Dahldf, 2006). Each treatment has a different level of
effectiveness for every individual, and often includes side effects that some patients
cannot or will not tolerate. Therefore, many individuals will utilize over the counter
medications.

Over the counter medications for migraine are available and usually consist of
aspirin, caffeine, and acetaminophen. The American migraine study reported that
approximately 58% of migraineurs primarily use over the counter therapy (Lipton et al,
2001). The best time for acute therapy is within the ﬁrst 60 minutes of the onset of
headache. This management strategy halts the sequence of the attack into the
development of central sensitizations and cutaneous allodynia, and thereby modiﬁes the
progression of the attack. This will help to decrease pain intensity (Gallagher, 2004).

Strategies used to decrease or combat progressions are to avoid triggers, early

30

intervention, use of preventative treatment including pharmacotherapy (Gallagher, 2004),

and to utilize daily headache diaries to identify triggers (Wilkinson, 1994).

Pathology of Migraine.

The pathology of migraine differs in migraineurs who suffer from aura than those
that do not suffer from aura (Society I. H., 2005). Most patients with migraine
exclusively suffer from attacks without aura. Many migraineurs who have attacks with
aura experience attacks of migraine both with and without aura on varying occasions
(Society I. H., 2005)

The older vascular theory of migraine proposed that the aura was secondary to
intracranial vasoconstriction and that the headache was an inﬂammatory reaction around
the walls of the dilated cephalic vessels (Graham & Wolff, 1938). This theory supported
the pulsing nature of the pain, however there appears to be a wave of “oligemia” (reduced
blood ﬂow) which starts in the posterior aspect of the brain and spreads to both the
parietal and temporal lobes along the cortical surface, not the vascular distribution pattern
(Graham & Wolff, 193 8). Therefore, arterial vasospasm alone cannot be responsible for
the decreased blood ﬂow (Goadsby & Olsen, 1996).

A subsequent theory is the neurogenic theory (Moskowitz, 1993). This proposed
that head pain is centrally generated and involves both serotonergic and adrenergic pain
modulating systems (Derman, 1994). Several lines of evidence link serotonin to migraine.
These include the drop in serotonin blood levels during migraine, as well as serotonin as
an effective treatment and serotonin antagonist as a prevention of migraine headaches

(Derman, 1994). Following this theory, it is now widely held that migraine is a

31

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neurovascular disorder with brain involvement with the pain occurring secondary to
involvement of the trigerrrinovascular system (Ravishankar & Demakis, 2007).

Many systems are involved and affected during migraine. The extrapyramidal
system is a complex neural network that provides a proper execution of voluntary
movements by correctly processing proprioceptive, cognitive, and motor information in
the brain (Barbanti & F abbrini, 2002). There is some evidence that the extrapyramidal
system is involved in migraine (Barbanti & F abbrini, 2002). Migraineurs often recognize
an exacerbation of their headaches as they bend over or exert themselves, this is referred
to as “central sensitization” (Unger, 2005). The central nervous system becomes more
excitable over time and less inhibited, leading to an increased perception of pain (U nger,
2005)

Researchers suggest migraine headaches may produce structural and functional
brain dysfunctions (Elkind & Scher, 2005; Swartz & Kern, 2004; Kruit, et al., 2004).
Speciﬁcally, MRI studies on migraines suggest asymptomatic subcortical and
abnormalities in the cerebellar region of the posterior circulation (Swartz & Kern, 2004)
as well as deep white matter changes (Swartz & Kern, 2004; Kruit, et al., 2004).
Reversible changes in the brain were conﬁrmed via positron emission tomography (PET)
and magnetic resonance imaging (MRI) in one case study (Gentile, Rainero, Daniele,
Binello, Valfre’, & Pinessi, 2009). Leistad et a1. (2006) reported that less pronounced and
more regional trigeminocervical sensitization seems to be important in migraines. After
60 minutes of cognitive stress, subjects were tested. Results included increased muscle
pain (visual analogue scale) that developed in the trapezius and neck regions. However,

there were no differences between migraine and controls in electromyographic (EMG)

32

studies (Leistad, Sand, Westgaard, Nilsen, & Stovner, 2006). With so many systems
involved, migraine is difﬁcult to treat, and often requires many trials with different types
of medications prior to reaching a therapy, due to the varying drug pathways.

Approximately 36% of individuals who suffer from migraine headaches reported
aura as a symptom (Lipton et al., 2001). During migraine with aura there is decreased
cerebral blood ﬂow to the clinically affected area and often includes a wider area in the
brain (Society I. H., 2005). Research also suggests a decreased blood ﬂow during the pre-
headache phase with pain occurring during the subsequent vasodilatation of the same area
(Hassinger, Semenchuk, & O'Brian, 1999). Most medications intervene with migraine
through one of the following methodologies: (1) vasoconstriction, (2) compounds that
inhibit the cortical depression that accompanies headache, or (3) constriction of cranial
vessels and arteriovenous anastomoses within the carotid vasculature (Unger, 2005).

Side of pain, handedness, and genetics play a role in migraine pathology. A study
of 1,283 migraine patients studied location and triggers for migraine (Kelman, 2005a).
Results reported that 67.1% migraineurs reported pain in the eyes, 58% in the temporal
region, 55.9% ﬁontal area, 39.8 occipital area, 39.7 neck areas, 17.5% diffusely and
24.1% at the vertex of the head. Henri cranial pain was present in two-thirds of all
migraines (Kelman, 2005a). Migraineurs are commonly left handed (Waldie, Hausmann,
Milne, & Poulton, 2002). Migraines are also theoretically genetically linked, with many
individuals indicating at least one other family member experiencing migraines (Ziegler,
Hur, Bouchard, Hassanein, & Barter, 1998). Pain location, often makes the migraine
difficult to diagnose, especially for the migraines that do not follow the typical

presentation.

33

Differential Diagnosis for Migraine Headache

When a patient presents with a headache it is important to determine the type and
cause of the headache. Primary and secondary are the two categories for classifying
headaches (Millea & Broadie, 2002). Primary headaches include migraine, tension-type,
and cluster headaches and have no apparent underlying organic disease process.
Secondary headaches are a result of underlying organic disease and are a symptom of a
recognized disease process. Primary headache is treated symptomatically, with the goals
centralizing on relief and prevention, while secondary headaches primarily treat the
underlying disease, but also treat the symptoms (Millea & Broadie, 2002). The IHS
criterion separates headache diagnosis into 14 main codes or categories and further
separates them into sub categories. Not all categories are discussed because they are
related to secondary causes. The following section will present differential diagnosis for
migraine headache, headache attributed to rhinosinusitis, tension-type headache, cluster
headache, headaches related to substances or their withdrawal, and medication overuse

headache.

Headache Attributed to Rhinosinusitis.

Migraineurs frequently report runny nose, congestion, and ocular symptoms, such
as reddening or swelling, during migraines. These are cranial autonomic symptoms
(Gupta & Bhatia, 2007). Many of these symptoms are also associated with sinusitis. As a
result, some physicians have misdiagnosed a migraine headache for a sinus headache.
Sinus headache related to acute sinusitis is relatively rare, and must occur in conjunction
with fever, diagnostic testing such as MRI, CT imaging, or lab results (Society I. H.,

2005) and include purulent discharge (Schreiber et al., 2004; Kehnan, 2005a). Schreiber

34

et al. (2004) examined individuals diagnosed with a sinus headache and found that 88%

of sinus headache patients had migraine-type headaches fulﬁlling IHS criteria. In
addition, Kelman (2005) investigated physician diagnosed migraine headaches and
reported that 67.1% of patients’ pain was located in the eyes, while 55.9% report pain in
the frontal region of their head. Both of these locations are also associated with “sinus”
headaches (Kelman, 2005a). Therefore, an incorrect diagnosed of sinus headache may be
assigned, thus decreasing the prevalence, and delaying treatment of this debilitating

disease.

Cluster Headache.

During a physician exam, it is essential to diagnose all types of headaches that the
individual is experiencing and list them in the order of importance to the patient (Society
I. H., 2005). To fulﬁll the diagnostic criteria, patients must have had at least ﬁve attacks
occurring from one every other day to eight per day. These headaches must not be
attributable to another disorder (Beck, Sieber, & Trejo, 2005). In addition, headaches
must cause severe or very severe unilateral orbital, supraorbital or temporal pain lasting
15 to 180 minutes if untreated. They must be accompanied by at least one of the
following: ipsilateral conjunctiva] injection and lacrimation, ipsilateral nasal congestion
or rhinorrhea (ﬂowing nasal discharge), ipsilateral eyelid edema, ipsilateral forehead and
facial sweating, ipsilateral rrriosis and or ptosis, or a sense of restlessness or agitation
(Society I. H., 2005). Cluster headaches are episodic or chronic. Episodic cluster
headache is two cluster periods lasting seven to 365 days that are separated by pain-free
remission periods that last one month or longer (Beck, Sieber, & Trejo, 2005). Chronic

attacks occur over more than one year without remission, or with remission lasting less

35

than one month (Beck, Sieber, & Trejo, 2005). The absence of aura, nausea or vomiting
has helped to distinguish migraine from cluster headache (Van Vliet, Eekers, Haan,
Ferrari, & Group, 2003), as well as the near daily attacks. The classic feature is
restlessness, with one study describing behaviors such as pacing and rocking with their

head in their hands in 93% of patients (Bahra, May, & Goadsby, 2002).

Tension-Type Headache.

Tension-type headache typically manifests as pain that radiates from the forehead
to the occiput in a band-like fashion. This band-like pain will also move into the neck and
shoulders and cause muscular tightness and pain (Millea & Broadie, 2002). Diagnostic
criteria through the IHS require the patient to have at least ten headaches fulﬁlling the
following criteria, and less than 180 per year or 15 per month (Society I. H., 2005).
Headaches must last from 30 minutes to seven days and may be continuous. The
headache must also have two of the following pain characteristics: (1) bilateral location;
(2) pressing or tightening (non-pulsating quality); (3) mild to moderate intensity; or (4)
not aggravated by routine activity such as walking or climbing stairs. Tension-type
headache may not include nausea or vomiting, but may have either photophobia or
phonophobia: however, if both are present, it would not meet the diagnostic criteria.
Tension-type headaches often occur with pericranial tenderness on manual palpation
(Society I. H., 2005). Tension-type headache is separated from typical migraine by
features such as unilateral pain, aggravation from activities of daily living, throbbing pain
and nausea may not be present (Millea & Broadie, 2002). Tension-type headaches are.
classiﬁed as chronic if they occur at least 15 days per month for more than three months

(Society 1. H., 2005).

36

Headaches Associated with Substances or their Withdrawal.

The diagnostic criteria for headaches associated with substances or their
withdrawal must include the following: Headache with at least one of the following
characteristics (a) bilateral, (b) frontotemporal location, (c) pulsating quality, or ((1) they
are aggravated by physical activity (Society I. H., 2005). The headache must be
associated with the ingestion of a speciﬁed substance such as alcohol, food component,
or additive known to cause headaches. The headache must develop within 1-12 hours
after intake of the substance. The headache must resolve within 72 hours. Headaches
associated with substance abuse or their withdrawal includes the following substances:
nitrates, monosodiurn glutamate, alcohol (withdrawal), ergotarnine and analgesics
(abuse), caffeine (withdrawal) or birth control pills (Society I. H., 2005). In this study,
individuals were speciﬁcally asked to differentiate between headache related to substance

abuse (i.e. alcohol, caffeine) and migraine headache in the migraine questionnaire.

Medication-Overuse Headache.

Well recognized for decades, analgesic abuse related migraine is a vicious cycle
of chronic pain and dependence on analgesics, followed by a rebound headache (Boes &
Capobianco, 2005). Speciﬁc criteria for analgesic overuse headache includes that the
headache is present on greater than 15 days of the month, with simple analgesics taken on
15 or more days per month for more than three months (Society I. H., 2005). Regular
overuse of one or more acute or symptomatic drug treatment for headache, longer than
three months is a requisite amid the symptoms. The headache must have worsened over

the period of analgesic overuse and must resolve or revert to its previous pattern within

37

two months of the discontinuation of analgesics (Society I. H., 2005). Primary headaches
are presented in Table 2, secondary headaches are presented in Table 3 below.

Table 2: Primary Headache Classification Criteria

 

Migraine without Aura

 

Diagnostic Criteria
A. At least 5 attacks fulﬁlling criteria B-D
B. Headache attacks lasting 4-72 hours (untreated or unsuccessﬁrlly treated)
C. Headache has at least two of the following characteristics

1. unilateral location

2. pulsating quality

3. moderate or severe pain intensity

4. aggravation by or causing avoidance of routine physical activity
D. During headache at least one of the following

1. nausea and/or vomiting

2. photophobia and phonophobia
E. Not attributed to another disorder

 

Typical Migraine with Aura

 

Diagnostic Criteria
A. At least two attacks fulﬁlling criteria B-D
B. Aura consisting of at least one of the following, but no motor weakness
1. Fully reversible visual symptoms including positive features (eg. ﬂickering
lights, spots or lines) and/or negative features (ie. loss of vision)
2. Fully reversible sensory symptoms including positive features (eg. Pins and
needles) and/or negative features (numbness).
3. Fully reversible dysphasic speech disturbance
C. At least two of the following
1. Homonymous visual symptoms and/or unilateral sensory symptoms
2. At least one aura symptom develops gradually over 2 5 minutes and/or
different aura symptoms occur in succession over 2 5 minutes.
3. Each symptom lasts 2 5 minutes and 5 60 minutes.
D. Headache fulﬁlling criteria for migraine without aura begins during the aura or
follows aura within 60 minutes
E. Not attributed to another disorder

 

38

Table 2 Continued

 

Cluster Headache

 

Diagnostic Criteria
A. At least ﬁve attacks fulﬁlling criteria B-D
B. Severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15-
180 minutes if untreated.
C. Headache is accompanied by at least one of the following symptoms.
1. Ipsilateral conjunctiva] injection and/or lacrimation
2. Ipsilateral nasal congestion and/or rhinorrhea
3. Ipsilateral eyelid edema
4. Ipsilateral forehead and facial sweating
5. Ipsilateral miosis and/or ptosis
6. A sense of restlessness or agitation
D. Attacks have a ﬁequency from one every other day to 8 per day
E. Not attributed to another disorder

 

Primary Exertional Headache

 

Diagnostic Criteria

A. Pulsating headache fulﬁlling criteria B and C

B. Lasting from 5 minutes to 48 hours

C. Brought on and occurring only during or after physical exertion
D. Not attributed to another disorder

 

Tension-Type Headache

 

Diagnostic Criteria
A. At least 10 episodes occurring on <1 day per month on average (<12 days per year)
and fulﬁlling criteria B-D* Note that more episodes per month will change it to episodic
or chronic.
B. Headache lasting ﬁom 30 rrrinutes to 7 days.
C. Headache has at least two of the following characteristics:

1. Bilateral location

2. Pressing/tightening (non-pulsating quality)

3. Mild or moderate intensity

4. Not aggravated by routine physical activity such as walking or climbing stairs
D. Both of the following:

1. No nausea or vomiting (anorexia may occur)

2. No more than one of photophobia or phonophobia
E. Not attributed to another disorder.

39

Table 3: Secondary Headache Classification Criteria

 

Headache attributed to a substance abuse or its withdrawal

 

Diagnostic Criteria
A. Headache with at least one of the following characteristics fulﬁlling C and D
1. Bilateral
2. Frontotemporal location
3. Pulsating quality
4. Aggravated by physical activity
B. Ingestion of speciﬁed substance such as alcohol, food component or additive
C. Headache develops within 1-12 hours after substance intake dependant on substance
D. Headache resolves within 72 hours

 

Medication-Overuse Headache

 

Diagnostic Criteria

A. Headache present on >15 days/month fulﬁlling criteria C and D

B. Regular overuse for >3 months of one or more drugs that can be taken for acute and/or
symptomatic treatment of headache.

C. Headache has developed or markedly worsened during medication overuse.

D. Headache resolves or reverts to its previous pattern within 2 months after
discontinuation of overused medication.

 

Headache attributed to Rhinosinusitis

 

Diagnostic Criteria

A. Frontal Headache accompanied by pain in one or more regions of the face, ears, or
teeth fulﬁlling criteria C and D.

B. Clinical, nasal, endoscopic, CT and/or MRI imaging and/or laboratory evidence of
acute or acute-on-chronic rhinosinusitis.

C. Headache and facial pain develops simultaneous with onset or acute exacerbation of
rhinosinusitis.

D. Headache and/or facial pain resolve within 7 days after remission or successful
treatment of acute or acute-on-chronic rhinosinusitis

Epidemiology of Migraine

In order to effectively treat and manage migraine it is important to investigate the
prevalence and economic burden of the disease. Recognition of the disability by general
practitioners is very important; however, it is still inconsistent due to underreporting by

40

patients, as well as failure of the physician to attain an accurate description and history of
their headaches. The prevalence, incidence, and burden of migraine are discussed in this

section.

Prevalence and Demographics of Migraine Headaches.

A study conducted by Lipton et al. (2001) reported the prevalence of migraine
headache was estimated at 18% for females and 6% for males in 1989 (Lipto et al.,
2001). Lipton et al. (2002) replicated the study in 1999 and found the prevalence rate of
migraine headache in the United States remained stable between 1989 and 1999. Results
of the 1999 study reported the prevalence of cases increased linearly ﬁom aged 12 to 40
years and then declined in both sexes after 40 years of age. Prevalence was highest in
subjects between the ages of 30 to 49 years, higher in whites compared to blacks, and was
inversely related to household income. Approximately 23% of households contain at least
one member who suffers from migraine headaches (Lipton et al, 2002; Lipton et al.,
2001). Similar prevalence rates of nrigraine in Caucasian (15.3%), Aﬁican-American
(14.3%) and other (11.6%) races (Bigal, Kolodner, Lafata, Loetta, & Lioton, 2006).
Brazilians reported a one-year and age adjusted prevalence rate of 15.2, with higher
incidence in women, individuals with less than 11 years of education, individuals who
did not exercise and individuals with poverty level income (Queiroz, et al., 2009).
Research shows one-year prevalence is an excellent method to determine current trends
in migraine.

In lifetime prevalence studies, many individuals report remission of the disorder
or low migraine frequency. For example, a study that examined lifetime prevalence of

migraine in the Netherlands found 33% lifetime prevalence and 25% one-year prevalence

41

in women (Launer, Terwindt, & Ferrari, 1999). In men, the lifetime prevalence was
13.3%, and the one-year prevalence was 7.5% (Launer, Terwindt, & Ferrari, 1999). In a
follow-up study done in Denmark, researchers reported that 42% of subjects had
experienced remission and 38% had a low frequency of migraine headaches (1-14
headache days per year) (Lynberg, Krogh, Rasmussen, J argensen, & Jensen, 2005).

