|Year : 2018 | Volume
| Issue : 3 | Page : 167-172
Executive function and its clinical correlates among migraineurs
Ashitha Sreedhar1, Suresh M Kumar2, Anjali N Shobha2
1 Department of Clinical Psychology, Amrita Institute of Medical Sciences, Ernakulam, Kerala, India
2 Department of Clinical Psychology, Composite Regional Center for Persons with Disabilities (NIEPMD), Kozhikode, Kerala, India
|Date of Web Publication||31-Dec-2018|
Dr. Suresh M Kumar
Department of Clinical Psychology, Composite Regional Center for Persons with Disabilities (NIEPMD), IMHANS Campus, Medical College, Kozhikode, Kerala
Source of Support: None, Conflict of Interest: None
Background: The studies conducted in the field of migraine and its effect on various cognitive functions revealed contradicting results mainly due to the incorporation of patients from varied socioeconomic status, clinical conditions, and the methodology adopted to the study. Methods: The participants of the study consist of 130 migraineurs, selected from the outpatient department of neurology from reputed tertiary centers at Chennai, South India, and controls were picked up from the community. Patients were selected on the basis of clinical examination and screening. The instruments used are Migraine Severity Scale, Headache impact test, hospital anxiety and depression scale (HADS), Wisconsin Card Sorting Test, Trail Making Test, and Controlled Oral word Association Test. Results: The study found that migraine group to have deficits in some aspects of problem-solving and concept formation competencies in comparison with healthy individuals and also found strong and weak correlation with various clinical variables such as its severity, duration, and headache impact indicating the role of migraine on cognitive functioning. Conclusion: The condition of migraine does lead to mild-to-moderate levels of impairment in various frontal lobe-involved cognitive functions such as attention, planning, and problem-solving even in a high-profile samples having higher levels of education and occupation. The relation between the migraine and impairment in cognitive functions are further cemented by the strong correlation found between various clinical factors such as its severity, duration, and its impact. Findings from such a study will also pave new ways and means to incorporate the implementation of a holistic approach in the treatment and management of migraine, and thereby to enhance the quality of life of these patients.
Keywords: Cognition, executive functions, headache, migraine, neuropsychology
|How to cite this article:|
Sreedhar A, Kumar SM, Shobha AN. Executive function and its clinical correlates among migraineurs. Indian J Pain 2018;32:167-72
| Introduction|| |
Migraine headaches are considered to be one of the genetically loaded cranial neurovascular defects., Migraine is typically characterized by recurrent and extended episodes of unilateral, pulsating and moderate-to-severe pain. Migraine with aura, visual, auditory, and olfactory disturbances are the most commonly reported aura symptoms, but other sensory, motor, affective, and cognitive symptoms may also occur in the prodrome, aura, and/or during the headache phase of an attack.,,, In some rare cases, patients suffer from other chronic neurological problems due to migraine.
Migraine is considered as one of the most frequent among pain disorders, due to its high prevalence in the general population., Despite the widespread disability produced by migraine, the disorder is considered as one among many underdiagnosed and treated illnesses. Migraine have its onset in either during adolescents or younger adulthood majorly before 30 years of age. Prevalence is much higher among female (31.6%) and among patients from rural areas (28.9%). Most migraineurs experience frequent attacks. Nearly 25% of patients experiences 4 + severe attacks per month, 35% experiences 1–3 severe attacks per month, 40% experiences 1 or less severe attack per month. Many migraineurs live in fear, knowing that an attack will disrupt their own official, familial, and social obligations. In spite of the minimized involvement in day-to-day affairs, migraineurs have been found to perform poorly in tests of attention, language, verbal and visual memory, and executive functioning. Several studies have addressed cognitive abnormalities in migraine patients outside headache attacks. However, the controversy still exists regarding the consistency of these findings from various studies, and no general consensus has yet been established regarding the cognitive deficits of these patients. Few studies revealed that executive dysfunction in migraineurs which affecting their academic, occupational functioning, and also to overall quality of life. Research has revealed that migraines may actually have a long-standing impact on the brain's overall structure, especially if they are coupled with an aura. Psychological distress has also been reported to be high among patients with chronic migraine. Researches indicates the presence of these disorders, leads to cognitive dysfunctioning. There have not been many studies in migraine indicating the role of effect on cognitive dysfunction and little is known about this in Indian context. Considering various contradictions and limitation observed from literature, the present study has been designed to examine the executive functions, one of the major cognitive functions and how it is related to the clinical variables in migraineurs.
