Patterns of Perceived Stress Throughout the Migraine Cycle: A Longitudinal Cohort Study Using Daily Prospective Diary Data

Abstract

Objectives To describe patterns of perceived stress across stages of the migraine cycle, within and between individuals and migraine episodes as defined for this study. Methods Individuals with migraine aged ≥18 years, who were registered to use the digital health platform N1‐HeadacheTM, and completed 90 days of daily data entry regarding migraine, headache symptoms, and lifestyle factors were eligible for inclusion. Perceived stress was rated once a day at the participant’s chosen time with a single question, “How stressed have you felt today?” with response options graded on a 0‐10 scale. Days were categorized into phases of the migraine cycle: Ppre = pre‐migraine headache (the 2 days prior to the first day with migraine headache), P0 = migraine headache days, Ppost = post‐migraine headache (the 2 days following the last migraine day with migraine headache), and Pi = interictal days (all other days). Episodes, defined as discrete occurrences of migraine with days in all 4 phases, were eligible if there was at least 1 reported daily perceived stress value in each phase. Individuals with ≥5 valid episodes, and ≥75% compliance (tracking 90 days in 120 calendar days or less) were eligible for inclusion in the analysis. Results Data from 351 participants and 2115 episodes were included in this analysis. Eighty‐six percent of the sample (302/351) were female. The mean number of migraine days per month was 6.1 (range 2‐13, standard deviation = 2.3) and the mean number of episodes was 6.0 (range 5‐10, standard deviation = 1.0) over the 90‐day period. Only 8 (8/351, 2.3%) participants had chronic migraine (defined as 15 or more headache days per month with at least 8 days meeting criteria for migraine). Cluster analysis revealed 3 common patterns of perceived stress variation across the migraine cycle. For cluster 1, the “let down” pattern, perceived stress in the interictal phase (Pi) falls in the pre‐headache phase (Ppre) and then decreases more in the migraine phase (P0) relative to Pi. For cluster 2, the “flat” pattern, perceived stress is relatively unchanging throughout the migraine cycle. For cluster 3, the “stress as a trigger/symptom” pattern, perceived stress in Ppre increases relative to Pi, and increases further in P0 relative to Pi. Episodes were distributed across clusters as follows: cluster 1: 354/2115, 16.7%; cluster 2: 1253/2115, 59.2%, and cluster 3: 508/2115, 24.0%. Twelve participants (12/351, 3.4%) had more than 50% of their episodes fall into cluster 1, 216 participants (216/351, 61.5%) had more than 50% of their episodes fall into cluster 2, and 25 participants (25/351, 7.1%) had more than 50% of their episodes fall into cluster 3. There were 40 participants with ≥90% of their episodes in cluster 2, with no participants having ≥90% of their episodes in cluster 1 or 3. Conclusions On an aggregate level, perceived stress peaks during the pain phase of the migraine cycle. However, on an individual and episode basis, there are 3 dominant patterns of perceived stress variation across the migraine cycl...

Perceived stress and pain severity in individuals with chronic migraine: A longitudinal cohort study using daily prospective diary data

“…Although stress has traditionally been construed as a trigger, whereby elevated stress is seen as preceding onset of the attack, 12–18 preliminary data suggest that the day‐to‐day relationship between stress and attacks may be more complex and may depend more on differential levels of stress from day‐to‐day than on the absolute stress levels on the day preceding attack onset 19–21 . In addition, our recent data illustrate that the day‐to‐day relationship between stress and migraine attacks may vary significantly from attack‐to‐attack and between individuals 22 . At present, the bulk of the data on the day‐to‐day relationship between perceived stress and attacks come from studies of individuals without CM 19,21,22 .…”

“…In prior work, at an aggregate level, perceived stress has been observed to be elevated on migraine days compared with nonmigraine days. 22,29 Prior studies have also used perceived stress ratings to predict attack onset on the subsequent day. [20][21][22] Most of these studies have included individuals with episodic migraine as opposed to CM.…”

“…After completing the baseline questionnaires, participants entered daily data for 90 days. These daily data comprised 81 potential risk factors, including data on sleep quality, emotions, environmental factors, lifestyle factors, diet, travel, and eight subject‐specific risk factor options 22 . The following stress question was asked daily: “How stressed have you felt today?,” with responses graded on an 11‐point scale ranging from 0 (not at all) to 10 (a lot).…”

“…A detailed description of the N1-Headache™ platform is available elsewhere. 22 When users register to use N1-Headache™, they are asked to review the Curelator Inc. Terms and Conditions and Privacy Policy, which includes a statement about agreement to have their data used for research.…”

Analyzing categorical time series in the presence of missing observations

“…on a daily basis that may influence [their] risk of attack” (https://n1-headache.com/patients/faq/; retrieved April 16, 2021). These data are then used to identify the lifestyle factors and medications that affect the migraine attacks, also see Vives‐Mestres et al, 11 Vives‐Mestres and Casanova 12 for further background. Many of the considered features are categorical, such as binary symptom features (“true” or “false”), dietary features regarding the consumption of certain foods (“no,” “some,” “a lot”), or emotional features being expressed on a 0 to 10 Likert scale (ranging from “not at all” to “a lot”).…”