Very few studies have investigated college-aged individuals who suffer from
migraine headaches. One research study conducted on male and female NCAA Division I
basketball players revealed only 2.9% of the population had migraine headaches that met
IHS guidelines (Kinart, Cuppett, & Berg, 2002). Results revealed females reported more
frequent migraine headaches that last longer and throb, which are accompanied by
phonophobia and photophobia. However, this study had a low response rate (13.2%) with
only 25% of schools participating and only included basketball players (Kinart, Cuppett,

& Berg, 2002).

Prevalence and Incidence of the Diagnosis of Migraine.

The prevalence of diagnosis of migraine headaches have increased over the past
decade, however, approximately 50% of migraine sufferers still remain undiagnosed
(Lipton et al, 2001; Bigal, Kolodner, Lafata, Loetta, & Lioton, 2006). The American
migraine study reported 38% diagnosis in 1989 increasing to 48% in 1999 (Lipton et al,
2001). This study utilized a validated, self-administered questionnaire distributed via US.
mail to a sample of 20,000 households in the United States. Questions included were self-
diagnosed or physician-diagnosed along with ﬁequency and intensity of their symptoms.
In the physician-diagnosed group, subjects were signiﬁcantly more likely to report

symptoms of nausea, vomiting, blurred vision, aura, neurological signs, photophobia, and

42

phonophobia when compared to the self-diagnosed group. Pulsatile pain occurred with
equal frequency in both groups. The physician-diagnosed percentage was higher in
females than males, associated with older age individuals, and household income greater
than $50,000 per year (Lipton et al, 2001). Prevalence of migraine has a trend to decrease
with increasing post high school education (Bigal, Kolodner, Lafata, Loetta, & Lioton,
2006). These studies demonstrated that while physician diagnosis may represent a
population that is more severely afﬂicted, diagnosis is not essential to many rrrigraineurs.
Studies comparing physician diagnosed and self-diagnosed migraineurs
demonstrate an inconsistency in diagnosis despite the IHS published criteria (Lipton,
Stewart, Celentano, & Reed, 1992). In a study by Lipton et al. (1992) physician-
diagnosed migraine headaches were reported in 41% of females and 29% of males. In the
self—diagnosed group, 80% indicated some headache related disability. The researchers
also reported that most, but not all of physician diagnosed migraine headaches agreed
with IHS diagnosis. A study conducted in France presented 49 general practitioners (GP)
with a questionnaire aimed at identifying if the patient was a migraine sufferer, and
requested a diagnosis. The patient also independently completed a similar questionnaire.
Results indicated that the GP’s did not recognize 59.7% of the patients as having suffered
a migraine headache (recognized by IHS criteria) and only 28% recognized the patients
as having management of their migraine (Vuillaume De Diego & Lanteri-Minet, 2004). A
recent study found an 82% agreement between clinical interview diagnosis of migraine
and diagnosis of migraine from a 4 to 8 week headache diary (Phillip, Lyngber, & Jensen,
2007). These studies show an increasing trend in physician interview to be more sensitive

to migraine diagnosis, and more reliance on a headache diary to assist in this process.

43

Medically recognized migraine diagnosis was described by Rozen et al. (1999) as
an incidence rate. The investigators deﬁned medically recognized migraine as individuals
who met diagnostic criteria of the IHS guidelines. Cases were classiﬁed independent of
physician recognition of the disease. Results revealed that the incidence rate of medically
recognized migraine increased for all female patients, with a peak incidence rate between
20 to 29 years. Male incidence rates increased slightly overall, with a relative increase
from 10 to 19 (89%) years of age (Rozen, Swanson, Stang, McDonnell, & Rocca, 1999).
With females reporting more frequently occurring migraines then males, and the
proportion of migraine headaches that goes undiagnosed, the burden of migraine impacts

society in many areas.

Burden of Migraine.

Migraine is currently ranked by the World Health Organization as number 19
among all diseases worldwide that cause disability (Society I. H., 2005). It is also more
common than many other chronic or disabling diseases in the primary care setting and
equals the prevalence of asthma and diabetes combined (Unger, 2005). Based on both
direct and indirect costs, the burden of migraine is vast. Indirect costs are lost
functionality at work, decreased social functioning, decreased patient well being,
disability, and loss of productivity at home. Results of the 1999 American migraine study
revealed that 91% of individuals who suffered from migraine headaches reported
functional impairment with 53% of respondents indicating that their headaches caused
severe impairment or required bed rest (Lipton et al, 2001). Approximately 31% missed
at least one day of work in the past three months due to their migraine; while 51%

reported school or work productivity was reduced by at least 50% during a migraine

44

episode. The frequency of severe headache was similar for males and females; however,
62% reported one or more severe headache per month, with only 10.8% reporting
headaches more than once per week. The most frequently neglected aspect of the
migraineurs life was household work with 76% of respondents reporting avoiding
household work at least once during the previous three months due to their migraine
headache (Lipton et al, 2001). A Dutch study where 1,292 of a large cohort of over 6,000
were given questionnaires on headache found that migraineurs suffered the burden of a
median of 12 migraines per year, and 25% had at least two attacks per month (Launer,
Terwindt, & Ferrari, 1999).

Kelman (2006) studied the changes of migraine through cross-sectional data in a
large cohort. Results suggest that there were no signiﬁcant changes related to age in
duration, frequency, sex, or triggers across a group ranging ﬁom 16-80 years. One
exception was that migraineurs in the 50+ age group tended to suffer from a less severe
migraine (pain), and are less affected by each attack (Kehnan, 2006). Frequency of
rrrigraine was positively associated with higher levels of disability for emotion, cognition
and pain in a primary study outcome utilizing the Health Utilities Index, which is a
widely used patient reported questionnaire (Brown, Neumann, Papadopoulos, Ruoff,
Diamond, & Menzin, 2008). However, most data is self-reported related to cognition,
with individuals reporting feelings of decreased cognition, not speciﬁcally tested in those
arenas.

With frequent attacks, migraine is directly costly to both the individual and the
economy as a whole. On average female migraineurs required 5.6 days of bed rest, while

males required 3.8 days of bed rest each year, resulting in a total of 112 million days each

45

year (Hu, Markson, Lipton, Stewart, & Berger, 1999). Estimated cost to employers hover
around $13 billion per year due to missed workdays and impaired work ftmction.
Furthermore, direct medical costs were estimated at one billion per year (Hu et al., 1999).
Another study that measured direct and indirect cost found individuals who suffered from
migraines had statistically higher direct medical costs, higher cost of low work
productivity, and higher combined total cost of direct and indirect costs compared to the
migraine ﬁee group (Edmeads & Mackell, 2002). This gap increased when they
compared moderate and severe migraine headaches. Severe migraineurs had signiﬁcantly
higher costs in all categories. On average, they found that migraine workers lost
statistically more days (nine vs. six in the comparison group) ﬁ'om work or household
activities in the previous six months than non-migraine workers (Edmeads & Mackell,
2002). Another study reported that mi graineurs used on average 2.3 more physician
ofﬁce visits than controls, and were more likely to be seen in an emergency room, or
admitted to a hospital adding up to an average $697 more in medical care costs during the
year compared to those without migraine (Lafata, Moon, Leotta, Kolodner, Poisson, &
Lipton, 2004). It is well recognized that lost time due to migraine headaches are a result
of short-term (hours-days/ non-permanent) effects, however, no research to date has

examined the relationship between cognitive function and migraine headaches.

N eurocognitive Function of Migraine Patients.

Several studies have examined cognitive function and migraine headaches;
however, research is inconclusive as to whether migraine headaches lead to cognitive
dysfunction over time (Jelicic, van Boxtel, Houx, & Jolles, 2000; Magnusson & Becker,

2003; Gaist, et al., 2005; Launer, Terwindt, & Ferrari, 1999; Waldie, Hausmann, Milne,

46

& Poulton, 2002). Furthermore, direct comparison is often difficult due to
methodological problems such as selection bias (convenience sample or hospital sample)
and small sample size (Hooker & Raskin, 1986; Leijdekkers, Goudswaard, Menges, &
Oriebeke, 1990; Le Pira, et al., 2004; Le Pira, Zappala, Giuffrida, Lo Bartola, Morana, &
Lanaia, 2000; Haverkamp, Honscheid, & Milller-Sinik, 2002; Zeitlin & Oddy, 1984). In
addition, most studies have utilized individuals in their 30’s and 40’s and beyond, that
presumably have along history of migraine (Zeitlin & Oddy, 1984; Hooker & Raskin,
1986). As a result, it is difﬁcult to determine long-term (years/permanent) effects of
migraine headache on an individual’s cognitive function. The following sections will
concentrate on migraine headaches associated with and without cognitive impairments

and reversible cognitive decline.

Migraine is not Associated with Long— Term Cognitive Decline.

A number of studies have found that migraine headaches are not associated with
cognition (Bell, Primeau, Sweet, & Loftland, 1999; Lipton et al, 2002; Hu, Markson,
Lipton, Stewart, & Berger, 1999; Schreiber et al., 2004; Kalaydjian, Zandi, Swartz,
Eaton, & Lyketsos, 2007). Bell, Primeau and Sweet et al., (1999) compared groups of 20
individuals recruited from a specialty clinic for the treatment of chronic pain. The
researchers found that migraine headaches were not associated with cognitive impairment
when compared to chronic pain and mild traumatic brain injured (MTBI) patients. This
study is difficult to compare with other studies due to the high number of migraines per
month the patients reported. The migraine subjects reported they had migraines on
average of 13.5 days per month for the last six months and ﬁve to six incapacitating

migraines per month. Most studies criteria include migraine headaches at a much lower

47

rate, such as greater than six per year with averages of 34 to 37 migraines per year
(Lipton et al, 2002). Therefore, Bell, Primeau and Sweet et al., (1999) average of 13.5
migraines a month would amount to 162 migraines a year which is much higher than the
average migraineurs experience.

Matching control and experiment groups in studies can be a daunting task. Twin
studies considered the ultimate epidemiological study because of the concordance in the
control and experimental group, are rare. A Dutch twin study found a lifetime diagnosis
of migraine was not associated with cognitive deﬁcits in middle-aged subjects (Gaist, et
al., 2005). In a study of children with migraines and their unaffected sibling, there was no
' cognitive difference between the control group of sibling pairs and the migraine group of
sibling pairs (Haverkamp, Honscheid, & Miiller-Sinik, 2002). Another study of female
college students found no signiﬁcant differences between migraine with aura, migraine
without aura and controls on a battery of memory and neuropsychological tests (Burker,
Hannay, & Halsey, 1989). Leijdekkers et al. (1990) also found there were no signiﬁcant
differences on test performance between a migraine and control group matched by age,
education, and social background. However, all the subjects recruited were from a local
migraine group, which may have contributed to a reporting bias. Additional research
utilizing 95 elderly volunteers, found no signiﬁcant differences in cognitive ability in
individuals with a long history of migraine (Pearson, Chronicle, Maylor, & Bruce, 2006).
Previous research has focused on long-term cognitive function following a migraine;
however, very few studies have examined short-term cognitive function during migraine

headaches.

48

Reversible Cognitive Decline.

A reversible cognitive decline was deﬁned as a cognitive decline during the
headache interval, which completely subsides during a measured period followed by a
period where the individual is headache free. Subjects tested when headache free and 30
hours following recovery ﬁ'om a headache and nocturnal sleep showed a reversible
cognitive decline when comparing migraine and cluster headaches (Meyer, Thomby,
Crawford, & Rauch, 2000). Results indicated that 86% of subjects showed cognitive
decline, however sleep and serotonin antagonists reversed the cognitive impairments.
One major problem with the Meyer and colleagues study was the lack of comparison to a
control group.

A study presented at the American Association for the Study of Headaches found
temporary impairments of immediate and sustained attention and verbal learning were
found accompanying headache intervals in a study where 30 mi graineurs were
interviewed in their clinic or via telephone during the headache interval (Black, Horn,
Miller, & Logue, 1997). Another study reported self-administered testing of the
Neurobehavioral Evaluation System (NES2) when the migraineurs were both headache-
free as well as 30 hours after a headache showed slower response times, but were not
measurably impaired 30 hours after a headache and nocturnal sleep (Mulder, Linssen,
Passchier, Orlebeke, & De Geus, 1999). Bedside testing administered over the phone, and
or self-administered are not the golden standard for encompassing the ﬁll] gamut of
cognitive impairments that occur after a migraine headache.

Similarly, two prescription drug studies utilizing Surnatriptan (injection and nasal

spray) found that cognitive impairments were reversible 15 minutes after medication

49

administration (Farmer, Cady, Bleiberg, & Reeves, 2000; Farmer, et al., 2001). Cognitive
function was measured in 15 minute intervals post sumatriptan administration and was
completely back to baseline 135 minutes post-dose (Farmer, Cady, Bleiberg, & Reeves,
2000). In both these studies cognitive function (simple reaction time, sustained
attention/concentration, working memory, visual-spatial processing) and alertness/fatigue
were adversely affected during a migraine headache. However, results of these studies
may be skewed due to lack of comparison to a control group and small sample size.
Another open label study on the effects of topiramate monotherapy in migraine treatment
showed that while the migraine and control group were comparable with no differences at
baseline. A side effect of the medication was decreased word ﬂuency. (Romigi, et al.,
2008). No research to date has examined short-term cognitive function comparing a

migraine and control group to their baseline cognitive ﬁrnction

Migraine is Associated with Long-Term Cognitive Decline.

Migraine studies have reported long-term (years/ permanent) cognitive decline in
information processing, reaction time, verbal ability and visual processing (Hooker &
Raskin, 1986; Zeitlin & Oddy, 1984; Waldie, Hausmann, Milne, & Poulton, 2002; Wray,
Mijovic-Prele, & Kosslyn, 1995). One study found a loss of cognitive habituation in
migraine, and an increased processing time (Evers, Bauer, Suhr, Husstedt, & Grotemeyer,
1997). Hooker and Raskin (1986) compared classic (migraine with aura) and common
(migraine without aura) migraine headaches. The classic migraine headache group
exhibited slower dominant hand motor speed, less dexterity, less efﬁcient learning of new
associations between dissimilar symbols, and dysphasic errors compared to the common

migraine group. Both migraine groups exhibited poorer free recall of semantic material

50

and lesser ability to discriminate forms and analyze spatial relationships in the tactile
modality. In addition, ﬁve subjects reported cognitive difﬁculties due to their migraine
headaches. However, this classic study did not have a control group, and mainly
examined differences between aura and no aura migraines.

Research shows information processing declines in migraine sufferers over time
(Zeitlin & Oddy, 1984; Wray, Mijovic-Prele, & Kosslyn, 1995)). Zeitlin and Oddy
(1984) found that severe migraine sufferers consistently gave poorer performances on a
series of memory and information processing tasks. A limitation to this study was a lack
of a control group and subjects were limited to a migraine clinic. Another study
conducted in New Zealand consisted of 979 subjects individually assessed on a variety of
measures on ten different occasions from age three to 26 at certain pre-determined age
intervals. Twelve percent of the 979 subjects fulﬁlled the H-IS diagnostic criteria for
migraine headaches. Results indicated that migraine patients were signiﬁcantly impaired
on verbal ability, independent of headache history (severity of pain of average migraine
headache), when compared with tension-type headache and controls (Waldie, Hausmann,
Milne, & Poulton, 2002). Results also revealed that visual processing is also slower in
migraine patients (Wray, Mijovic-Prele, & Kosslyn, 1995). Overall, many studies have
found neurocognitive deﬁcits in migraineurs, with the main limitation of the studies
lacking a control group and only using diagnosed migraine patients.

Researchers suggest migraine headaches may produce structural and functional
brain dysfunctions (Elkind & Scher, 2005; Swartz & Kern, 2004; Kruit, et al., 2004). In a
study of Dutch adults 30 to 60 years of age, patients with migraines exhibited a higher

prevalence of infarct in the cerebellar region of the posterior circulation. and deep white

51

matter (Kruit, etal., 2004). Swartz and Kern (2004) concluded from a meta-analysis of
published case-control studies utilizing magnetic resonance imagining that migraine
patients are at higher risk of having asymptomatic sub cortical and deep white matter
abnormalities. Abnormalities found in the cerebellar region of the posterior circulation
may affect long-term cognitive function. Overall, cognitive function is impaired during a
migraine. While long-term changes are important, the short-term effects should not be
overlooked, due to the impact on the daily lives of migraineurs. Migraines headaches,
impacting daily, weekly, or even monthly can effect decisions, actions, and may possible

determine long-term outcomes in an individual’s life.

Physical Activity and Migraine.
Exercise through the life span is important to the health and well-being of all

individuals. Currently, there are inconsistent research results on the relationship between
exercise and migraine. It is well known that regular exercise can decrease stress levels.
Research has shown stress to be a trigger for migraine (Turner, Molgaard, Gardner,
Rothrock, & Stang, 1995). Consequently, exercise has been promoted as a method of
migraine management and prevention (Folkins & Sime, 1981). Case report data shows
that some individuals use exercise as a successful method of aborting a migraine
headache. During the prodromal (aura and pre-migraine symptoms) phase the individual
may go for a run to prevent the subsequent headache (Darling, 1991). On the contrary,
exertional exercise without a proper warm-up can also be a trigger for migraine
headaches. This may occur as a result of a Valsalva maneuver (holding ones breath in an

effort to lift heavier weights), or initiating vigorous exercise without warming up and

52

stretching, which allows the body to adapt to the new energy level (Lambert & Bumet,

1985; Rooke, 1968).

Very few studies have examined the relationship between migraine and exercise.
Lockett and Campbell (1991) initiated a six-week cardiovascular exercise program and
found decreases in the pain level during their migraine headache. They also found trends
toward decreased frequency, intensity, and duration, but felt that with an increased
period, signiﬁcant differences would arise. Another six-week study where subjects
exercised at 60% of their max heart rate for 40 minutes (10 minute warm-up, 20 minute
exercise, 10 minute rest) three times a week found that subjects reported a signiﬁcant
decrease in intensity and frequency of migraine (Koseoglu, Akboyraz, Soyuer, & Ersoy,
2003). One study reported a reduction in vascular headache activity in four out of ﬁve
subjects after a six week exercise intervention (Fitterling, Martin, Gramling, Cole, &
Milan, 1988). The results of this study suggest maintenance of an exercise program is

essential for decreased migraine frequency.

Migraine and Exercise Physiology.