| Methods|| |
The current study adopted a hospital-based, cross-sectional method. Given due consideration to time and low frequencies of pure migraine patients, a purposive sampling technique was employed. A sample of 130 patients with migraine was selected from the outpatient department of neurology of reputed tertiary referral centers from Chennai on the basis of clinical examination and screening according to the international criteria for migraine headache either with or without aura. Another sample of age- and education-matched control group were also selected from the community for the purpose of comparing the test performance. The diagnosis of migraine was confirmed by the neurologist and general medicine practitioner and the severity was assessed using MIGSEV (Migraine Severity Scale) and HIT (headache impact test) by clinical psychologist.
The study inclusion criteria consist of patients diagnosed with migraine with or without aura, according to the International Headache Society criteria and who are ready to accept for participating in the study by signing an informed consent. The study participants' age ranges from 20 to 40 years. Although the prevalence of migraine is high among female, more efforts have been initiated to include the male participants too. Participants with a formal education of at least 12 + years is another major requirement for enrolling into the study. Patients with any neurosensory deficits, communication problems, developmental disabilities such as mental retardation or similar problems, behavioral disorders such as addiction to drugs and alcohol, and patients with any other disabling comorbid physical, neurologic, and psychiatric conditions were excluded from the study.
The patients for both groups thus recruited were subjected to a detailed evaluation for executive functions using a battery of neuropsychological tests consists of Wisconsin Card Sorting Test (WSCT), Trail Making Test (TMT), and Controlled Oral Word Association Test (COWA). Data were collected from the samples in one session of 1–2 h duration. The obtained data were subsequently scored, coded, and analyzed using SPSS for Windows, Version 16.0. Chicago, SPSS Inc., USA. The major statistical techniques used in the study are descriptive statistics, t-test (independent), and Pearson product-moment correlations.
| Results|| |
The study sample consists of more female participants (90%) than the male (10%) and the study included participants having high levels of education. The data set shows that more number of participants having their education up to postgraduation or more (63%) and least number of participants having their educational qualifications up to + 2 (3%). The mean duration of illness reported is 5.93 ± 5.20 years with a range of 1 year to 20 years. The severity and impact of headache evaluation show that migraineurs participated in the study are suffering from moderate-to-severe level of migraine. The presence of anxiety and depression (variables which may influence the test performance among the participants of both groups) between groups also were compared that revealed no significant differences [Table 1] and [Table 2].
|Table 2: Performance of migraineurs and controls on various executive functions tests|
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Among the various assessment done to find out the performance of both migraineurs and controls, the study did not find any statistically significant difference between both groups performance expect for the number of trails administered (NTA) and the nonperseverative errors made by the migraineurs in the WCST. This may be due to the inclusion of highly educated samples as well as young patients, both conditions are considered to be protective factor for cognitive deterioration. During qualitative analysis, it was very obvious that in most of the tests, the performances of migraineurs were found to be poorer when compared with their counterparts, indicating a tendency toward vulnerability for cognitive impairment [Table 3].
The analysis also found that there are many strong and weak correlation between clinical variables and neuropsychological test performances. A moderate level of relationship was found between clinical variables such as migraine severity, duration of illness, and headache impact as well as neuropsychological functions assessed using WCST, COWA, and TMT, and strong correlation was found between anxiety and depression with clinical variables. The findings indicate the presence of impact of illness on neuropsychological functions, especially on executive functions.
