Keywords:
Migraine Headaches - Posture Balance - Postural Control
Palavras-chave:
Transtornos de Enxaqueca - Equilíbrio Postural - Controle da Postura
INTRODUCTION
Migraine is defined as a neurovascular syndrome that is triggered by various factors,
characterized by headache and accompanied by different symptoms[1]. Episodic migraine gradually progresses into chronic migraine, which is a more severe
form. Moreover, approximately 3% of patients with episodic migraine progress into
chronic migraine within a period of one year[2],[3]. Chronic migraine is defined as a headache (tension-type and/or migraine headache)
occurring on 15 or more days/month for more than 3 months, which has the features
of migraine headache on at least 8 days/month[4].
Besides vestibular anomalies, auras and subclinical ischemic brain lesions, balance
control impairments are also highly frequent among migraine patients[5]. Although the exact mechanism of these impairments in migraine patients remains
unknown, they have been attributed to subclinical cerebellar or brainstem dysfunction
and to central vestibular disorders[5],[6]. Nevertheless, migraine patients are considered to have normal peripheral vestibular
function. It can be highlighted that balance control impairments, together with the
pain associated with migraine episodes, are likely to have a negative effect on the
functional abilities of patients.
Although the effects of auras and the frequency of attacks on balance have been extensively
investigated in migraine patients, the effects of episodic and chronic migraine on
balance have not been studied. The aim of our study was to evaluate the effects of
episodic and chronic migraine on postural balance by performing static and dynamic
posturographic tests, on a balance platform (Techno-body Prokin).
METHODS
The study included 32 chronic migraine patients and 36 episodic migraine patients
who presented to the neurology outpatient clinic of Van Yüzüncü Yıl University Medical
School between February 2018 and April 2018 and a control group of 36 healthy volunteers.
The study was started after obtaining approval from the local ethics committee. Informed
consent was obtained from each participant.
The Migraine Disability Assessment Scale (MIDAS) was used to evaluate the impact of
migraine headache on patients’ work, daily activities and social lives. A visual analogue
scale (VAS) was used to objectively assess the severity of headache during the pain-free
time.
Some migraine patients were under prophylactic treatment, including propranolol, amitriptyline,
sodium valproate and topiramate.
Patients with neurological or orthopedic problems that could affect balance, or with
musculoskeletal diseases, advanced hearing and vision impairment, polyneuropathy,
diabetes mellitus, body mass index (BMI) of >30 or vestibular diseases, and patients
that did not complete their balance tests, were excluded from the study.
Static and dynamic balance tests were performed in all three groups using a posturographic
balance platform (Prokin 212-252, Pro-Kin Software Stability, TecnoBody S.r.l., Dalmine,
24044 Bergamo, Italy). All the patients were evaluated during a pain-free period.
The minimum interval between pain and balance evaluation, and also between using a
symptomatic drug during the pain period and this balance evaluation was stipulated
as at least 48 hours.
This platform allows assessment of static balance and proprioception and can also
be used for rehabilitation exercises that are performed to improve these senses. Additionally,
the monitor attached to the platform provides objective live data regarding balance
measurements ([Figure 1]).
Figure 1 Techno-body Prokin balance measurement device.
Static balance test
The subjects were asked to stand on the balance platform, which detected pressure
sways in all directions, and were instructed to first look straight ahead at a screen
surface in front of them with their eyes open for 60 sec, while trying to keep their
balance on both legs, with their eyes focused on the stationary target. Subsequently,
they were instructed to keep their balance on both legs with their eyes closed for
another 60 sec. After these measurements, the patients were asked to try to maintain
their balance for 60 sec on the right and left leg, respectively. At each interval
between the tests, the subjects were allowed a resting period of 60 sec. At the end
of these measurements, the device provided visual feedback regarding the length (mm)
and average speed (mm/s) of body sway (total and along the anteroposterior [AP] and
mediolateral [ML] axis) and the area of body sway (area of the ellipse) (mm2). The parameters measured in the static balance test were as follows[7]:
-
Average center of pressure X (CoP-X).
-
Average center of pressure Y (CoP-Y).
-
Standard deviation of AP sway.
-
Standard deviation of mediolateral sway.