Physiological changes associated with exercise provide a plausible explanation
for exercise moderated pain relief (Darling, 1991). The endorphin system is known for its
analgesic properties, lower plasma beta-endorphin levels are found in migraineurs
(Fettes, Gawel, Kuzniak, & Edrneads, 1985), and serotonin, which is known to inhibit
pain perception (Anthony, 1984) has been found to drop during a migraine attack and
cause vascular changes (Anthony, 1972). Research on beta-endorphin levels after
exercise in migraineurs showed increased levels with regular exercise (Koseoglu,
Akboyraz, Soyuer, & Ersoy, 2003). Serotonin, plasma beta-endorphin levels and

53

endorphins increase during exercise, which alters the vasodilation process and provides a
natural preventative, or relief of a migraine headache (Farell, Gates, Maksud, & Morgan,
1982). Perception of pain decreases after a single bout of resistance exercise (Koltyn &
Arbogast, 1998; Whiteside, Hansen, & Chaudhuri, 2004). This may also be facilitative

during a migraine.

Physical Activity Defined.

Regular physical activity done at a moderate intensity level is proven to result in
health beneﬁts (U .S. Department of Health and Human Services, 2008). Healthy People
2010, established in 2000, contains 467 objectives designed to serve as a road map for
improving the health of all people in the United States during the ﬁrst decade of the 215t
century. At the midpoint of 2005, a check-up survey completed by Healthy people 2010
found that the country is moving toward the physical activity recommendations of 50%
of adults, whereas many of the other goals are not meeting their outcomes (Department of
Health and Human Services Centers for Disease Control and Prevention, 2008). In 2007,
50.7 % of adults in Michigan are meeting the physical activity guidelines

The Centers for Disease Control and Prevention (CDC) deﬁned physical activity
reccomendations for adults as moderate-intensity for at least 150 minutes per week, or
vigorous-intensity for at least 75 or more minutes per week. In addition to cardiovascular
activity, participants must perform at least two days a week of muscle strengthening
activities that work all major muscle groups (legs, hips, back, abdomen, chest, shoulder,
arms). Moderate physical activity can be deﬁned as some increase in breathing or heart
rate, or any activity that burns 3.5 to 7 kcal per minute such as walking briskly, mowing

the lawn, dancing, and swimming, bicycling on level terrain or gardening. Vigorous

54

physical activity is a large increase in breathing or heart rate (conversation is difficult or
broken), and any activity that burns more than 7 kcal per min. This represents the effort a
healthy individual might expend while jogging, mowing the lawn with a non-motorized
push mower, participating in high-impact aerobic dancing, swimming continuous laps,
bicycling uphill, or carrying more than 25 pounds up a ﬂight a stairs (U .S. Department of

Health and Human Services, 2008).

Physical Activity and Neurocognitive Function.

The physiological effects of exercise on the human body are well known.
Physical activity causes changes in the cardiovascular, skeletal and respiratory systems to
improve the bodies function. Most prior research has focused on the ability of the
exercisers to perform motor tasks both during and after exercise, as many exercisers
report that exercise training improves psychological well being and mood state (women)
(Cramer, Neiman, & Lee, 1991, Folkins & Sime, 1981). The CDC reported from their
2007 National Health Interview Surveys that people with a college degree were three
times as likely to report regular leisure time physical activity (43.3%) than those who did
not complete high school (14.9%) (CDC's MMWR Weekly, 2009).

Extensive research in the last two decades has shown that exercise can have a
strong positive effect on cognitive function (Medina, 2003; McMorris & Keen, 1994;
Davey, 1973). Studies that have focused on physical activity and neurocognitive ﬁrnction
have mainly focused on an elderly population (Eusop, Sebban, & Piette, 2001) and have
reported that physical activity decreases the atrophy in the brain that is association with
aging (Schuit, Feskens, Launer, & Kromhout, 2001). Previous research has found that

exercisers exhibited improvements in pattern matching and problem solving (Medina,

55

2003). McMorris and Keen (1994) found that exercise affects reaction time during
maximal training in their small sample study (12) where individuals took simple reaction
time tests at rest and while cycling at a 70%, and 100% workload. Other studies have
investigated how cognition is affected during exertion. One study looked the individual’s
ability to perform perception of geometric ﬁgures while performing hand dynamometer
at four levels and found the testing at moderate tension levels to be facilitative
(Andreassi, 1965). A 12-minute treadmill test in which discrimination tasks were
performed both during and after exercise was found to be facilitative at both samples
(McGlynn, Laughlin, & Rowe, 1979). Bicycle pedaling at a constant resistance measured
at 15 seconds, 30 seconds, and 2, 5, and 10 nrinutes with the cognitive task of short-term
memory found facilitative effects after short bouts, and impairments after 10 minutes
(Davey, 1973). Comprehensive reviews of the effect of exercise on cognitive processes
reveal mixed results (Tomporowski & Ellis, 1986). These tests looked at the effect of
physical exertion of a variety of tasks from simple arithmetic to reaction time. Most
found that exercise bouts had a facilitative effect or no effect on the tests.

Few studies have investigated the relationship of cognition and exercise in young
adults. One recently published study with young adults (mean age 21.1) found the
cognitive effects of physical activity could be observed using a simple paradigm, and that
physical activity has a beneﬁcial effect on the cognitive processes of young adults
(Karnijo & Takeda, 2009). Another study found that a lifestyle of physical activity
appeared to play a more dominant role in simple reaction time and discrimination
reaction time than age. Older men who were active were compared to both active and

non-active younger men and it was found that older men that were active were at a

56

similar level as non-active younger men when looking at reaction time. Spiriduso
repudiated the hypothesis that most of the slowing of reaction time was attributable to the
Central Nervous System processing in aging rather than response speed and timing

(Spirduso, 1975).

Instrument Validity
Headache Impact Test (HIT).

Headache impact test is a test derived from several traditional migraine
instruments including the Migraine Quality of Life Questionnaire, the Headache
Disability Instrument, the Headache Impact Questionnaire, and the Migraine Disability
Assessment. The HIT consists of 53 items to assess the individuals’ status of disability
related to migraine. The HIT normally requires about ﬁve to ten minutes to complete.

The HIT is available free online at littp://www.headachctcstcom or can be taken on paper

 

(Pryse-Phillips, 2002; Vuillaume De Diego & Lanteri-Minet, 2004). The test has multiple
levels with each question based on the individual’s answer to the preceding question that
is appropriate for a person with that level of disability. The instrument has strong
correlations with the previously validated traditional migraine tests ﬁom 0.51 to 0.87.
This test was validated utilizing the item response theory (Cella & Chang, 2000) and
compared to the Migraine-Speciﬁc Quality of Life Questionnaire, the Headache
Disability Instrument, the Migraine Disability Assessment and the Headache Impact
Questionnaire. Over 10,000 subject’s scores were utilized to validate each test question
(Pryse-Phillips, 2002). The HIT normally requires ﬁve or fewer questions to allow a
reliable estimate of a subject’s score. Conﬁdence intervals are set at ﬁve to 15 for severe

and less severe impact, respectively. The ﬁrst question is the standard question, and based

57

on the reply a score is assigned within the computer program. The next question is then
selected based upon the level of disability that was indicated in the ﬁrst question. If the
answer is in a consistent response, further questions may or may not be required to
achieve the response that ﬁts in the narrow pre-speciﬁed conﬁdence limits set. The level
of disability is then expressed around an arbitrary mean of 50, which reﬂects the average
disability suffered by members of the headache population. The HIT-6 is a paper version

of the HIT and an example is available in Appendix A (Pryse-Phillips, 2002).

Behavior Risk Factor Surveillance System.

The Behavioral Risk Factor Surveillance System (BRFSS) was established in
1984 by the CDC. Collectively it is a state-based system of surveys that collect health
risk behavior information, preventive health practices and access health care information
related to chronic disease and injury (www.cdc. gov). For the purpose of this study eight
standard core questions relating to establishing an individual’s physical activity level

recommendations were utilized.

Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT).

ImPACT version 5.0 is a computer-based program that will be used to assess
neurocognitive function and migraine symptoms (Lovell, 2007). The software program is
run from either a desktop PC or laptop using Windows NT operating system or higher
(Lovell, Collins, Podell, Powell, & Maroon, 2000). The program uses a keyboard and
external mouse to allow participants to select responses and navigate through the six test
modules. Normative data can be found in Tables 7 and 8.

The ImPACT protocol consists of three categories. The ﬁrst category includes a

demographic information section. The user navigates through a series of instructional

58

screens where they enter descriptive information about themselves, such as
demographics, years in school, presence of any learning disabilities, and neurological
disorders.

The second category consists of 22 symptoms. Participants ﬁrst indicate yes or no
that they are experiencing a symptom then quantify the severity using a seven point
Likert scale. These concussion symptoms are similar to migraine symptoms that include
headache, nausea, vomiting, balance problems, dizziness, fatigue, trouble falling asleep,
sleeping more than usual, sleeping less than usual, drowsiness, sensitivity to light,
sensitivity to noise, irritability, sadness, nervousness, feeling more emotional, numbness
or tingling, feeling slowed down, feeling mentally foggy, difﬁculty concentrating,
difﬁculty remembering, and visual problems. Participants self-rate their symptoms by
clicking on a number between zero (not experiencing) and six (severe).

The third category consists of six neurocognitive test modules. It is important to
note that ImPACT has multiple built-in word/design groups. This is important to limit
practice effects. A different word/design group will be administered to the participant for
each ImPACT test. Module one of the neurocognitive test battery focuses on word
discrimination. This section is used to evaluate verbal memory and attentional processes.
Subjects are presented with 12 words two times each for 750 milliseconds. Individuals
are then tested to recall words from a 24-word list. There are 12 target words and 12. non-
target words. Using the mouse, subjects are prompted to select “yes” or “no” depending
on whether or not the word was presented in the original list. After a 20 minute delay,
subjects are asked again to recall this list of words. Displayed at the end of the battery is a

total score of percent correct.

59

Module two evaluates attention and visual recognition through design memory.
Similar to Module one, 12 target designs are presented twice for 750 milliseconds.
Following the presentation subjects are asked to recall these designs, choosing from the
12 target and 12 non-target designs presented. Subjects are prompted to click “yes” or
“no” depending on whether or not the design was originally presented. After a 20 minute
delay, subjects are asked again to recall this list of words. A total score of percent correct
is given at the end of the battery.

Module three is designed to measure visual working memory, visual processing
speed, and visual memory. This section incorporates a distracter task which is a reaction
time test that asks the subject to click the left mouse button if a blue square appears, and
the right mouse button if a red circle appears. For the memory test, a random assortment
of X’s and O’s are displayed for 1.5 seconds. Of this random assortment, three X’s and
0’s are illuminated in yellow. The subject is instructed to remember the placement of
these illuminated objects. Immediately following the presentation of the three illuminated
X’s and O’s, the subject is asked to complete the distracter task. After the completion of
the distracter task, the memory screen reappears and the subject is asked to click on the
X’s and O’s that were originally highlighted. Four trials are completed for this section.
Scores for this section include percent correct for identiﬁcation of the X’s and 0’s and
also reaction time scores for the distracter task.

Module four is a symbol-matching task that evaluates processing speed, learning,
and memory. A grid with nine common symbols and accompanying numbers is presented
to the subject. The subject is presented with a symbol below the grid, and is asked to

click the number of the corresponding design. After 27 trials, the symbols are removed

60

from the grid. The symbols again are presented below the grid, and the subject is asked to
recall the correct symbol/number pairing by clicking the appropriate button. Reaction
time scores and memory scores are both calculated.

Module ﬁve measures choice reaction time and impulse control. Subjects are
presented with the words red, green, and blue each written in their respective color.
Subjects are instructed to click the mouse when the word correctly matches with the color
ink. For this section, a reaction time score and task error score are provided.

The sixth and ﬁnal module examines working memory and visual motor response
speeds. This module is comprised of both a distracter task and memory component.
Participants are presented with and asked to remember three letters. Once the letters are
removed item the screen, the participant is presented with the distracter task. A 5x5 grid
appears on the screen consisting of 25 numbered boxes. The participant is asked to count
backwards, clicking on the corresponding numbered box with the mouse. Following the
completion of the distractor task, the participant must input the three letters in the exact
order they were previously presented. There are ﬁve trials for this test module.

ImPACT has been utilized in several studies to determine neurocognitive function
(Maroon, Lovell, Norwig, Podell, Powell, & Hart], 2000; Mihalik, Stump, Collins,
Lovell, Field, & Maroon, 2005). A consistent and ﬂuid process will make each test easily
endurable for all individuals. ImPACT was utilized because it is an efficient method for

measuring neurocognitive function in college-aged students.

61

Computation of Composite Scores

Verbal Memory Composite Score
Average of these scores:

. Word Memory total percent correct (immediate + delay) / 2

. Symbol Match (hidden symbols)/9*100
. Three letters Total letters correct

Visual Memory Composite Score
Average of these scores:

0 X's and 0's Total correct (memory)/12*100
0 Design memory-total percent correct (immediate + delay) / 2

Reaction Time Composite Score
Average of these scores:

a X's and 0's average correct RT
0 Symbol Match average correct RT/ 3
0 Color Match average correct RT

Processing Speed Composite Score
Average of the following scores:

. X's and D's-total correct (interference) total/4
. Three letters-average counted correctly*3
. Symbol Match (average correct responses)

Table 4: Approximate Classiﬁcation Ranges for Index Scores-University Women

 

 

 

 

 

 

 

 

Verbal Memory Visual Memory Processing Speed Reaction Time
Impaired < 70 < 48 < 23.3 > .70
Borderline 71 - 82 49 — 59 23.4 - 29.7 .69 - .64
Low Average 83 - 86 60 - 69 29.8 - 34.3 .63 - .60
Average 87 - 97 70 - 88 34.4 - 42.1 .59 - .52 ’
High Average 98 - 100 89 - 93 42.2 - 46.3 .51 - .50
Superior --- 94 — 96 46.4 - 49.2 .49 - .48
Very Superior --- 97 —- 100 > 49.3 < .47

 

 

 

 

 

Data from www.impacttest.com

62

 

Table 5: Approximate Classification Ranges for Index Scores- University Men

 

 

 

 

 

 

 

 

Verbal Memory Visual Memory Processing Speed Reaction Time

Impaired < 71 < 51 < 23.8 > .75
Borderline 72 - 77 52 - 60 23.9 - 28.3 .74 - .67
Low Average 78 - 82 61 - 68 28.4 - 32.4 .66 - .61
Average 83 - 94 69 - 94 32.5 - 42.0 .60 - .52
High Average 95 - 97 95 - 97 42.1 - 46 .0 .51 - .48
Superior 98 - 99 98 - 99 46.1 - 50.0 .47 - .45
Very Superior 100 100 > 50.1 < .44

 

 

 

 

 

 

Data ﬁom www.impacttest.com
Summary of the Literature
Migraine headaches are an episodic and progressive disorder that affects 18-25%
of females and 6-13% of males (Lipton et al, 2002; Lipton et al, 2001; Launer, Terwindt,
& Ferrari, 1999; Lipton, Stewart, Celentano, & Reed, 1992). Migraines are classiﬁed as
migraine with aura or migraine without aura using the IHS diagnostic criteria. During a
migraine attack, progression is seen in aura development (if present) and intensity of
pain, with prodromal and postdromal symptoms often leaving the rrrigraineurs performing
at decreased capacity for up to a week surrounding a migraine attack. With frequent
attacks, migraine is directly costly to both the individual and the economy as a whole.
Furthermore, indirect and direct cost relating to migraine headaches are estimated at 13
billion dollars, affecting society in many venues including work productivity,
absenteeism and social function (Edmeads & Mackell, 2002).
College students are expected on a daily basis to be ready to perform on pop
(Illizzes, tests or practical skills tests. Often students will study for months for a licensure
0T certiﬁcation test which the outcome will determine their future in their profession.

From 1 8-28 years of age the prevalence of migraine increases yearly, and the life of the

63

college student is full of migraine triggers (irregular sleep patterns, stress, alcohol, etc.),
therefore it is important to determine if migraines affect their cognitive function
following an attack.

Previous research has focused on long-term cognitive function following a
migraine headache and has produced contradictory results. Very few studies have
examined short-term cognitive frmction and recovery patterns following mi grai'ne
headaches. Little research has examined the effect of physical activity on the recovery
pattern of migraine headaches. Some individuals may suffer from exertional migraine,
while others ward off a migraine through exercise. The purpose of this study was to
investigate the effects of physical activity on neurocognitive function and recovery
patterns in collegiate students who incur a migraine headache compared to collegiate

students who do not incur migraines.

64

CHAPTER 3
Methods

The purpose of this study was to examine neurocognitive ﬁmction and recovery
patterns between two groups of college aged students who experience migraine
headaches: a group who meet physical activity recommendations and a group who did
not meet physical activity recommendations and compare them to a control group who
did not experience migraine headaches. This chapter isdivided into six major sections: (a)
Experimental Design, (b) Research Participants, (0) Instrumentation, (d) Procedures (e)

Data Analysis, and (f) Threats to Internal and External Validity.

Experimental Design

A quasi-experimental design was used to compare baseline neurocognitive scores
and migraine symptoms to post-test neurocognitive scores and symptoms. The
independent variables were migraine status (migraine [M], non-migraine [NM]), physical
activity (meet physical activity recommendations [PA], do not meet physical activity
recommendations [NPA]) and testing occasion (baseline [B], within 24 hours [24h], 24-
48 hours [48h], and one week [7days]). The dependent variables were the four composite
scores of ImPACT. The four subscales of ImPACT are verbal memory composite score,
visual memory composite score, reaction time composite score, and processing speed
Composite score. The ImPACT composite scores are collectively referred to as

neurocognitive function.

65

Research Participants

A total of 122 people volunteered to participate in the study. Twenty-three males
and 99 females were baseline tested. One hundred and two individuals completed
physical activity data with 74 meeting physical activity recommendations and 28 not
meeting the aerobic (but not necessarily weight lifting) physical activity
recommendations of the CDC. Of the 122, 71 were migraineurs with 54 of them
physician diagnosed and the other 17 met IHS criteria for diagnosis of migraine. Subjects
were matched to a control for age, sex and education level. Age was considered a match
if the subjects were plus or minus one year. Education level was considered matched if
the subjects were in their ﬁrst or second years of college, third or fourth years of college,
or beyond their fourth year of college. Ethnicity was recorded, but not considered for
group designations due to the local area not consisting of an ethnically diverse
population. Migraine subjects were included if they were (a) physician diagnosed with
migraine headaches or (b) self-diagnosed with migraine headaches and meet the IHS
criteria. Controls subjects must have had HIT score less than 50 to be included in this
study. Physical activity questions were asked, but participants were not told that they
were grouped by physical activity level to encourage truthful reporting.