| Discussion|| |
The present study was an attempt to see whether the patients who are suffering from migraine have any cognitive impairment, especially in executive function and to compare their performance with healthy controls, and secondarily to learn about its relationship with the clinical variables. As the study included only participants with strict age, sex, and education-matching inclusion parameters, observations from demographic details were not included in the analysis. Implementations of such inclusion criteria will tend to have more control over the influence of these variables on patients performance on various neuropsychological tests, and thereby can increase the probability of its generalizability in spite of inclusion of a fair number of sample. Among these variables, high education has given more importance for the current study because of its neuropsychological relevance. Moreover, education has always been considered as a protective factor from neurodegeneration or impairment.,. Considering all these factors, the study included patients from higher level of education which may provide a definite and more generalizing finding than including patients from lower level educational background. The female-to-male participant's ratio is 9:1. This high number of inclusion of female patients is not uncommon because of its high prevalence among female.,, The presence of comorbid conditions of anxiety and depression has been studied and reported in the literature., In the current study, a mild-to-moderate level of these conditions are accepted due to its unavoidable presence, but a comparison score of anxiety and depression for these two groups also did not differ so the interference of these negative emotions can be minimized or controlled.
The studies done in early 90s showed that there is no significant impact of migraine on neurocognitive functions using a robust sampling, screening, and neuropsychological tests. Although the recent studies using various newer and sophisticated methods of investigations such as neuroimaging, neurophysiological, and neuropsychological investigations highlighted the frontal lobe abnormalities and related cognitive impairments in migraineurs. Neurophysiological studies using ERP established a strong correlation with P300 elevation with cognitive functions such as attention, executive function, and problems-solving abilities. Evidence from these also suggests a decreased frontoparietal gray matter density which serves as an underlying cause of slower response time to tasks such as set shifting. The main objective of the current study is to find out the gap between these two potent studies using a similar kind of sampling in the Indian scenario in the context of little-published data from India. The present study analysis shows partial difference in the performance found between two groups. In the WCST, the NTA, and the nonperseverative errors committed by the migraineurs are significantly higher than that of the control group. Furthermore, in other parameters of WCST, the former scored poorer than the latter, indicating the presence of cognitive deterioration in the educationally and occupationally high-profile study sample. The lower number of trails indicates the patient's innate ability to solve problem and also it provides information about the patient's concept formation competency. The finding from the study indicates migraineurs are poor in these two abilities which are evidenced from WCST performance.
The current study results are also in corroboration with the earlier-mentioned studies, indicating the high possibilities of risk in cognitive functions such as problem-solving and concept formation deficits in migraine, though the underlying pathophysiology is not yet clear. Perseverative errors of WCST are considered to be one of the more sensitive measures to find out executive dysfunction. There are studies which highlight the role of perseverative error as a key element in discriminating patients who have dorsolateral frontal lobe dysfunction. Nonpreservative error in the WCST reflects the patient's inability to focus attention and becoming easily distractible. Unlike perservative errors, the nonpreservative errors are not considered as sensitive to dorsolateral frontal lobe functions, but it shows some kind of dysregulation in some of the frontal lobe functions. The migraine patients in the current study also committed significant level of nonperseverative errors in comparison with their counterparts indicating probability of having attention impairment or distractibility. Although the studies done recently using WCST among migraine patients not highlighted the role of nonperseverative errors by migraine patients, the attention and concentration deficits in migraineurs measured using other neuropsychological tests have been highlighted. Hence, from the current study results, it can be confirmed that decreased attention and concentration is indeed an inevitable deficit in neurological condition of migraine.
The verbal and category fluency tests are considered as a simple way to measure executive function, language ability, and semantic memory. The brain regions involved in processing of verbal and category fluency are both the frontal and temporal lobe, respectively. In the current study, the mean number of words produced by the migraine patients and healthy control groups on verbal as well as category fluency tests did not differ statistically. The study carried out by Gaist, Pedersen, and Madsen (2005) also reveals the same findings. They did comparison of Danish migraine twin to see the long-term effect of migraine on cognitive function and they have used verbal and category fluency test as a measure. A subsequent meta-analysis done by Araujo, Barbosa, Lemos, Domingues, and Teixeira in 2012, studied cognitive impairment in migraine. They included studies which have been conducted to evaluate various neuropsychological functions includes memory, attention, and information processing. From the studies that they have included, a majority reveal no significant difference in the executive function evaluated using verbal and category fluency test in the migraine group. In-depth analysis of their study attributes its reason to the heterogeneity of the population studied and the neuropsychological tests administered. Another explanation provided by them is that cognitive dysfunctions are seen predominantly in the subset of migraineurs with more severe neurological involvement and community-based sample hardly shows any kind of cognitive impairment.
