Abstract| Volume 37, 101539, January 2020

Headache Prevalence in Multiple Sclerosis at Al-Azhar Multiple Sclerosis Unit

      People with multiple sclerosis (MS) have an increased incidence of headaches, although the comorbidity of headaches and MS is poorly understood. Lifetime prevalence are variable with incidence ranging from 4% to 58%. Evidence suggests that headaches may vary based on MS form and lesion location. MS patients with migraines have a more symptomatic clinical course of the disease.
      This study conducted on 100 Egyptian patients coming to MS clinic at Al-azhar university hospitals (75 female and 25 male) diagnosed as clinically definite multiple sclerosis according to Mc Donald criteria for Multiple Sclerosis 2017.The survey was conducted from May 2017 till May 2019. Patients with MS underwent baseline and 2-year follow-up scans. All patients underwent an examination by MS specialist neurologist. Patients completed a 28-item questionnaire about headache. Only MS patients with a self-identified history of headaches were asked to participate. For patients with more than 3-months history of headache,patients were invited to complete this survey in the waiting room. To ensure anonymity, no names or other patient identifiers were recorded. From the responses, we examined in detail each patient's demographics, medications use, headache characteristics, frequency, location, duration, pain description, modifying factors, triggers, and impact on patient functioning. We also assessed headache features in relation to MS diagnosis, disease exacerbations, and physiological conditions such as pregnancy and menses.
      Patients who reported the presence of headaches before the start of their MS symptoms were 70% (P < .013). Out of them, 40% reported that they had headaches at least once a week (P < .001), with the majority stating that their headaches were severe at least some of the time. 60% of the patients reported that their headaches lasted for more than 4 hours without medication (P < .001). If they took medication immediately after headache onset, many patients reported a reduction in headache duration (P < .001), although for 17% headaches continued to last for more than 4 hours. Among patients who waited until headaches became severe to take medication, far fewer received considerable benefits in headache reduction. 25 % of patients who had headaches before MS onset had migraine with aura. However, 60 % of the patients who did not experience headaches before MS reported the presence of aura. Headache severity was increased during MS exacerbation: only 8 % of patients who never or rarely experienced severe headaches had worsening upon MS exacerbation. The most common lesions locations were cortex (33.3%) and cortex plus brainstem (43.%). Among headache-positive MS patients, there were 31 (45.6%) patients with cortical and brainstem lesions, 20 (29.4%) patients with cortical lesions, 16 (23.5%) patients with cortical plus brainstem and spinal cord lesions and 1 (1.5%) patient with spinal cord and cortical lesions.
      The majority of headaches reported in our study were migraine, although tension-type headache (TTH) is also commonly observed. Although the mechanisms of this correlation were unknown, several theories were suggested. The first was that migraine could initiate an inflammatory response in the brain that would be associated with greater numbers of T1- and T2-enhancing MS lesions. Headache may be the only symptom of a flare-up in MS patients. The relationship between stabbing g headache and MS relapses merits further investigation. Therefore, we suggest that headache should be investigated during examination of MS patients and a concurrent MS attack should be suspected at the time of headache in MS patients.