The subjects in this study were a convenience sample of individuals recruited
from Health, Physical Education and Recreation classes along with others via word of
mouth and advertisement in the Northwind, a weekly student paper for Northern
Michigan University (N MU). Other methods of recruiting were via e-mail through NMU

professors. A letter was sent to local physicians explaining the study and asking them to

66

give a ﬂyer with contact information to any patients who were college students (18-28
yrs) they treat who suffer from migraine headaches. In addition, several physicians posted
them in their waiting room.

Exclusion criteria were substance abuse, diseases linked to decreased cognitive
skills, individuals with cluster or tension-type headache, a history of a learning disability
or special education, central nervous system disease, history of head trauma including
concussion within the last six months, or color-blindness. Individuals who were pregnant
were excluded due to hormonal changes that might have changed their migraine proﬁle.
Individuals with learning disabilities and previous special education, including all
individuals who have been formally diagnosed with a learning disability or attended
special education classes, along with individuals who have self-reported any past speech
therapy, learning problems (e.g. reading or math), or have attention deﬁcit hyperactivity
disorder (ADHD). Individuals in this group tend to have lower scores on ImPACT that
may skew the current data (Iverson, Lovell, Podell, & Collins, 1999).

Originally, data collection was to occur over a one- year time frame: however,
this time interval was not adequate and required an additional year. This additional time
was necessary due to attrition of subjects (who completed baseline, and did not follow-up
after the baseline, or dropped out of the study) and subjects who reported that they suffer
from migraines, but did not have a migraine headache during the time interval. To
decrease attrition of subjects, frequent reminder e-mails were sent to the subjects.

Subjects had the chance to win numerous prizes for completing all phases of the
study including two I-Pod shufﬂes (approximate value $75.00), and 15 ﬁve or ten dollar

gift certiﬁcates to local area businesses. Chances of winning a prize were greater than one

67

in six. Once a subject completed all aspects of the study, he/ she picked a slip of paper
out of a bowl and ﬁnd out what they won. All subjects received at least a candy bar type

item (gum, Mentos, candy, granola bar) of their choice.

Sample Size Estimate.

Sample size estimates were derived from free software downloaded from the
CDC called EPI CALC 2000. Power analysis assumed a .80 power. Based on normative
data for university women (Iverson, Lovell, & Collins, 2003) and the reliable change
estimates (Iverson, Brooks, Collins, & Lovell, 2006). Power estimates for sample size
were derived (see Table 9). Sample size was conﬁrmed utilizing Cohens d with an effect
size of .80 derived from the formula ES: (Ml-M2)/s where M indicates the mean and 3

indicates the standard deviation (Thomas, Nelson, & Silverman, 2005).

Table 6: Sample Size Estimates

 

Impact category Average score, Reliable change Power estimate
SD estimates at the .80 level.
Subjects per
group/ total
subjects

 

Verbal memory 87-97, 5 +/- 9 points 6 per group/24
total

Visual memory 70-88, 9 +/- 14 points 6 per group/24
total

Processing 34.4-42.1, +3/-7 points (+3) 25 per
speed 3.85 group/ 100 total
(-7) 4 per
group/ 16 total

Reaction time .59-.52, .035 +/- .06 sec 5 per group/ 20
total

 

Total sample 25 per
size group/100 total

68

Instrumentation

Headache Impact Test (HIT).

HIT is a test derived from several traditional migraine instruments including the
Migraine Quality of Life Questionnaire, the Headache Disability Instrument, the
Headache Impact Questionnaire, and the Migraine Disability Assessment. The HIT
consists of 53 items that assess the individuals’ status of disability related to migraine.
The HIT takes approximately ﬁve to ten minutes to complete. The test has multiple levels
with each question based on the individual’s answer to the preceding question that is
appropriate for a person with that level of disability. The instrument has strong
correlations with the previously validated traditional migraine tests from 0.51 to
0.87(Cella & Chang, 2000). This test was validated utilizing the item response theory and
compared to the Migraine-Speciﬁc Quality of Life Questionnaire, the Headache
Disability Instrument, the Migraine Disability Assessment and the Headache Impact
Questionnaire. Over 10,000 subject’s scores were utilized to validate each test question
(Pryse-Phillips, 2002). The HIT is available free online at http://www.headachetest.com/

(Pryse-Phillips, 2002; Vuillarnne De Diego & Lanteri-Minet, 2004).

Migraine History Questionnaire.

The migraine history questionnaire (Appendix C) was developed from the IHS
classiﬁcation 2005 criteria. Participants were asked to answer all questions about
headaches that were not caused by head injury, pregnancy, hangover or acute illness. The
questionnaire includes questions about history of severe headache in the past six months
and characteristics of their headache. In addition, it asked participants questions related to

aura (if they experienced it) and medications used as treatment for their migraine

69

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headaches. It was pilot tested on a collegiate population to clarify all questions and
answers. It was utilized to determine self-reported migraine headaches in the absence of a
physician diagnosis. Similar questionnaires were utilized in the American migraine study
(Lipton et al., 2001) and a prevalence study in collegiate basketball players (Kinart,

Cuppett, & Berg, 2002).

Physical Activity Questionnaire.

The physical activity questionnaire (Appendix D) was an eight question
assessment from the Behavioral Risk Factor Surveillance System (BRFSS). The BRFSS
is a nationally recognized test that was established in 1984 by the CDC. The BRFSS
measures current ﬁtness level related in conjunction with the American College of Sports
Medicine (ACSM) and the CDC guidelines (About the BRF SS). If they meet or exceed
ACSM/CDC healthy guidelines they were included in the “meet physical activity
recommendations” (PA) group. If they do not exercise or do not meet the currently
recommended guidelines, they were not included in the “do not meet physical activity
recommendations” (N PA) group. PA was deﬁned as 150 rrrinutes of moderate physical
activity per week or 75 nrinutes of vigorous activity per week. If they did not meet this

threshold they were considered NPA.

24 Hours Questionnaire.

The intention of the 24 hour questionnaire (Appendix E) was to capture
information about the individuals’ migraine just after it occurs so it is still fresh in their
memory. Questions were asked about the medication they took, time frame, hours of
sleep they have had since their migraine, if they experienced an aura with their migraine,

location (right or left) and level of the pain during their migraine. They were also asked

70

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to list anything that they perceived may have been a trigger for their migraine. These
were sorted into psychological triggers (i.e. stress), environmental triggers (i.e. hot or
Cold), food related triggers (i.e. red wine), and others (i.e. ovulation or menstruation).
Participants were also asked to shade in the location of their pain on a picture of the skull.
Location areas included the front of the head, occipital, crown of the head, temporal,

behind the eyes or other.

Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT).
ImPACT version 5.0 (ImPACT Applications Inc.) is a computer-based program
that was used to assess neurocognitive function and migraine symptoms (Lovell, 2007).
The soﬁware program was run on the researcher’s laptop using Windows Vista (Lovell,
C011 ins, Podell, Powell, & Maroon, 2000). The program uses a keyboard and external
mouse to allow participants to select responses and navigate through the six test modules.
A" Stlldents at NMU have a laptop upon admission and they were tested on a similar
model laptop.
The ImPACT protocol consists of three categories. The ﬁrst category includes a
demo gl‘aphic information section. The participant was asked to navigate through a series
0f instructional screens where he/ she was asked to enter descriptive information about
Ahnsel f/ herself, such as years in school, presence of any learning disabilities, and
nellr()logical disorders.
'The second category consists of 22 symptoms that participants rate using a seven
point Likert scale. These concussion symptoms are similar to migraine symptoms and
inCIUde headache, nausea, vomiting, balance problems, dizziness, fatigue, trouble falling

‘Q \%9 sleeping more than usual, sleeping less than usual, drowsiness, sensitivity to light,
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sensitivity to noise, irritability, sadness, nervousness, feeling more emotional, numbness
or tingling, feeling slowed down, feeling mentally foggy, difﬁculty concentrating,
difficulty remembering, and visual problems. Participants self-rated their symptoms by
clicking on a number between zero (not experiencing) and six (severe).

The third category consists of six neurocognitive test modules. It is important to
note that ImPACT had multiple built-in word/design groups. This was important to limit
practice effects. A different word/design group was administered to the participant for
each ImPACT test. Module one of the neurocognitive test battery focuses on word
discrimination. This section was used to evaluate verbal memory and attentional
processes. Subjects were presented with 12 words two times each for 750 milliseconds.
Individuals were then tested to recall words from a 24-word list. There were 12 target
words and 12 non-target words. Using the mouse, subjects were prompted to select “yes”
or “no” depending on whether or not the word was presented in the original list. After a
20 minute delay, subjects were asked again to recall this list of words. A total score of
percent correct was displayed at the end of the battery.

Module two evaluated attention and visual recognition through design memory.
Similar to module one, 12 target designs are presented twice for 750 milliseconds.
Following the presentation subjects were asked to recall these designs, choosing from the
12 target and 12 non-target designs presented. Subjects were prompted to click “yes” or
“no” depending on whether or not the design was originally presented. After a 20 minute
delay, subjects were asked again to recall this list of designs. A total score of percent

correct was given at the end of the battery.

72

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Module three was designed to measure visual working memory, visual processing
speed, and visual memory. This section incorporates a distractor which is a reaction time
test that asks the subject to click the left mouse button if a blue square appears, and the
right mouse button if a red circle appears. For the memory test, a random assortment of
X’s and O’s are displayed for one and one-half seconds. Of this random assortment, three
X’s and O’s are illuminated in yellow. The subject was instructed to remember the
placement of these illuminated objects. Immediately following the presentation of the
three illuminated X’s and O’s, the subject was asked to complete the distractor task. After
the completion of the distractor task, the memory screen reappears and the subject was
asked to click on the X’s and O’s that were originally highlighted. Four trials were
completed for this section. Scores for this section include percent correct for
identiﬁcation of the X’s and 0’s and reaction time scores for the distractor task.

Module four was a symbol-matching task that evaluates processing speed,
learning, and memory. A grid with nine common symbols and accompanying numbers
was presented to the subject. The subject was presented with a symbol below the grid,
and was asked to click the number of the corresponding design. After 27 trials, the
symbols were removed from the grid. The symbols were presented below the grid, and
the subject is asked to recall the correct symbol/number pairing by clicking the
appropriate button. Reaction time scores and memory scores were both calculated.

Module ﬁve measures choice reaction time and impulse control. Subjects were
presented with the words red, green, and blue each written in their respective color.
Subjects were instructed to click the mouse when the word correctly matches with the

color ink. For this section, a reaction time score and task error score were provided.

73

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The sixth and ﬁnal module examined working memory and visual motor response
speed. This module is comprised of both a distractor task and memory component. .
Participants were presented with and asked to remember three letters. Once the letters
were removed from the screen, the participant was presented with the distractor task. A
5x5 glid appears on the screen consisting of 25 numbered boxes. The participant was
asked to count backwards, clicking on the corresponding numbered box with the mouse.
Following the completion of the distractor task, the participant must input the three letters
in the exact order they were previously presented. There were ﬁve trials for this test

module.

Reliability and Validity of ImPACT.

Test-retest reliability for ImPACT was assessed over eight days across four
administrations, yielding correlation coefﬁcients ranging from 0.66 to 0.85 for the verbal
memory index, 0.75 to 0.88 for the processing speed index, and 0.62 to 0.66 for the
reaction time index (Lovell, Collins, Fu, Burke, & Podell, 2001). Using reliable change
indices, repeated administrations over a 2-week period revealed no practice effects
(Iverson G. L., Lovell, Collins, & Norwig, 2002c). In another study, one-week test-retest
reliability coefﬁcients were as follows: 0.70 for verbal memory, 0.67 for visual memory,
0.79 for reaction time, and 0.86 for processing speed, with signiﬁcant test-retest
differences for only the processing speed composite scores on with-in subject
comparisons (Iverson, Lovell, & Collins, 2005). Concurrent validation of ImPACT
revealed correlations with the Symbol-Digit Modalities test (SDMT) which ranged from
0.37 and 0.46 for visual and verbal memory indices, to 0.60 and 0.70 for reaction time

and processing speed indices, respectively (Iverson, Lovell, & Collins, Validity of

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ImPACT for measuring attention and processing speed following sports-related
concussion, 2005). Since the SDMT is believed to measure scanning and tracking
aspects of attention, as well as processing speed these coefﬁcients represent good
convergent and divergent validity (Spreen & Strauss, 1998). Correlations between
ImPACT visual and verbal memory composites with the Brief Visual Spatial Memory
Test-Revised total score (r=.50) and the delayed recall score (r=.85) have been
established; the processing speed composite was shown to correlate with the Trailmaking
Tests A (r= -.49) and B (r= -.60), and the SDMT (r=.68) (Iverson, Franzen, Lovell, &
Collins, 2004. Schatz and colleagues documented a combined sensitivity of 81.9% for
ImPACT indices and total symptom score, and a speciﬁcity of 89.4%; positive likelihood
ratio was approximately 8:1 and negative likelihood ratio was 2:1 (Schatz, Pardini,

Lovell, Collins, & Podell, 2006).

Procedures

Baseline Evaluation.

After completing informed consent, collegiate students were administered the
Migraine History Questionnaire (10 minutes) (Appendix C), the HIT (10 minutes), a
Physical Activity Questionnaire (Appendix D) and the ImPACT (approximately 25
minutes) neurocognitive test battery in the researcher’s ofﬁce. The subjects received
information about how to reach the researcher after a migraine headache (Appendix B).
Subjects were encouraged to treat their migraine as usual throughout the study. This
meant that if they normally took over the counter medications, or prescription
medications or slept following a migraine, they should continue that pattern with no

changes. If subjects experienced a migraine in the past week or were experiencing any

75

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symptoms of an oncoming attack they were not baseline tested. Another time was
arranged for these subjects to take the baseline measures. All subjects indicated they were
alcohol and drug free for 24 hours prior to all tests. After baseline testing was complete,
subjects determined a quiet location for all post—tests. If the student resided in a dorm, the
post-tests were administered in a common study room in the students’ dorm. If the
student resided off campus, the post-tests were administered in place at the students’
home or at NMU, whichever location the student was the most comfortable. If the
location was the student’s home, testing was administered in the living room, kitchen, or
a common area that is quiet. The experimenter was not in the room during baseline or
post-testing. The HIT score was the impact of headaches variable for the purpose of this

study.

Post-tests Evaluation.

After a subject suffered a migraine headache, he/she was administered the
ImPACT neurocognitive test battery minus the demographic/descriptive section
(approximately 20 minutes) within 24 hours, 48 hours, and 7 days post-migraine.
Migraine was determined to initiate from the onset of headache symptoms. Migraine
subjects also completed the 24 Hour Questionnaire during the ﬁrst post-test. All post-
tests were administered in a comfortable environment to the subject. The physical activity
questionnaire were given at the ﬁrst post-test except for the ﬁnal volunteers to capture
current physical activity levels. All volunteers that completed the physical activity
questionnaire at the baseline testing completed testing within one month of the baseline

or were excluded from the physical activity data analysis. This excluded two individuals.

76

Data Analysis

Analysis of the data included both descriptive statistics and inferential statistical
analysis of the ImPACT scores. The ImPACT software yields individual scores as well as
composite scores for verbal memory, visual memory, processing speed, and reaction time
composite scores. Higher scores on verbal memory, visual memory, and processing speed
indicate a better performance. Lower scores on reaction time indicate a faster reaction
time, thus, better performance. The migraine questionnaire was utilized to qualify those
individuals who have self-diagnosed their migraine, to assure that the IHS criteria are
met. All analyses were conducted using the Statistical Package for the Social Sciences

version 16.0 (spss Inc.).

Hypotheses 1, 2, and 3.

Hypotheses one, two, three, and the related sub-hypotheses were concerned with
the effects of testing occasion, migraine status, and physical activity on neurocognitive
ftmction post-migraine headache. Descriptive statistics (means and standard deviations)
are presented for each of the four ImPACT composite scores for each of the independent
variables. A four testing occasion (baseline, up to 24 hrs, 48 hrs, 7days) x two migraine
group (M and NM) was utilized . A one-way AN OVA, or MANOVA was utilized to
determine the signiﬁcance of each of these hypotheses. All tests were conducted at the p
5 .05 level of signiﬁcance, and each subsequent post-hoe test were conducted at the p <

.051eveL

Exploratory Hypotheses.
Hypotheses four and ﬁve were concerned with the effects of sex and diagnosis

status on pain. Descriptive statistics (means and stande deviations) are presented for

77

each of the independent variables: migraine status, sex, diagnosis status and testing
occasion. An independent t-test with pain as the dependant variable was conducted at the
p 5 .05 signiﬁcance level.

Hypothesis six and the related sub-hypotheses were concerned with the effects of
physical activity on the impact of headaches. Descriptive statistics (means and standard
deviations) are presented for each of the independent variables: migraine status, impact
of headaches, and physical activity. A two physical activity (PA and NPA) x two
migraine group (M and NM) two-way analysis of variance (ANOVA) test with HIT

scores as the dependent variable were conducted at the p 5 .05 signiﬁcance level.

Research Questions.

Research question seven concerned the pain level reported at 24 hours post-
migraine for college students who use prescription medication, over-the-counter
medications or no medications for their migraine headache. The independent variables
are migraine status (migraine only), and medication status (RX, OTC, none) exercise. A
one migraine by three medication status (Rx, OTC, none) AN OVA test with pain scores
as the dependent variable were conducted at the p 5 .05 signiﬁcance level, and each
subsequent post-hoe test were conducted at the p 5 .05 level.

Research Question 8 concerns the effect of exercise post-migraine on pain levels
24 hours post-migraine. Descriptive statistics (means and standard deviations) are
presented for each of the independent variable migraine status. An independent t-test with

pain as the dependant variable was conducted at the p 5 .05 signiﬁcance level, and each

subsequent post-hoc tests were conducted at the p 5 .05 level.

78

Research Question nine concerns the effect of sleep on neurocognitive function
post-migraine. Descriptive statistics (means and standard deviations) were presented for
each of the four ImPACT composite scores for each of the independent variables. A one
testing occasion (24 hrs) x four sleep levels (none, 3 little-4, 4-8, more than 8 hours)
analysis of a one—way repeated measures AN OVA was used to determine the signiﬁcance
of this research question. The AN OVA tests were conducted at the p 5 .05 level of

signiﬁcance and each subsequent post-hoc test were conducted at the p < .05 level.

Threats to Validity and Study Limitations

In a quasi-experiment with no randomization to group, it is especially important
to determine all threats to internal and external validity and careﬁrlly control for each
threat. The next two sections will list all threats to internal and external validity and
explain the controls the experimenter took for each threat (Thomas, Nelson, & Silverman,

2005), then limitations of the study will be examined.
Threats to Internal Validity.

Internal validity was deﬁned as the extent to which the results of a study can be
attributed to the treatments used in the study. There are nine threats to internal validity.
Each threat to internal validity was discussed in the following manner, deﬁnition ﬁrst,
then how the study controlled the threat.