The current samples mean difference between patients with migraine and controls over the verbal fluency test “S” and category fluency test for animal, shows a trend toward statistical significance implying the vulnerability of migraine patients on frontal and temporal lobe functions. The sensitivity of verbal and category fluency test has been implicated in many severe clinical conditions involving the frontal lobe such as Parkinson's disease, Schizophrenia, and in variants of Alzheimer's disease. Verbal and category fluency tests have been repeatedly studied and found to be influenced by education. Still, the numbers of responses from the current samples in the migraine group are found to be lower than that of the performance by healthy controls in spite of inclusion of sample having higher level of education.
Performance on TMT, the part A is more considered to be as a measure of sustained attention and concentration, whereas the part B is considered to be more sensitive for brain pathology. A study done by Parisi et al., in 2009, among children using TMT showed that the migraine patients are poorer on visual attention, scanning, and alternating attention with pathophysiology involved in various brain regions such as the brain stem and cerebral cortex and limbic system. However, the current study did not find any quantitative or qualitative difference between the both group patient's performances. One of the largest cross-sectional studies by Gaist et al. also supports the same findings. They found average cognitive scores on fluency, delayed word recall, and digit symbol substitution test which did not differ for migraineurs overall, compared to nonmigraineurs. A subsequent study by Rist, Dufouil, Glymour, Tzourio, and Tobias (2011) shows a result similar to what the current study revealed. They made a comparison of various neuropsychological function comparisons with migraine and nonmigraine headache and found no greater rate of cognitive decline, especially on visuomotor tracking using measure other than TMT.
A systematic review done by Araujo et al., in 2012, after reviewing 23 articles confirmed the relation between migraine and cognitive impairment, and they also highlight the role of drugs they are taking and other emotional factors such as depression ignoring other probable clinical factors such as duration, severity, and frequency. But a more recent study by Huang, Dong, Wang, Wang, and Xiao in 2017 indicated the role of clinical factors in cognitive impairment in migraine. Other than the study done by Hauang et al., no much studies either in the West or in the Asian context, the present study also made an attempt to see the relation with certain clinical variables such as headache impact and its severity, which are measured objectively using standardized tests and duration of illness with tests performance and found strong significant relationship between executive function and clinical variables. The findings also clearly established a link between the impact, severity, and duration of illness on risk for various cognitive functions. Probable reason for this kind of cognitive deterioration may be due to the frequent or severe migraine attacks may alter the brain structure, function, and its neural networks, which may leave a long time cognitive deterioration., Taking a lead from the results of the current study as well from the findings of other studies, it is suggested that along with other interventions such as drug therapy and other behavior therapy modalities which gives a prophylactic power, considerations may also be given for neuropsychological interventions to prevent the migraineurs from related impairment and a holistic approach in the intervention in the field of migraine will further increase their quality of life.
| Conclusion|| |
The study findings indicate that patients who are suffering from migraine do have mild-to-moderate level of impairment in various frontal lobe involved cognitive functions such as attention, planning, and problem-solving, even in high-profile samples having higher education and occupation. The study sample showed decreased or poorer performance in various neuropsychological tests administered such as WCST, COWA, and TMT indicates statistically mild-to-moderate vulnerability of migraine patients on various frontal and temporal lobe functions. The relation between the migraine and impairment in cognitive functions are further established by the strong correlation found between various clinical factors such as its severity, duration, and its impact. Though very little studies are conducted so far in the current area of research, initiating further studies using more sophisticated investigative measures and sound research designs may yield much more valuable information. Findings from such well-devised research will also pave new ways to incorporate the implementation of a holistic approach in the treatment and management of migraine, and thereby to enhance the quality of life of these patients.
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Conflicts of interest
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[Table 1], [Table 2], [Table 3]