History: Events occurring during the experiment that are not part of the
treatment.

Control: Participants not present during the summer months were not baseline

tested until they returned for the fall semester.

79

Maturation: Processes within the participants that operate as a result of time
passing.

Control: An attempt was made to decrease the time between baseline testing and
post-testing through reminder e—mails. Time between baseline and post-testing was
matched in the controls. The exercise questionnaire was given at the ﬁrst post-test. With
the testing occurring within one year, maturation should have little effect.

Testing: The effects of one test on subsequent administrations of the same test.

Control: Within ImPACT there are ﬁve different versions of the post-test.
Internal validity has been tested and retested numerous times (Iverson, Franzen, Lovell,
& Collins, 2004).

Instrumentation: changes in instrument calibration, including lack of agreement
within and between observers.

Control: ImPACT does not need calibration and all data were collected by one
researcher.

Statistical regression: The fact that groups selected on the basis of extreme scores
are not as extreme on subsequent testing.

Control: Repeated measures were taken on each individual. Individuals will be
volunteers who are included based on a history of migraines. The exercise group was
determined as to individuals who meet the CDC requirements of moderate exercise and
those who do not meet the requirements. A matched group technique was used with age,
sex and education as equivalent variables.

Selection bias: Choosing comparison groups in a nonrandom manner.

80

Control: Controls were matched on age, sex and education level to control for
selection bias. Controls were included if they have an HIT score of less than 50. All
subjects were volunteers. No special treatment was given to any one group. No extra
credit was given to participants. All prizes were drawn from a hat at the end of data
collection from individuals who completed the study.

Experimental mortality: loss of participants from comparison groups for
nonrandom reasons.

Control: Over sampling was utilized with baseline testing. Reminder e-mails were
be sent to subjects frequently.

Selection-maturation interaction: The passage of time affecting one group but no
the other in nonequivalent group designs.

Control: All subjects were recruited from the Marquette area and placed in groups
be migraine and physical activity status. Controls were place in groups by physical
activity status. Subjects were blind to physical activity as a variable. While questions
about their physical activity habits were asked, they were not told that this separated them
' into a group.

Expectancy: experimenters’ or testers’ are anticipating that certain participants
will perform better.

Control: The tester was not in the room while the subject took all tests. All tests

were taken in a comfortable, quite room.

81

Threats to External Validity.

External Validity is deﬁned as the generalizability of the results of the study.
There are four threats to external validity. Each threat to external validity is discussed in
the following manner, deﬁnition ﬁrst, then how the study controlled the threat.

Reactive or interactive effects of testing: The pretest may make the participant
more aware of or sensitive to the upcoming treatment. As a result, the treatment is not as
effective without the pretest.

Control: All subjects control or experiment, received the same questionnaires and
ImPACT tests in the same order. ImPACT was repeated four times, and no treatment is
given in this study.

Interaction of selection bias and the experimental treatment: When a group is
selected on some characteristic, the treatment may only work on groups possessing that
characteristic.

Control: All tests took place in a normal testing setting that will duplicate a
college testing environment. Tests were completed in a comfortable quiet testing
environment.

Reactive effects of experimental arrangements: Treatments that are effective in
very constrained situations (laboratories) may not be effective in less constrained settings
(more like the real world).

Control: During testing in college universities students have a quite comfortable
setting in which to take most if not all tests. These testing environments were duplicated

in this study.

82

Multiple-treatment interference: When participants receive more than one
treatment, the effects of previous treatments may inﬂuence subsequent ones.

Control: The ImPACT controled for subsequent testing through a series of tests
that can be taken as post tests. No treatments were given in this experiment. The
migraineur treated the migraine with no medication, over the counter medication,
prescription medication or sleep as usual. ImPACT is currently used throughout the

world.

Limitations of the Study.

Some of the limitations of this study include the population. The population of the
upper peninsula of Michigan was not ethnically diverse, thus making the sample mainly
white. Generalizability of the results to the general population were difficult, although
results may be generalized to a similar population of college-aged individuals 18-28
years. Sex was not be equal due to the prevalence of migraine in females occurring at a
rate of three times that of males. It was likely that more females will volunteer for the
study due to this ratio. There are difﬁculties in objectively quantifying the subjective

complaints of a migraine, therefore physician diagnosis may have been incorrect.

83

CHAPTER 4

Results

The purpose of this study was to investigate the effects of physical activity on
neurocognitive function and recovery patterns in collegiate students who incur a migraine
headache compared to collegiate students who do not incur a migraine. A pre-test, post-
test design where the independent variables were: migraine status, physical activity,
testing occasion, sex, exercise, sleep and diagnosis status was utilized. The dependent
variables were the four composite scores of ImPACT (verbal memory composite score,
visual memory composite score, reaction time composite score, and motor processing
speed), level of pain, and impact of headache scores. Analysis of the data included both
descriptive statistics and inferential statistical analysis of the ImPACT scores including
repeated measures ANOVA, MANOVA, one-way AN OVA, two-way AN OVA and t-
tests. All data were analyzed at the alpha p < .05 level. Mauchly’s W test for sphericity
was utilized for all analyses. Greenhouse-Geisser corrections were made on any analysis
that violated sphericity. The following chapter is divided into three sections: (a)

demographic data, (b) hypothesis data, and (c) additional ﬁndings.

Demographic Data

A total of 122 people volunteered to participate in the study. Twenty-three males
and 99 females were administered all baseline tests. Of the 122 participants, 71 were
migraineurs with 54 of them physician diagnosed, while the other 17 met IHS criteria for

diagnosis of migraine. Of the 71 migraineurs, 44 incurred a migraine and completed

84

testing, (one completed half of the testing, and was excluded from analysis). The other 27
did not complete subsequent testing because they did not incur a migraine during the
testing period. F ifty-one of the volunteers were controls with 50 of the controls
completing all testing. One control quit without reply despite several attempts through e-
mail. The participants ethnicities were reported on the physical activity questionnaire.
Ethnicities were not varied with 83 reporting their ethnicity as Caucasian, two as Black,
or African American, two as Asian, and one as Alaskan/ Native American Indian.
Controls and migraineurs were matched for age, sex and education level. Age was
considered a match if the subjects were plus or minus one year. Education level was
considered matched if the subjects were in their ﬁrst or second years of college, third or
fourth years of college, or beyond their fourth year of college. Education included all
completed years of schooling except kindergarten (ex, college freshmen=12). This left 44
subjects in each group (migraine and non-migraine), 6 of these male, and 38 female.

Demographic data by group can be found in Tables 7 and 8.

85

Table 7: Demographic Data of Migraine and Physical Activity Groups

 

 

Migraine PA Migraine NPA Non-migraine Non-migraine
Group Group PA Group NPA Group
(M, SD) (M, SD) (M, SD) Q“. SD)
N 32 12 33 1 1
Age (yrs) 22.12 1; 2.49 23.38 1 2.60 21.02 i 1.80 22.68 + 3.34
Weight (lbs) 154.25 : 45.47 159.75 : 32.75 163.30 1 30.35 152.27 : 24.41
Heights (in) 66.13 i 4.82 66.92 i 2.50 67.15 i 2.88 66.04 i 2.77
Sex: Male 6 0 5 1
Female 26 12 28 10
Handedness:
Right 31 10 27 9
Left 1 1 4 2
Both 0 1 2 0
Education (yrs) 14.66 i 4.82 15.17 i 1.27 14.48 i 1.62 15.45 i 2.38
Treatment by Dr.
for any headaches: 21 8 0 3
Yes
No 1 l 4 33 8
Immediate family
have migraines:
Mom 16 7 8 2
Dad 2 4 3 0
Sibling 12 5 3 0
Grandparent 5 1 0 1
None 0 l 18 6
I don’t know 0 0 3 3
HIT scores (range 59.25 1 12.46 65.833 i 3.18 39.76 i 3.98 43.18 i 9.35

ﬁns)

86

Table 1
Scores

Hours (
48 hour

Hours (
days

Total S}
Baselin

Total 5}
24 hour

Total S
48 hour

Total S
7 days

Verbal
Compo
at Base

Verbal
COmth
at 24 h

Verbal
Cumm
at 48 h

Verbal
Comp,
at 7 (13

Visual
COm
at Bas‘

VisHal
Cump‘
3&1]

Table 8: Hours of Sleep, Total Symptoms, and ImPACT Neurocognitive Composite
Scores for Migraine and Physical Activity Groups

 

 

Migraine PA Migraine NPA Non-migraine Non-migraine
Group (M, SD) Group (M, SD) PA Group (M, NPA Group
SD) (M. SD)

N 32 12 33 11
Hours of Sleep at 7.59 i 1.33 6.96 i .865 7.08 i 1.74 7.32 i 1.23
48 hours
Hours of Sleep at 7 7.45 i 1.27 7.58 i 2.15 7.21 i 2.04 7.41 i 1.48
days
Total symptoms at 13.00 : 11.35 16.83 : 17.34 6.12 i 6.58 4.91 i 7.96
Baseline
Total symptoms at 46.69 : 20.82 50.250i 19.44 5.36 i 8.92 8.46 i 19.31
24 hours
Total Symptoms at 18.69 : 18.10 24.17 1 13.64 5.03 i 5.87 5.36 1 16.51
48 hours
Total Symptoms at 6.13 i 8.01 8.58 1 12.21 5.12 1 12.39 2.91 i 6.61
7 days
Verbal Memory 87.7 I: 8.00 86.03: 7.67 89.81 i 7.17 89.37 i 6.95
Composite Scores
at Baseline
Verbal Memory 86.41 i 9.43 83.65 i 8.48 90.60 i 8.41 91.76 i 6.60
Composite Scores
at 24 hours
Verbal Memory 85.35 i 9.08 8.71 i 8.79 88.34 1 10.04 87.18 i 8.16
Composite Scores
at 48 hours
Verbal Memory 89.95: 7.88 87.07 i 8.56 89.58 1 11.80 90.18 i 9.24
Composite Scores
at 7 days
Visual Memory 73.20 1 11.30 74.65 + 9.36 72.76 : 12.44 81.92 i 6.74
Composite Scores
at Baseline
Visual Memory 69.66 : 13.18 66.84 : 14.60 76.42 1 11.95 83.14 i 7.57
Composite Scores
at 24 hours

 

87

#—

Tahle l

/

Visual
C om pt.
at 48 h

Visual
Compt
at '.' da

31010r
Speed
Baselir

Slotor
Speed
hour's

Motor

Speed
hours

Klotor
Speed
da}s

Reacti
(:Onlp.
31333

RQacﬂ
COR")
1112.“

RCacu
COmp
at 48 1

Ram
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\

 

Table 8. Continued

 

Visual Memory
Composite Scores
at 48 hours

Visual Memory
Composite Scom
at 7 days

Motor Processing
Speed Scores at

Baseline

Motor Processing

Speed Scores at 24

hours

Motor Processing

Speed Scores at 48

hours

Motor Processing
Speed Scores at 7
days

Reaction Time
Composite Scores
at Baseline

Reaction Time
Composite Scores
at 24 hours

Reaction Time
Composite Scores
at 48 hours

Reaction Time
Composite Scores
at 7 days

72.60 : 10.96

74.16 : 12.95

37.90 : 5.37

35.14: 5.86

37.85 : 5.44

37.39 : 8.57

0.60 : 0.07

0.62 : 0.09

0.58 : 0.07

0.57 : 0.06

74.65 : 13.59

73.35 : 10.04

36.61 : 7.38

34.05 : 6.06

34.50 : 8.43

35.66 : 5.87

0.61: 0.08

0.62 : 0.10

0.61 : 0.09

0.56 : 0.09

74.62 : 12.15

77.18: 13.26

36.88 : 7.64

38.04 : 6.70

39.49 : 6.43

40.68 : 7.21

0.58 : 0.06

0.57 : 0.06

0.56 : 0.07

0.57: 0.08

82.01 : 10.62

80.60 : 9.55

40.25 : 4.99

41.05 :5.03

41.65:4.11

42.64 : 6.45

0.55 : 0.06

0.56 : 0.06

0.53 : 0.05

0.53 : 0.05

 

88

Hypothesis Data
The following hypotheses were tested for the study. All of the hypotheses were
tested at the .05 level. Mauchly’s W sphericity test was performed on all analyses, and

corrected with Greenhouse-Geisser corrections if violated.

Results: Effects of Testing Occasion on Neurocognitive Function among the
Migraine Group

Hla. Baseline neurocognitive ﬁrnction scores will be higher than 24 hours post-
migraine scores for migrainous college students.

Hlb. Neurocognitive ftmction scores at 24 hours will be lower than 48 hours post-
migraine scores for migrainous college students.

H1 0. Neurocognitive ﬁrnction scores at 48 hours will be lower than 7 days post-
migraine scores for migrainous college students.

H1 (1. Neurocognitive ﬁrnction scores at baseline will exhibit no difference than 7 days
post-migraine scores for migrainous college students.

Results: A series of one—way ANOVAs with repeated measures was used to
determine if the neurocognitive function scores differed at baseline, 24 hours, 48 hours,
and 7 days in the migraine group. Means and standard deviations for each ImPACT score
x time are shown in Table 9. Results revealed a main effect for verbal memory composite
scores (p=.045) (see Table 10). Post-hoe pairwise comparisons with Bonferroni
adjustments for multiple comparisons revealed the migraine group scored signiﬁcantly
worse at 24 hours (p=.018) and 48 hours (p=.011) compared to seven days following a
migraine (see Table 11).

A main effect was also found for visual memory composite scores (p=.041) (see

Table 10). Post-hoc pairwise comparisons with Bonferroni adjustments for multiple

89

comm"
133581111:

hours It

Agaurr
irnprox-
(see Ta
process

Tahle‘
\1igrai

“

Baseli
24 Ho
48 Ho

7 d3}:

comparisons revealed the migraine group scored worse at 24 hours (p=.052) compared to
baseline, and then signiﬁcantly improved from 24 hours to 48 hours (p=.043), and 24
hours to 7 days (p=.006) (see Table 12).

A signiﬁcant main effect was found for reaction time composite scores (p=.001).
Again using Bonferroni corrections, multiple comparisons revealed signiﬁcant
improvements between 24 and 48 hours (p=.024), and baseline to seven days (p=.003)
(see Table 13) following a migraine. No signiﬁcant differences were found on motor
processing speed (p=.109).

Table 9: Means and Standard Deviations for ImPACT Composite Scores for
Migraine Group

 

 

Verbal Memory Visual Memory Motor Reaction Time
Composite Composite Processing Composite
Scores (M,SD) Scores (M,SD) Speed Scores Scores (M,SD)
(M,SD)

Baseline 87.25 : 7.86 73.60 : 10.72 37.55 : 5.92 0.60 : 0.07

24 Hours 85.66 : 9.17 68.89 : 13.47 34.84 : 5.87 0.62 : 0.09

48 Hours 85.83 : 8.93 73.13 : 11.61 36.93 : 6.46 0.58 : 0.07

7 days 89.15 : 8.07 73.94 : 12.12 36.92 : 7.90 0.57 : 0.07

 

90

Table 10: One-way AN OVAs for Migraine Group x Time for Neurocognitive

Composite Scores

 

 

df F P-value Power
Verbal 3 2.764 0.045* 0.657
Memory
Comp. Score
Visual Memory 3 2.83 0.041 * 0.669
Comp. Score
Motor 3 2.062 0.109 0.518
Processing
Speed Score
Reaction Time 3 9.361 0.000012* 0.996

Comp. Score

* Signiﬁcant at the p <.05 level

Table 11: Pairwise Comparisons for Migraine Group Verbal Memory Composite

 

 

Scores
Mean Difference Standard Error Significance
Baseline to 24 1.591 1.179 0.184
hours
24 hours to 48 0.169 1.50 0.91]
hours
48 hours to 7 days 3.334 1.261 0011*
Baseline to 7 days 1.912 1.305 0.150
24 hours to 7 days 3.503 1.422 0.018*

 

* Signiﬁcant at the p <.05 level

91

Table 12: Pairwise Comparisons for Migraine Group for Visual Memory Composite

 

 

Scores
Mean Difference Standard Error Significance
Baseline to 24 4.704 2.354 0.052
hours
24 hours to 48 4.238 2.031 0043*
hours
48 hours to 7 days 0.805 1.910 0.676
Baseline to 7 days 0.339 2.036 0.869
24 hours to 7 days 5.043 1.734 0.006*

 

* Signiﬁcant at the p <.05 level

Table 13: Pairwise Comparisons for Migraine Group for Reaction Time Composite

 

 

Scores

Mean Difference Standard Error Signiﬁcance
Baseline to 24 0.020 0.014 0.921
hours
24 hours to 48 0.032 0.010 0024*
hours
48 hours to 7 days 0.023 0.009 0.067
Baseline to 7 days 0.035 0.009 0.003*
24 hours to 7 days 0.055 0.012 <0.01*

 

* Signiﬁcant at the p <.05 level

92

Results: Effects of Testing Occasion on Neurocognitive Function among the Non-

Migraine Group

Hle. Neurocognitive function scores at baseline will exhibit no difference than 24
hours, 48 hours or seven days post-baseline scores for non-migrainous college
students.

Result: A series of one-way AN OVAs with repeated measures was used to
determine if the neurocognitive function scores differed at each time in the non-migraine
group. Post-hoe pairwise comparisons with Bonferroni corrections were completed to
determine if there were any signiﬁcant differences by time. Means and standard
deviations for each composite score x time are shown in Table 14. Results revealed a
main effect for motor processing speed (p=.011) (see Table 15). Pairwise comparisons
revealed a learning effect with the non-migraine group performing signiﬁcantly better
from baseline to 7 days (p=.047) (see Table 16). There were no signiﬁcant differences
found for verbal memory composite scores (p=.180), visual memory composite scores

(p=.304, or reaction time composite scores (p=.179).

93

Table 14: Means and Standard Deviations for ImPACT Composite Scores for the

Non-migraine Group

 

 

Verbal Visual Memory Processing Speed Reaction Time
Memory Composite Scores Scores (M,SD) Composite
Composite (M,SD) Scores (M,SD)
Scores (M,SD)

Baseline 89.70 : 7.04 75.05 : 11.91 37.72 : 7.17 0.57 : 0.06

24 90.89 :7.94 78.10 : 11.33 38.79 : 6.40 0.57 : 0.06

Hours

48 88.05 : 9.53 76.47 : 12.11 40.04 : 5.97 0.56 : 0.07

Hours

7 days 89.73 : 11.11 78.03 : 12.42 41.17 : 7.00 0.56 : 0.07

 

Table 15: One-way AN OVAs for Non-migraine Group x Time for Neurocognitive

Composite Scores

 

 

df F P-value Power
Verbal 3 1 .655 0. 1 80 0.426
Memory
Comp. Score
Visual 3 1.149 0.332 0.304
Memory
Comp. Score
Motor 3 3.829 0.011* 0.810
Processing
Speed Score
Reaction Time 3 1.661 0.179 0.427

Comp. Score

 

* Signiﬁcant at the p <.05 level

94

Table 16: Pairwise Comparisons for Non-migraine Group for Motor Processing
Speed Composite Scores

 

 

Mean Difference Standard Error Signiﬁcance
Baseline to 24 1.067 1.140 1.00
hours
24 hours to 48 1.239 1.047 1.00
hours
48 hours to 7 days 1.141 0.739 0.779
Baseline to 7 days 3.447 1.237 0.047*
24 hours to 7 days 2.380 1.078 0.195

 

* Signiﬁcant at the p <.05 level

Results: Effects of Migraine Status on Neurocognitive Function
H2a. The migraineurs and non-migraineurs will exhibit no difference in neurocognitive

function at baseline.

H2b. The migraineurs will exhibit lower neurocognitive function scores than the non-
migraineurs at 24 hours post-migraine.

H2c. The migraineurs will exhibit lower neurocognitive function scores than non-
migraineurs at 48 hours post-migraine.

H2d. The migraineurs will exhibit lower neurocognitive function scores than the non-
migraineurs at 7 days post-migraine.

Results: A repeated measures MANOVA for group x time was used to determine
differences between the migraine and non-migraine groups. Means and standard
deviations for both groups are presented in Tables 9 (migraine) and 14 (non-migraine).

A signiﬁcant interaction was found for group x time for visual memory composite
scores (p=.036), motor processing speed composite scores (p=.044), and reaction time

composite scores (p=.002) (see Table 17, Figures 1-4). There were no signiﬁcant

95

differences for verbal memory composite scores for the interaction between group x time
(p=.100). To further examine the relationships occurring at each time, Univariate
ANOVAs were performed.

Post-hoe univariate AN OVAs for baseline composite scores revealed a signiﬁcant
difference for reaction time composite scores with migraineurs exhibiting a slower
reaction time (p=.045) compared to the non-migraine group. Verbal memory composite
scores (p=.128), visual memory composite scores (p=.549) and motor processing speed
composite scores (p=.899) were not signiﬁcantly different for the migraine and non-
migraine groups at baseline (see Table 18).

Univariate ANOVAs for neurocognitive composite scores at 24 hours revealed
that migraineurs had a signiﬁcantly slower reaction time (p=.002), decreased verbal
memory (p=.005), decreased visual memory (p=.001) and decreased motor processing
speed (p= .003) after a migraine headache when compared to non-migraine controls at 24
hours (see Table 19).

Univariate AN OVAs for neurocognitive composite scores at 48 hours indicated a
signiﬁcantly decreased motor processing speed (p=.022) as well as a continuance of a
slower reaction time (p=.028) after a migraine when compared to non-migraine controls.
Verbal memory (p=.263) and visual memory (p=.109) composite scores were not
signiﬁcantly different at 48 hours between groups (see Table 20).

Univariate ANOVAs for ImPACT composite scores at seven days indicated that
the migraine group performed signiﬁcantly worse in motor processing speed compared to

the non-migraine group (p=.009), while verbal memory (p=.785), visual memory

96

(p=.121), and reaction time (p=.883) were not signiﬁcantly different between the
migraine and non-migraine controls (see Table 21).

Table 17: Repeated Measures MANOVAs for Group x Time for Neurocognitive
Composite Scores

 

 

df’ F P-value Power
Verbal 3 2.103 0.100 0.534
Memory
Comp. Score
Visual 3 2.898 0036* 0.687
Memory
Comp. Score
Motor 3 2.741 0.044* 0.660
Processing
Speed Score
Reaction Time 3 5.116 0.002* 0.919
Comp. Score

 

* Signiﬁcant at the p <.05 level

Table 18: Univariate ANOVA for Group Differences at Baseline for Neurocognitive
Composite Scores ‘

 

 

df F P-value
Verbal Memory 1 2.364 0.128
Comp. Score
Visual Memory 1 0.361 0.549
Comp. Score
Motor 1 0.707 0.899
Processing
Speed Score
Reaction Time 1 4.128 0.045*

Comp. Score

 

* Signiﬁcant at the p <.05 level

97

Table 19: Univariate ANOVA for Group Differences at 24 hours for Neurocognitive

Composite Scores

 

 

df F P-value
Verbal Memory 1 8.176 0.005*
Comp. Score
Visual Memory 1 12.052 0.001 *
Comp. Score
Motor 1 9.093 0003*
Processing
Speed Score
Reaction Time 1 10.034 0.002*

Comp. Score

 

* Signiﬁcant at the p <.05 level

Table 20: Univariate ANOVA for Group Differences at 48 hours for Neurocognitive

Composite Scores

 

 

df F P-value
Verbal Memory 1 1.271 0.263
Comp. Score
Visual Memory 1 1.742 0.109
Comp. Score
Motor 1 5.456 0022*
Processing
Speed Score
Reaction Time 1 4.982 0.028*

Comp. Score

 

* Signiﬁcant at the p <.05 level

98

Table 21: Univariate ANOVA for Group Differences at 7 days for Neurocognitive

Composite Scores

 

 

df F P-value
Verbal Memory 1 0.075 0.785
Comp. Score
Visual Memory 1 2.450 0.121
Comp. Score
Motor 1 7.142 0009*
Processing
Speed Score
Reaction Time 1 0.022 0.883

Comp. Score

 

"' Signiﬁcant at the p <.05 level

99

Figure 1. Means of Group x Time for Verbal Memory Composite Scores

 

anno-

esco-

 

 

 

 

dd

I I
2 3

Verbal Memory Composite Score

100

‘—

Migraine or Control

—-—Mgrum
-~-~~Conrot

Figure 2. Means for Group x Time for Visual Memory Composite Scores

 

73W

7811)“

7am

 

 

 

*1

I I
2 3

Vleuel Memory Composite Score

101

..

Migraine or Control

"— tug-he
-- Comet

Figure 3: Means for Group x Time for Motor Processing Speed Composite Scores

 

42.00-

40.1”“

 

 

 

“‘1

Motor Proceeelng Speed Score

102

‘q

Migraine or Control

*Mwehe
”Coma

FrgUI

 

Figure 4: Means for Group x Time for Reaction Time Composite Scores.

 

0.62"t

0.80“

058‘

0.56"

 

 

 

 

‘1

I I
2 3

Reaction Time Composite Score

103

..

Migraine or Control

--Mgraho
--- Coma

Results:
Functio

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BBC.

BRFSS
31 indi
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Results: Effects of Physical Activity by Testing Occasion on Neurocognitive

Function

H3a. Physically active migraineurs will exhibit higher neurocognitive ﬁmction scores
than non-physically active migraineurs at 24 hours.

H3b. Physically active migraineurs will exhibit higher neurocognitive function scores
than non-physically active migraineurs at 48 hours.

H3c. Physically active migraineurs will exhibit no difference on neurocognitive
function scores than non-physically active migraineurs at 7 days.

H3d. Physically active non-migraineurs will exhibit no difference in neurocognitive
function scores than non-physically active non-migraineurs at any testing
occasion.

Results: Due to the change in testing protocol in the administration of the
BRF SS, the number of subjects completing the same protocol decreased to 42. This left
31 individuals who were considered PA and 11 who were considered NPA. Repeated
measures ANOVAs revealed no signiﬁcant main effects between physically active and
non-physically active migraineurs for verbal memory composite scores (p =.325), visual
memory composite scores (p=.545), motor processing speed composite scores (p=.716)
and reaction time composite scores (p =.314) (see Table 22).

Repeated measures ANOVAs found no signiﬁcant main effects between
physically active and non-physically active non-migraine controls for verbal memory
composite scores (p =.869), visual memory composite scores (p=.627), motor processing
speed composite scores (.933) and reaction time composite scores (p = .232) (see Table

23).

104

Table 22: Repeated Measures ANOVA for Neurocognitive Function Composite

Scores for Migraine x PA Status x Time

 

 

df F P-value Power
Verbal 3 1 .139 0.325 0.224
Memory
Comp. Score
Visual 3 0.612 0.545 0.149
Memory
Comp. Score
Motor 3 0.336 0.716 0.102
Processing
Speed Score
Reaction Time 3 1.177 0.314 0.251

Comp. Score

 

* Signiﬁcant at the p <.05 level

Table 23: Repeated Measures ANOVA for Non-Migraine x PA Status it Time for

Neurocognitive Function Scores

 

 

df F P-value Power
Verbal 3 0.239 0.869 0.094
Memory
Comp. Score
Visual 3 0.583 0.627 0.168
Memory
Comp. Score
Motor 3 0.144 _ 0.933 0.076
Processing
Speed Score
Reaction Time 3 1.44 0.232 0.376

Comp. Score

 

* Signiﬁcant at the p <.05 level

105

Exploratory Hypotheses

The purpose of the exploratory hypotheses was to examine the relationships
between additional variables collected throughout the study. The independent variables
were:
1. migraine status migraine (M) and non-migraine (N M])
2. sex female and male

3. diagnosis status physician diagnosed (PD) and self-diagnosed (SD)

A

. testing occasion 24 hours only

LII

. physical activity met physical activity recommendations (PA)
did not meet physical activity recommendations (N PA).
The dependent variables were level of pain and impact of headache scores.

The Headache Impact Test (HIT) score was referred to as impact of headache scores.
H4. Female migraineurs will rate their pain higher than male migraineurs at 24 hours
post-migraine.

Result: Six males and 38 females completed the 24 hour questionnaire reporting
their pain level 24 hours after a migraine. A t-test revealed females (6.167 : 2.228)
signiﬁcantly rated their pain higher than males (7.592 : 1.283) after a migraine (p=.028)
( Table 24).
H5. Physician diagnosed migraineurs will rate their pain higher than self-diagnosed
rrrigraineurs at 24 hours post-migraine:
Result: Thirty-three migraineurs had obtained a diagnosis of migraine ﬁom their

physician, while 11 had not sought physician diagnosis, but met IHS 2005 diagnostic

106

criteria. A t-test revealed there were no signiﬁcant differences between the physician

diagnosed (7.58 : 1.50) and self-diagnosed (6.86 : 1.42) groups (p=.175) (see Table 24).

Table 24: T-test for Pain level at 24 hours x Sex or Diagnosis Status

 

 

df F-value P-value
Males vs 42 1.474 0.028*
Females
Physician 42 0.227 0. 1 75
Diagnosed vs
Self-diagnosed

 

* Signiﬁcant at the p <.05 level

H6a. Physically active individuals will score lower than non-physically active
individuals on their impact of headache score.
H6b. Physically active rrrigraineurs will score lower than non-physically active

mi graineurs on their impact of headache scores.

H6c. Physically active non-migraineurs will score lower than non-physically active
non-migraineurs on their impact of headache scores.

Result: A two-way ANOVA was used to determine the impact of migraine group
and physically activity on HIT scores. Means and standard deviations were reported in
Table 25. Physically active individuals rated their headache impact scores signiﬁcantly
lower than non-physically active individuals (p= .020). Lower HIT scores in physically
active migraineurs (p=.080) and physically active controls (p=.094) compared to non-

physically active migraineurs and controls approached signiﬁcance (see Table 26).

107

Table 25: Means and Standard Deviations for Migraine Group and PA Status for
HIT Scores

 

 

Migraine Migraine Non- Non— All PA All
PA NPA Group migraine migraine (M, SD) NPA
Group (M, (M, SD) PA Group NPA (M, SD)
SD) (M, SD) Group (M,
SD)
N 32 12 33 1 l 65 23
HIT 59.25 : 65.83 : 39.76 : 43.18 : 49.35 : 55.00 :
scores
(range 12.46 3.16 3.98 9.35 13.41 13.36
36-78)

 

Table 26: Two-way AN OVA for Migraine Group x PA Status

 

 

df F-value P-value Power
All 1 5.660 0.020* 0.652
Migraine 1 3.226 0.080 0.419
Non-migraine 1 2.945 0.094 0.389

 

* Signiﬁcant at the p <.05 level

Results: Exploratory Research Questions

The purpose of the exploratory research questions was to examine the relationship
between additional variables previously not researched in the literature. The independent
variables were migraine status (migraine only), exercise (yes and no), and sleep (none, a
little to 4 hours, 4-8 hours, more than 8 hours). The dependent variables were pain, and
the four composite scores of ImPACT.
RQ 1. Was there a difference in pain reported at 24 hours post-migraine for college

students who use prescription medications, over-the-counter medications, or no

medications for their migraine headaches?

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Result: A one-way AN OVA found no signiﬁcant difference between migraine
groups (p=.205) (Table 27).

Table 27 : Means and Standard Deviations for Migraine Group x Type of
Medication

 

OTC (M, SD) RX (M, SD) None (M, SD) OTC and RX

 

(M, SD)
N 27 7 7 3
Migraine 7.39 i 1.52 7.71 i 1.70 6.57 i 1.13 8.67 i .58

 

RQ 2. Was there a difference in pain reported at 24 hours post-migraine for college
students who did or did not exercise during the 24 hours immediately following
onset of a migraine headache?

Result: Thirty-seven individuals did not exercise (7.50 : 1.34) 24 hours prior to
their migraine, and seven did exercise (6.86 : 2.19) prior to their migraine. A t-test found
no signiﬁcant differences between individuals who exercised and did not exercise in the

24 hours prior to their migraine (p=.303).

RQ 3. Was there a difference in neurocognitive function at 24 hours post-migraine for
college students who did or did not sleep during hours immediately following onset of a
migraine headache?

Result: Seven individuals had not slept since onset of their migraine, seven had
slept a little to four hours, 18 had slept 4-8 hours and 12 had slept more than 8 hours.
Means and standard deviations by neurocognitive composite scores are listed in Table 28.
A one-way ANOVA found no signiﬁcant main effects between hours of sleep since

migraine for verbal memory composite scores (p =.446), visual memory composite scores

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(p=.421), motor processing speed composite scores (p=.955) and reaction time composite

scores (p= .913) at 24 hours (see Table 29).

Table 28: Means and Standard Deviations for Neurocognitive Function and Hours

 

 

of Sleep since Migraine

None A little to 4 4-8 Hours More than 8

hours hours

N 7 7 18 12
Verbal 80.58 : 7.61 87.50 : 6.57 86.86 : 9.65 85.75 : 10.42
Memory Comp.
Score
Visual Memory 62.95 35 15.26 70.24 i 6.25 72.22 :10.66 66.58 : 18.37
Comp. Score
Motor 34.45 : 2.93 34.71 : 6.57 35.40 + 3.96 35.40 : 3.96
Processing
Speed Score
Reaction Time 0.63 : 0.07 0.60 : 0.11 0.63 : 0.12 0.61 : 0.06

Comp. Score0

 

Table 29: AN OVA for Hours of Sleep since Migraine for Neurocognitive Function

 

 

df F P-value

Verbal Memory 3 0.907 0.446
Comp. Score

Visual Memory 3 0.960 0.421
Comp. Score

Motor 3 0.049 0.985
Processing

Speed Score

Reaction Time 3 0.175 0.913

Comp. Score

 

* Signiﬁcant at the p <.05 level

110

CHAPTER 5

Discussion

The purpose of this study was to investigate the effects of physical activity on
neurocognitive ﬁrnction and recovery patterns in collegiate students who incur a migraine
headache compared to collegiate students who do not incur a migraine. Migraine and
non-migraine groups were matched for age, sex and education level. A pre-test, post-test
design where the independent variables were: migraine status, physical activity, testing
occasion, sex, exercise, sleep and diagnosis status was utilized. The dependent variables
were the four composite scores of ImPACT, level of pain, and impact of headache scores.
The following section is divided into four sections: (a) discussion of results, (b)

conclusions, (c) limitations and ((1) recommendations for future research.

Discussion of Results

Effect of Time on Neurocognitive Function Scores

It was ﬁrst hypothesized that there would be an effect of testing occasion on
neurocognitive function. For migraineurs, it was hypothesized that 24 hours post-
migraine neurocognitive function would be signiﬁcantly lower than baseline scores. Then
at 48 hours, neurocognitive function would be signiﬁcantly better than 24 hours and
continue to get better by seven day. It was hypothesized that seven days scores would be
similar to baseline scores in migraineurs. The non-migraine controls were expected to
have similar scores at each time. Each of the four composite scores will be discussed

separately with differences noted between migraineurs and non-migraine controls.

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The migraine group exhibited signiﬁcant neurocognitive impairments on verbal
memory composite scores. Speciﬁcally, verbal memory was impaired 24 hours and 48
hours after incurring a migraine compared to seven days post-migraine. Verbal memory
composite score is comprised of the average percentage correct of three tasks: a symbol
number match task, word recognition, and a letter memory task with an accompanying
distractor task (Iverson, Lovell, & Collins, 2003). As expected the non-migraine group’s
verbal memory composite scores consistently stayed in the average range compared to
normative data with no signiﬁcant differences noted across time.

Collegiate students who suffered from migraine headaches exhibited verbal
memory impairments up to 48 hours following their migraine. Other researchers have
reported that migraineurs were found to suffer from temporary impairments in verbal
learning after suffering from a migraine headache (Black et al. 1997). However, Black et
al. conducted a qualitative study by interviewing 30 migraineurs in their clinic or on the
telephone to determine their cognitive deﬁcits. Although, these ﬁndings were similar to
this study, Black and colleagues used qualitative methods and did not compare their
results to controls.

A Dutch life course study found that individuals who suffered from migraine
headaches had decreased verbal performance at 26 years of age (individuals were tested
from 3-26 yrs at speciﬁc intervals) compared to controls aged 3 to 13 years. These verbal
memory deﬁcits were not present beyond 15 years. The researchers suggest that verbal
memory deﬁcits in migraineurs was unlikely to have resulted from cumulative attacks

and may be related to developmental factors (Waldie, Hausmann, Milne, & Poulton,

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2002). Other studies have also found no differences at baseline between migraineurs and
controls in verbal memory (Bell, Primeau, Sweet, & Loftland, 1999).

These studies are consistent with this study that found baseline verbal memory scores
were similar in migraineurs and non-migraineurs, thus, illustrating no verbal memory
impairments in college students in their early twenties.

In contrast to this study, Zeitlin and Oddy (1984) found baseline decreases in
forced choice word scores for rrrigraineurs when compared to controls. However, there
were differences in methodology as Zeitlin and Oddy utilized a small sample of poorly
matched subjects, used older subjects (mean age 36 with at least a 10 year history) than
tested in this study, and only migraineurs who were considered severely affected by their
migraine.

The migraine group exhibited signiﬁcant neurocognitive impairments on visual
memory scores. Speciﬁcally, visual memory was impaired at 24 hours, compared with
baseline, 48 hours, and seven days. Visual memory composite scores are comprised of
the average percent correct of two separate tasks: a recognition memory task that requires
the abstract discrimination of a number of line art drawings, and a memory task that
requires the identiﬁcation of a series of highlighted X5 and Os after a distractor task
(Iverson, Lovell, & Collins, 2003).

The only research found that measured visual memory following migraine
headache were two drug studies utilizing sumatriptan. A drug study with sumatriptan
injection during a migraine found similar cognitive declines in all areas, speciﬁcally
visual memory (matching to sample) (Farmer, Cady, Bleiberg, & Reeves, 2000). Farmer

and colleagues found that visual memory scores returned to normal 15 minutes after

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injection. While our results were not that speciﬁc to medication and did not include the
migraine interval, further testing during the headache interval may show increased
cognitive deﬁcits at that time. A follow-up study also found cognitive declines in visual
memory (matching to sample) (Farmer, et al., 2001). Similar to the last study their
cognitive decline resolved quickly after sumatriptan (nasal spray). In contrast to this,
Leijdekkers and colleagues (1990) did not ﬁnd signiﬁcant differences between controls
and migraineurs in pattern memory tests (task similar to ImPACT’s visual memory task)
two days symptom free after incurring a migraine.

The non-migraine group’s motor processing speed composite scores consistently
stayed in the average range compared to a normative group with incremental
improvements in scores that resulted in the seven days scores being signiﬁcantly higher
scores than baseline scores. These differences between trials were found in other
ImPACT tests with insigniﬁcant improvements made between trials (Iverson, Lovell, &
Collins, 2003). This is most likely due to testing effects and familiarity with the program,
although no other studies have found testing effects relating to ImPACT. Therefore, it
may have been related to the population utilized.

The migraine group did not exhibit signiﬁcant differences over time in motor
processing speed. The motor processing speed composite score represents the Xs and Os
total correct (interference task) and a three letter recall that are completed as distractor
tasks for the memory paradigms as well as average correct for symbol match (Schatz,
Pardini, Lovell, Collins, & Podell, 2006). This takes into account individuals who may

slow down their speed to increase their accuracy (Zeitlin & Oddy, 1984).

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To date, no studies have been conducted that speciﬁcally examined the
relationship of motor processing speed after a migraine headache. However, the Trail-
Making test A and Trail-Making test B have been validated to be signiﬁcantly correlated
with motor processing speed (Iverson, Franzen, Lovell, & Collins, 2004). Zeitlin and
Oddy (1984) found signiﬁcant differences between migraineurs and controls in the
Trailmaking B test when migraine free, with migraineurs signiﬁcantly slower. Another
study utilized ﬁnger tapping for motor speed testing and found no signiﬁcant differences
between migraineurs and controls when migraine free (Leijdekkers, Goudswaard,
Menges, & Oriebeke, 1990). Reliable change estimates for ImPACT indices indicate that
a decline of three points or an improvement of 7 points is considered within an 80%
conﬁdence interval for motor processing speed (Iverson, Lovell, & Collins, 2003). This
study found a decrease of 2.7 points at 24 hours and then improvements of 2.1 points at
48 hours. While the results were not statistically signiﬁcant, further examination of motor
processing speed is warrented following migraine headache.

The migraine group in this investigation exhibited signiﬁcant neurocognitive
impairments on reaction time composite scores. Speciﬁcally, reaction time was impaired
at 24 hours compared to 48 hours and seven days. Reaction time composite scores consist
of the speed of the reaction (in milliseconds) when a correct score is given for several
tests. This includes a choice reaction test, symbol match test, and a go/no go test (Iverson,
Lovell, & Collins, 2003) (see page 61 for computations). In the non-migraine group
reaction time scores were consistently in the average range compared to normative scores

with no signiﬁcant differences noted by time.

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Collegiate students who incurred a migraine had decreased reaction time 24 hours
following their migraine. In a study that utilized the Headache Care Center Automated
Neuropsychological Assessment Metrics (HCC-ANAM) test during migraine and 15, 30
and 45 minutes after taking sumatriptan found a signiﬁcant drop in cognitive
performance during the migraine. Speciﬁcally, simple reaction time, continuous
performance test (recall tasks requiring focus, concentration and attention), and math
(simple arithmetic) skills were signiﬁcantly lower 15 minutes after a migraine compared
to their baseline scores. However, these impairments were not found at 30 or 45 minutes
after a migraine. Similarly to ImPACT, HCC AN AM is a computerized neurocognitive
test battery used to measure cognitive deﬁcits. A possible reason for lack of cognitive
deﬁcits at 30 or 45 minutes post-migraine may have been due to a learning effect.
Furthermore, the HCC ANAM study did not measure cognitive function after 45 minutes.
The current study found a decreased reaction time 24 hours post-migraine, which may
affect collegiate students’ daily lives and performance on tests and term paper.

Overall, these cognitive declines in average college students may result in reduced
test grades dependent on the level of individual cognitive decline experienced during and
after migraine. Individuals who have a decreased reaction time may be more likely to
react slower while driving, potentially resulting in an injury they typically would have
been able to avoid. Verbal and visual memory deﬁcits may result in difficulty
concentrating when writing a paper or studying for exams. Family, friends, and
professors may not understand why the migraineur is still experiencing difﬁculty

processing and remembering one to two days after the migraine headache itself is gone,

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leading to frustration and self-doubt. Therefore, cognitive declines following migraine

headache affect daily living in various situations.

Effect of Migraine Status on Neurocognitive Function Scores

It was also hypothesized that migraineurs would score signiﬁcantly less than
controls at 24 hours, 48 hours, and seven days for neurocognitive function with baseline
testing hypothesized to be equal between the groups. Migraine status had an effect on
neurocognitive function of collegiate students. Overall, migraineurs were signiﬁcantly
different than controls for visual and verbal memory, motor processing speed and
reaction time scores. Speciﬁcally, at 24 hours migraineurs neurocognitive function was
decreased in verbal memory, visual memory and motor processing speed and had a
slower reaction time when compared to non-migraine controls. At 48 hours motor
processing speed remained lower, as well as a continuance of a slower reaction time
when migraineurs were compared to non-migraine controls. At seven days, motor
processing speed remained lower while verbal memory, visual memory and reaction time
were not signiﬁcantly different between migraineurs and non-migraine controls.

At baseline, the only neurocognitive decreases found were reaction time, with
migraineurs exhibiting a slower reaction time than non-migraineurs. One study found
slower choice reaction time in migraineurs when headache free (Zeitlin & Oddy, 1984).
In a dominant ﬁnger tapping test (10 3) individuals with classic migraine exhibited slower
pure motor speeds than controls (Hooker & Raskin, 1986). Therefore, there may be
reaction time deﬁcits in individuals who suffer from migraine headaches.

Collegiate students were still impaired on motor processing speed 7 days after

incurring a migraine compared to controls. Researchers have reported that processing

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speed has been found to decline in migraineurs (Evers, Bauer, Suhr, Husstedt, &
Grotemeyer, 1997; Wray, Mijovic-Prele, & Kosslyn, 1995). This study provides
preliminary data that demonstrate motor processing speed takes the longest to recover
following a migraine headache. A possible explanation may be due to structural or
functional brain dysﬁmctions (Swartz & Kern, 2004; Kruit, et al., 2004) that have not yet
been detected in a younger population.

Overall, when compared to controls, migraineurs signiﬁcantly declined after a
migraine headache on neurocognitive function tests. These comparisons may provide
some insight on how a non-migraine brain functions compared to a migraine brain after a
migraine attack. Motor processing delays can change the ability of an individual to
execute and modify a plan of action (Gaudino, Geisler, & Squires, 1995). This could
affect the individual in physical events, or in academia where new concepts introduced
the days after a migraine may not be conceptualized, which can further delay processing

when the student is asked to recall or explain the information for a written exam.

Effect of Physical Activity Status on Neurocognitive Function Scores

Finally, it was hypothesized that physically active migraineurs would exhibit
higher neurocognitive function scores than non-physically active migraineurs at 24 and
48 hours post migraine. This hypothesis was consequently formed from the relationship
between migraines and exercise. Stress is a trigger for migraines (Turner, Molgaard,
Gardner, Rothrock, & Stang, 1995). Exercise, a form of migraine management, is known
to decrease stress levels (F olkins & Sime, 1981). After a cardiovascular exercise program
intervention migraineurs reported decreased frequency, intensity and duration of migraine

headaches (Lockett & Campbell, 1991). Therefore, it was expected that regular physical

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activity would assist the migraineur in recovering from cognitive declines. It was also
hypothesized that neurocognitive function would remain the same in non-migraineurs
regardless of their physical activity status. Physical activity was determined by number of
minutes per week of moderate and vigorous activity the individual reported. Individuals
were considered physically active if they reported exercising more than 150 minutes of
moderate activity or 75 minutes of vigorous activity per week. This study found there
were no Signiﬁcant differences between physically active and non-physically active
migraineurs. In addition, there were no signiﬁcant differences in non-migraine controls
with different physical activity status.

This study had a large majority of collegiate students who were physically active
compared to sedentary students. As a result, this may have contributed to the lack of
signiﬁcant differences found in this study. Other research studies that have found an
exercise program improves migraine outcomes did not use a collegiate population
(Ktiseoglu, Akboyraz, Soyuer, & Ersoy, 2003; Fitterling, Martin, Gramling, Cole, &
Milan, 1988; Lockett & Campbell, 1991). Lockett and Campbell (1991) initiated a six-
week cardiovascular exercise program and found decreases in pain level during migraine
headache as well as trends toward decreased frequency, intensity, and duration. Similarly,
another six-week study where subjects exercised at 60% of their max heart rate for 40
minutes (10 minute warm-up, 20 minute exercise, 10 minute rest) three times a week
found that subjects reported a signiﬁcant decrease in intensity and frequency of migraine
(Koseoglu, Akboyraz, Soyuer, & Ersoy, 2003). While, F itterling and colleagues (1988)
reported a reduction in vascular headache activity in four out of ﬁve subjects after a six-

week exercise intervention. The results of these studies suggest maintenance of an

119

exercise program is essential for decreased migraine frequency; however, these studies
did not examine cognitive function. Furthermore, it is not clear if collegiate students in
this study were more aerobically ﬁt compared to other studies. College students in the
current study has multiple avenues available to them for physical activity including
numerous sports clubs, classes, an onsite recreation facility, as well as a local community
that embraces outdoor recreation. They also were more likely to walk to bike to class than
a general population would walk or bike to work. With previous research ﬁnding physical
activity improves migraine outcome, further research is warranted to examine this
relationship. In addition, ﬁrture research should continue to research the collegiate
population as well as delve into a general population where larger variety of ﬁtness levels

may be found.

Additional Hypotheses and Research Questions

It was hypothesized that females would rate their pain higher than males 24 hours
post migraine. Females signiﬁcantly reported higher levels of pain at 24 hours for their
last migraine than males. Female prevalence of migraine is estimated at 18% and males
6% (Lipton et al., 2001; Lipton et al., 2002). College aged females reported more
frequent migraines that last longer, and throb more (Kinart, Cuppett, & Berg, 2002). In.
contrast, an epidemiological study of a nationwide sample found similar ﬁ'equency of
severe headaches between males and females (Lipton et al., 2001).

With approximately 50% of migraineurs seeking diagnosis (Lipton etal., 2001;
Bigal, Kolodner, Lafata, Loetta, & Lioton, 2006), and age of the ﬁrst attack about 18
years, most members of our demographic were expected to have a shorter migraine

history. It was hypothesized that physician diagnosed migraineurs would rate their pain

120

higher than self-diagnosed migraineurs at 24 hours post-migraine. No signiﬁcant
differences were found between groups. Other researchers have found that physician
diagnosed individuals more frequently report symptoms (nausea, vomiting, blurred
vision, aura, neurological signs, photophobia, phonophobia) of migraine; however, they
reported equal levels of pulsitile pain in both physician and self-diagnosed groups (Lipton
et al, 2001). A possible explanation for differences between this study and Liptons study
may be due to the ability of over the counter medications to effectively treat the
individual’s migraine. A higher number of migraineurs reported (75%) physician
diagnosis compared to the general populations 50% physician diagnosed.

It was hypothesized that physically active individuals would score lower on their
impact of headache scores in both migraineurs and non-migraine controls. Headache
Impact test (HIT) scores (range 36-78) increased with the amount of reported disability
that headaches have on their daily activities, with the highest HIT scores indicating
severe daily disruptions. Signiﬁcant differences were found with physically active
individuals rating their daily impact of headaches lower than those who were not
physically active. When separated into migraine and non-migraine, physically active
individuals consistently scored lower than non-physically active individuals. Previous
research has linked moderate exercise to improvements in psychological well being and
mood states in women (Cramer, Neiman, & Lee, 1991), and suggested trends toward
improvements in frequency, intensity and duration of migraines through a cardiovascular
exercise program (Lockett & Campbell, 1991). Others indicate exercise as a method of

migraine abortion (Darling, 1991). Regular exercise increases beta-endorphin levels

121

(Koseoglu, Akboyraz, Soyuer, & Ersoy, 2003), which may cause migraineurs to rate their
daily impact of their headaches lower with its natural analgesic properties.

It was hypothesized that the type of medication (OTC, RX, None, OTC and RX)
would have an impact on pain levels of migraineurs at 24 hours. Migraineurs were
speciﬁcally asked to contact the investigator after the onset of a migraine to facilitate a
meeting within 24 hours of their migraine. Migraineurs were allowed to sleep, take
medication, and any other means necessary to rid themselves of the migraine. Most
migraineurs were not still suffering from the migraine during testing, but many still had
lingering headaches and other side effects. There were no signiﬁcant differences found in
type of medication. Lipton et a1. (2001) found that 41 % of the population utilizes
prescription medications and 58% utilizes OTC. With most of our population (with 75%
seeking physician diagnosis compared to 50% in the general population) utilizing OTC
medications (68%), and only 10 (22%) utilizing prescriptions, it is assumed that the OTC
was adequate in providing pain relief. Furthermore, OTC medication is easier to access
and cheaper for college students who may be struggling with ﬁnances due to high cost of
tuition.

It was hypothesized that exercise in the 24 hours preceding testing (prior to their
migraine) would decrease college students’ perception of pain during their migraine. No
signiﬁcant differences were found for individuals who exercise prior to their migraine
compared to those who did not exercise. Previous research has found that exercise
decreases perception of pain after a single bout (Koltyn & Arbogast, 1998; Whiteside,
Hansen, & Chaudhuri, 2004), however, this did not occur in our sample. Although, most

of our sample had not exercised (84%) prior to their migraine, it is difficult to compare

122

our results to other researchers. The ﬁnding that a large majority of collegiate subjects in
this study did not exercise prior to their migraine may be related to the timing of their
migraine. Speciﬁcally, the question asked if the individual exercised 30 min or more in
the past 24 hours. With individuals testing anywhere from just after their migraine
headache up to 24 hours after the onset of their migraine, the exercise bout may have
been prior to or after their migraine. Numerous researchers have reported that
migraineurs reported reduced physical activity following a migraine headache including
activities of daily living (Blau, 1991). Feelings of fatigue or “hangover” in the postdrome
phase (Blau, 1991) and prodromal phase fatigue (Charbriat, Danchot, Michel, J oire, &
Henry, 1998) are common which may have contributed to their inactivity.

It was hypothesized that the number of hours of sleep after the onset of their
migraine headache would affect neurocognitive function scores. There were no
signiﬁcant differences found between the number of hours of sleep for 24 hours
neurocognitive function scores after migraine. Most cognitive function studies have been
completed during the headache phase (Farmer, Cady, Bleiberg, & Reeves, 2000; Farmer,
et al., 2001), therefore the individuals had not had an opportunity to sleep. Collegiate
students with the lowest mean (composite verbal and visual memory scores) scores were
those who had no sleep prior to testing. The postdrome phase of migraine lasts an average
of 25.2 hours and affects the entire brain, particularly the frontal lobes and hypothalamic
areas (Blau, 1991). Approximately 41% of our population had 4-8 hours of sleep prior to
neurocognitive testing with only 16% experiencing no sleep at all. Common methods of
treating a migraine include sleep (Bigal, Kolodner, Lafata, Loetta, & Lioton, 2006), but

amount of sleep does not appear to be associated with their level of cognition.

123

Limitations

This study had several limitations that need to be addressed. First, the population
of the upper peninsula of Michigan is not ethnically diverse, thus, making the sample
mainly Caucasian. Second, males were under-represented in the sample due to the
prevalence of migraines in females occurring at a rate of three times that of males. Our
population was similar to prevalence in the general population with males representing
6% of the population of migraineurs. Third, the numbers of physically active and non-
physically active individuals were not equal, with much smaller numbers of non-
physically active individuals, although in the migraine and non-migraine groups the
percentage per group was similar. Fourth, in the 24 hour questionnaire, the question
regarding exercise did not specify whether the exercise took place prior to or after the
migraine, just if they had exercised in the past 24 hours. With very few of our
migraineurs stating they had exercised in the past 24 hours further research is necessary
to examine this relationship. Fifth, power was compromised for some analyses. Sixth,
Treatment for headache was not standardized. Seventh, there were a higher number of
physician diagnosed migraineurs in this sample compared to the general population.
Seventh, all history data was subjectively reported by the individuals. Eighth, there are

difﬁculties in objectively quantifying the subjective complaints of migraine.

Conclusions

Overall, rrrigraineur’s neurocognitive function is affected in the postdromal phase
of migraine, with this cognitive decline reversible within a few days of the headache. I
This short interval of decline can affect individuals in their daily activities and may lead

to deleterious effects if the “wrong” situation (such as a normally avoidable vehicle

124

accident) presents in the recovery phase. Individuals need to understand their limitations
during this period, adjust their schedules according to their own personal deﬁcits, and
educate others who may impact their daily lives. The purpose of this study was to
investigate the effects of physical activity on neurocognitive function and recovery
patterns in collegiate students who incur a migraine headache compared to collegiate
students who do not incur a migraine. The following was a list of conclusions deduced
from this study.

A. Migraine signiﬁcantly decreases neurocognitive function scores in verbal
memory, visual memory, and reaction time within 24 hours after a
migraine headache compared to baseline testing.

B. Migraine signiﬁcantly decreases neurocognitive function scores in verbal
memory after 48 hours. Reaction time, and visual memory signiﬁcantly
improved compared to 24 hours after a migraine headache.

C. Compared to non-migraine controls migraineurs scored signiﬁcantly
slower on reaction time neurocognitive function scores at baseline.

D. Compared to non-migraine controls migraineurs scored signiﬁcantly lower
on neurocognitive ﬁrnction scores for reaction time, verbal memory, visual
memory and motor processing speed at 24 hours.

E. Compared to non-migraine controls migraineurs scored signiﬁcantly lower
on neurocognitive function scores for motor processing speed and reaction
time at 48 hours.

F. Compared to non-migraine controls migraineurs scored signiﬁcantly lower

on neurocognitive function scores for motor processing scores at 7 days.

125

G. Physical activity level had no impact on neurocognitive ﬁrnction scores.
H. Females rate their pain higher than males after a migraine.
1. Physician diagnosed migraineurs rate their pain similar to their non-
physician diagnosed counterparts.
J. Physically active individuals rate their HIT scores lower than those who
are non-physically active.
K. Type of medication and exercise after a migraine does not appear to have
an effect on level of pain during a migraine headache.
L. The number of hours of sleep after a migraine does not appear to affect
their neurocognitive function scores.
Recommendations for Future Research
While this study focused on the neurocognitive function scores of college-aged
individuals, further research is warranted to determine the amount of cognitive deﬁcits
the general population may incur after a migraine, and ways to minimize the postdromal
effects. The following recommendations were suggested for future research in this area.
A. Testing a general population may allow conclusions to be more generalized.
B. Testing a general population may show differences between certain
prescription medications and over the counter treatments on neurocognitive
function scores.
C. Exercise related testing such as proprioception, balance, reaction time, and
strength should be conducted on individuals who have just incurred a

migraine.

126

D. Test a wider range of physical activity levels (i.e., low aerobic ﬁtness
compared to high aerobic ﬁtness) and include strength training to determine if
neurocognitive function is affected.

E. Determine if aura affects the level of disability found in neurocognitive
function scores.

F. Test individual’s cognitive function online (ImPACT version recently
available) to allow individuals to test both during headache phase, within 4
hours headache free, and again after a full night’s sleep to determine if there is
a signiﬁcant difference by time, and to make it more convenient to the
subjects.

G. Determine self-efﬁcacy for tasks prior to and post-migraine to determine if

differences exist.

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APPENDIXES A-E

128

APPENDIX A

HEADACHE IMPACT TEST SIX- PAPER VERSION

129

HEADACHE IMPACT TEST

_ ..HlI.-.:.6T_‘7 ._ . . .._- ..... .. .HEADAQHE-

(VERSION 1.1)

This questionnaire was dsigned to help you describe and communicate
the way you feel and what you cannot do because of headaches.

To complete, please circle one answer for each question. . I lMPACT TE ST.“

 

0 When you ‘iravc headaches. how often Is the parn severe?

'I-I

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How'often .do headaches limit tonnabrlrty to do usUal daily activities including household
wotik. .w'orrk. séiiobl. or -sbc'ial activities?

Never , Rarely Sometrmes VcnyrGftcn

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‘ ‘1".1-7'113‘." ’.: Jig"): M7: 1:4.

Vin the past 4 weeks, how often have you felt too tired to do work or daily activities because
of your headaches?

. .. . Iii-1. wars"
Never Rarely- " "S‘b‘m‘e‘fimesé‘iff \Very’Oftcn I. :A‘lways

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a linthcmast-4tweeks..how1.often have you feltfed up or irritated because of your headaches?

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f“ e

in the past 4 weeks. how often did headaches limit your ability to concentrate on work or
daily actiVities’?

. -. .
. . . . .. . . - . - . . :_- . I

J. .. .‘ ._..‘ ..,‘. c...- -_,.4 -.- .o 313-". *-° - _r~_o ' ‘f—P-T- '1.‘
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Never Rarely Sometimes- ' chrry‘Oﬁtcn 'A‘lvrays 7

COLUMN 1 COLUMN 2 COLUMN 3 COLUMN 4 COLUMN 5
16 points each) 18 points each) 110 pornts each) {It pltmIS each! [13 pomts each)

     

 

 

 

To score. add points for answers in each column. T0131 SCOI’E
Please share your HIT-6 results with your doctor.

 

Higher scores indicate
greater impact on your life.

Score range is 36-78.

130

   

- - -‘¢-— N '.... aa.v-‘.Lt.ar.K&-‘—.$Ji;h «.

1 V

_ .
r

' What Does Your Score Mean?

If You Scored 60 or More

Your headaches are having a very severe impact on your life. You may be experiencing disabling pain and other symptoms that
are more severe than those of other'hea‘dache suffereIs. Don't let your headaches stop you from enjoying the important things In
your life, like family, work, school or social activities.

Make an appointment today to discuss your EFT-6 results and your headaches with your doctor.

If You Scored 56 -— 59

Your headaches are having a substantial impact on your life. As a result you may be experiencing severe pain and other
symptoms. causing you to miss some time from family, work, school, or social activities.

Make an appointment today to discuss your HIT -6 results and your headaches with your doctor.

If You Scored 50 — 55

Your headaches seem to be having some impact on your life. Your headaches should not make you miss time from family,
work, school, or social activities. ‘

Make sure you discuss your HIT-6 results and your headaches at your next appointment with your doctor.

V If You Scored 49 or Less

Your headaches seem to be having little to no impact on your life at this time. We encourage you to take HIT—6 monthly to
continue to track how your headaches affect your life.

V If Your Score on HIT-6 is 50 or Higher ':

You should share the results with your doctor. Headaches that are disrupting your life could be migraine.

Take HIT -6 with you when you visit your doctor because research shows that when doctors understand exactly how badly
headaches affect the lives of their patients, they are much more likely to provide a successful treatment program, which may
include medication.

HIT is also available on the Internet at www.[ggﬁggghgtgstmm.

The internet version allows you to print out a personal report of your results as well as a special detailed version for your doctor.

Don’t forget to take HIT-6 again or try the lntemet version to continue to monitor your progress.

About HIT

The Headache impact Test (HIT) is a tool used to measure the impact headaches have on your ability to function on the job, at
school, at home and in social situations. Your score shows you the effect that headaches have on normal daily life and your .
ability to function. HIT was developed by an international team of headache experts from neurology and primary care medicme
in collaboration with the psychometricians who deveIOped the SF-36"' health assessment tool.

HIT is not intended to offer medical advice regarding medical diagnosis or treatment. You should talk to your healthcare
provider for advice specific to your situation.

131

APPENDIX B

INFORMED CONSENT

132

THE EFFECTS OF MIGRAINE HEADACHE AND PHYSICAL ACTIVITY ON
COGNITIVE FUNCTION MEASURED BY IMPACT

INFORMED CONSENT

For questions regarding this study,

Please contact:

Dr. Tracey Covassin
Department of Kinesiology
Michigan State University
Phone: (517) 353-2010
E-mail: covassin/a‘msuedu or

I‘ .‘
A I
v

Marguerite Moore, MS., ATC
Health Physical Education and
Recreation Department

Northern Michigan University
Email: moorem25@msu.edu
Or mmoore@gmu.edu

Ofﬁce: (906) 227-2228

Cell: (517) 331-1444

 

 

For questions regarding your rights
as a research participant, please contact:
Peter Vasilenko, Ph.D.
Committee on Research Involving Humans
Michigan State University
202 Olds Hall
East Lansing, MI 48824
ucrihs@msu.edu
Phone: (517) 355-2180
Fax: (517) 432-4503
or
Dr. Cynthia Prosen
Dean of Graduate Studies
Northern Michigan University
cprosen@nmu.edu

(906) 227-2300

 

Your voluntary participation is requested in the research study in which the
purpose is to examine the effects of migraine headache on an individual’s neurocognitive
function; speciﬁcally: memory, concentration, processing speed, and reaction time. The
research study will use the Immediate Post-Concussion Assessment and Cognitive
Testing (ImPACT) computer program as an assessment tool. In this study, ImPACT will
be used to test your short and long-term memory, concentration level, processing speed,

and reaction time following migraine.

You are being asked to voluntarily participate in this research study. Your
voluntary participation will consist of one initial 60-minute orientation and testing
session at which you will complete a migraine history questionnaire, the headache impact
test (HIT) online at http://www.headachetest.com (10 minutes), a physical activity
questionnaire (5 minutes), and a baseline impact test.

If you are in the migraine group, following your next migraine headache, you
are to call Maggy Moore at (517)-331-1444 or (906) 227-2228 to complete a series of
three ImPACT tests over the next week. Each of these testing sessions will take
approximately 30 minutes. Each subsequent testing session will take place in a common
area (such as a dorm common room) agreed on by the participant and examiner. The ﬁrst
test will take place within 24 hours of onset of your migraine. The second test will take
place 24-48 hours aﬁer onset of your migraine, and include a 24-hour questionnaire, and
physical activity questionnaire, and the third test will take place one week following

onset of your migraine.

If you are in the control group, the testing session tests will be the same intervals

133

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ref

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as the migraine group. These test sessions will be set up at your convenience over a one-
week period sometime following your baseline testing and will take place on campus at
NMU in room 2011 of the PEIF building. Maggy Moore will be the only person to
contact you for testing.

You are free to take any medication prescribed to you by a physician for your
migraine or other disorders as well as any over the counter medications that you would
normally take for treatment of a migraine headache or other disorders.

There are no foreseeable risks associated with this test, but the beneﬁts that come
ﬁom your participation will help further advancements in understanding the short-term
neurocognitive effects of migraine headache. Test results will be provided at your request
at the last session. The HIT test result will be printed for you and will be available to take
home aﬁer the initial testing session. You will not be compensated for the study;
however, you will be entered into a drawing for two I-pod shufﬂes or several ﬁve to ten
dollar gift cards to local businesses at the completion of your participation. Chances of
winning a prize are greater than 1/7.

NMU students who volunteer for this study should not expect extra course credit
nor will their grade be adversely affected if he/she drops out of the study. Furthermore,
the NMU instructor is not involved in any part of the research except recruitment and
referral.

Participation in this study is voluntary. You must be 18 years or older to
participate in this study. Your identity and information recorded during the study will
remain conﬁdential. Conﬁdentiality will be protected by; (a) results will be presented in
aggregate form in any presentations and publications; and (b) all data will be stored in a
computer that has a password necessary to see conﬁdential data. Your privacy will be
protected to the maximum extent allowable by law. MSU Institutional Board will have
access to all research records for auditing purposes. You may also discontinue
participation at any time without penalty. Your participation in this research study will
not involve any additional costs to you or your health care insurer.

Any questions concerning participation in this study should be directed to Maggy
Moore at (517) 331-1444 or (906) 227-2228 or Tracey Covassin at (517) 353-2010. If
you have any questions or concerns about your role and rights as a research participant,
or would like to register a complaint about this study, you may contact, anonymously if
you wish, the Michigan State Human Research Protection Program, at 517-355-2180, Fax
517-432-4503, or e-mail irb@msu.edu or regular mail at 202 Olds Hall, MSU, East
Lansing, MI 48824. Or you may contact Dr. Cynthia Prosen, Dean of Graduate Studies of
Northern Michigan University (906)-227-2300 cprosen@nmu.edu.

 

Your signature below indicates your voluntary agreement to participate in this
research study.

 

 

Print Name (Last, First) Date

 

 

Signature Date
1 34

APPENDIX C

MIGRAINE HISTORY QUESTIONAIRRE

135

The Effects of Migraine on Short-Term Cognitive Function Measured by
ImPACT

MIGRAINE I-HSTORY QUESTIONAIRRE

 

 

 

 

Please answer the following questions about any moderate to severe headaches you have
experienced in the last 6 months, remembering to not consider symptoms you
experienced related to substance abuse.

 

1. Are you subject to moderate to severe headaches? El Yes C] No

2. Have you ever received a diagnosis of migraine headache from a physician?
El Yes El No

3. Have you had at least one moderate to severe headache in the past 6 months?
[I Yes El No

4. Have you had a moderate to severe headache in the last 3 months?
CI Yes Cl No

5. When you have a moderate to severe headache, is it only on one side of your head?
Cl Yes CI No El NA

6. When you have a moderate to severe headache, does the pain throb or pulsate?
El Yes El No El NA

7. When you have a moderate to severe headache, do you have nausea or vomit?
El Yes El No El NA

8. When you have a moderate to severe headache, does activity make it worse?
El Yes CI No CI NA

9. When you have a moderate to severe headache, does light bother you?
D Yes Cl No Cl NA

10. When you have a moderate to severe headache, does sound bother you?
El Yes D No D NA

11. When you have a moderate to severe headache, does it last for 4-72 hours
when you do not take medication?

El Yes E] No C] NA/ I don’t know

12. How many moderate to severe headaches have you had in your lifetime?
Cl 1-2 El 3-4 El 5-10 [310+

136

13. Do any members of your immediate family suffer from migraine headaches?
Cl Yes D No CI NA/ I don’t know

If yes, who?

CIMom ElDad DSibling DGrandparents El Other

 

14. Do you have any symptoms prior to the moderate to severe headache to let you know
that it is coming, that last about 5 minutes to one hour? Cl Yes El No

If no please stop questionairre here,
Thank you for your participation

A. If yes which of the following best describes these symptoms? You. may check
more than one symptom.
Difﬁculty in speaking
Visual disturbances (ﬂashing lights, zig-zag lines, loss of vision)
Anomia (forgetting the name of things)
Depersonalization (feeling as if another person)
Dizzyness / Lightheadedness
Seeing the world as strange
Macropsia (apparent increase in object size)
Micropsia (apparent decrease in object size)
Simultaneous agnosia (only the object or part of the object being
looked at is
recognized)
Cl Motor Weakness
El Numbness or tingling in face, or extremities
El Inability to understand language (difﬁculty/inability with reading)
El Olfactory Hallucinations (smelling something that is not there)
El Photophobia (light bothers you) or phonophobia (sound bothers you)
El Other, Please describe

CID

UCIEJEJDUU

 

 

 

B. How many of these moderate to severe headaches have you experienced in the
past 6 months?

C. How many headaches of this nature have you had in the past 3 months?

 

D. Can you estimate how many headaches of this nature you have had in your
lifetime?
El 1-2 Cl 3-4 El 5-10 E|10+

137

14. Read the criteria listed below, and think about the number of headaches that were
moderate to severe that you have had in the last month?

A. Headache attack lasts 4-72 hours (untreated or unsuccessfully treated with
medication)

B. The headache had at least two of the following characteristics:
1. It was only on one side of the head
2. Pulsed or throbbed
3. It was moderate to severe in intensity
4. The pain was aggravated by walking stairs or similar routine activities

C. The headache attack was accompanied by at least one of the following:

1. Nausea or vomiting
2. Photophobia (light bothers you) and phonophobia (sound bothers you)

Please tell us the number of headaches in the last month with the above criteria

 

15. On a scale of 1-10 with 1 being no pain, 5 moderate pain, and 10 severe pain, what
would you rate your moderate to severe headache that met the above criteria listed in
Question 14?

l 2 3 4 5 6 7 8 9 10
no pain moderate pain severe pain

138

APPENDIX D

PHYSICAL ACTIVITY QUESTIONNAIRE

139

Subject # __

PHYSICAL ACTIVITY QUESTIONAIRRE

BRF SS (www.cdc. gov)
Please answer the following questions related to your physical activity levels. All
answers are conﬁdential and will only be made available by the number assigned to you

to the investigators involved directly in this study.

1. Name

 

2. Height

 

3. Weight

 

4. How would you characterize your racial group?
El White C] Black, African-American El Native Hawaiian, Paciﬁc Islander
El Asian CI Alaskan Native, American Indian El Hispanic

5. During the past month, other than your regular job, did you participate in any physical
activities or exercise such as running, calisthenics, golf, gardening, or walking exercise?

El Yes
CI No
El Idon’t know

6. When you are at work, which of the following best describes what you do? Would you
say:

El Mostly sitting or standing

CI Mostly walking

1:] Mostly heavy labor or physically demanding work

Cl I don’t know

7. We are interested in two types of physical activity: vigorous and moderate. Vigorous
activities cause large increases in breathing or heart rate, while moderate activites cause
small increases in breathing or heart rate. Now thinking about the moderate physical
activities you do in a usual week, do you do moderate activities for at least 10 minutes at
a time, such as brisk walking, bicycling, vacuuming, gardening, or anything else that
causes small increases in breathing or heart rate?

Cl Yes

Cl No

Cl I don’t know

140

8. How many days per week do you do these moderate activities for at least 10 minutes at
a time?
Days of the week

Ell do not do any moderate physical activity for at least 10 minutes at a time

9. On days when you do moderate activities for at least 10 minutes at a time, how much
total time per day do you spend doing these activities?
Hours Minutes

El I don’t know

10. Now thinking of vigorous physical activities you do in a usual week, do you do
vigorous activities for at least 10 minutes at a time, such as running, aerobics, heavy yard
work, or anything else that causes large increases in breathing or heart rate?

Cl Yes
El No
El I don’t know

11. How many days per week do you do these vigorous activities for at least 10 minutes
at a time?

Days of the week
DI do not do any vigorous physical activity for at least 10 minutes at a time
12. On days when you do vigorous activities for at least 10 minutes at a time, how much
total time per day do you spend doing these activities?

Hours Minutes

CI I don’t know

141

APPENDIX E

24 HOUR QUESTIONNAIRE

142

ICE ZErLrL 3rLF. 4:1.

 

24 HOUR QUESTIONAIRRE

Participant Number

Please answer the following questions as honestly and completely as you can about the
last 24 hours.

1. How long has it been since the ﬁrst signs of your migraine headache occurred?
El 0—6 hours Cl 6-12 hours
[112-l8 hours CI 18-24 hours

2. What type of medication did you take to treat your migraine headache?

Cl Over the counter available medication (i.e., Advil migraine, Tylenol, etc.)
El Prescription medication for migraine (i.e., Maxalt, etc.)

E] I did not take any medication for my migraine.

3. How many hours of sleep have you had since the ﬁrst signs of your migraine occurred?
[3 None [3 A little to 4 hours
13 4-8 hours Cl More than 8 hours

4. Did you exercise for 30 minutes or more at a moderate-to-vigorous intensity in the last
24 hours?
El Yes D No

5. Did you experience an aura (visual or sensory disturbance such as tingling, ﬂashing
lights, sparkles) with the most recent migraine?
El Yes [3 No

If Yes, Describe the aura and how long the symptom/s lasted.

6. On a scale of 1-10 with 1 being no pain, 5 moderate pain, and 10 severe pain, what
would you rate your most recent migraine?

1 2 3 4 5 6 7 8 9 10
no pain moderate pain severe pain

143

7. Regarding location of pain, where was your pain during your most recent migraine
located?
El Right Side Cl Left Side El Both

Please circle/shade the location/s of pain

 

 

 

 

 

8. Thinking back over the last 24-48 hours, can you pick out one or two factors that may
have triggered your migraine? Please describe them below.

WORKS CITED

145

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