-
Average speed of anteroposterior sway (mm/s).
-
Average speed of mediolateral sway (mm/s).
-
Standard deviation of anteroposterior total body sway.
-
Standard deviation of mediolateral total body sway.
The total length of body sway (perimeter) (mm) was calculated as the total length
of the chaotic lines recorded during the patient's body sway. The shorter this length
is, the better the postural balance is[8].
Area of body sway (area of the ellipse) (mm2) refers to the area of a well-defined elliptical shape that covers at least 90 or
95% of the chaotic sway lines. The smaller this area is, the better the balance performance
is[9].
Dynamic balance test
A dynamic balance test was performed using the posturographic balance platform to
assess proprioception. The movable balance platform of the system works with air piston
servo motors and can perform measurements in every direction with an operating angle
of 15°. The subjects were asked to stand on the platform with their legs together
and their hands supported on the sides. An image of three intertwined circles was
then shown on the screen and the subjects were asked to rotate the cursor, which showed
the net vector of the load applied on the platform by the subject, over the circle
in the middle in a clockwise fashion while avoiding deviation as much as possible,
at least five times within a period of 120 sec. The live feedback provided by the
monitor was viewed by the subject and recorded on the device.
During the test, the average trace error (ATE) was calculated for each subject. An
ATE of 0‒35% was considered very good, 35‒100% was considered adequate and >100% was
considered to indicate a problem in terms of proprioceptive control. To obtain a statistically
significant ATE index, the subjects needed to rotate the cursor at least five times
within 120 sec[10].
Statistical analysis
Statistical analyses were performed using Statistical Package for the Social Sciences
(SPSS) version 17.0 for Windows (Released 2008; SPSS Inc., Chicago, United States).
Normal distribution of data was assessed using the Kolmogorov-Smirnov test and histogram
plots. Descriptive parameters were expressed as frequencies (n), percentages (%) and
mean, standard deviation (SD), median and minimum-maximum values. Variables with normal
distribution (parametric data) were compared using an independent t test and variables
with non-normal distribution (parametric data) were compared using the Mann-Whitney
U test. Correlations were determined using Spearman's correlation coefficient. P<0.05
were considered significant.
RESULTS
The 32 chronic migraine patients comprised 27 women (84.38%) and 5 men (15.63%), the
36 episodic migraine patients comprised 27 women (75%) and 9 men (25.00%), and the
36 healthy volunteers comprised 21 women (58.33%) and 15 men (4 1.67%). Overall, the
104 participants included 75 women (72.12%) and 29 men (27.88%). Accordingly, the
female-to-male ratio was 3.8/1 among the migraine patients. The mean age was 30.53±7.02
years in the episodic group, 30.88±8.37 years in the chronic group and 28.33±6.17
years in the control group. No significant difference was found between the patient
and control groups in terms of mean age.
Seven patients (four patients with chronic and three patients with episodic migraine)
were excluded from the study since they could not perform the dynamic test.
No significant difference was found between the episodic and chronic groups in terms
of disease duration or age at the onset of the first symptoms. The mean VAS and MIDAS
scores were significantly higher in the chronic group (7.69±0.69 and 3.75±0.44, respectively)
than in the episodic group (7.11±1.12 and 2.94±0.58, respectively) (p=0.019 and p<0.001).
The mean number of laps in the dynamic balance test was significantly lower in the
episodic group (3.72±1.26) and chronic group (2.84±1.39) than in the control group
(5.00±0.00) (p<0.001). Moreover, the mean number of laps was significantly lower in
the chronic group than in the episodic group (p=0.008).
The mean ATE was 24.78±13.50 in the episodic group and 24.78±10.84 in the control
group and no significant difference was found between the two groups (p=0.813). Moreover,
the mean ATE was significantly lower in the chronic group (19.66±15.65) than in the
control group (24.78±10.84) (p=0.029). In the episodic, chronic and control groups,
ATE was accepted as very good in 29 (80.56%), 27 (84.38%) and 30 (83.33%) of the subjects
and was accepted as adequate in 7 (19.44%), 5 (15.63%) and 6 (16.67%) of the subjects,
respectively.
The eyes-open perimeter value was significantly lower in the episodic group than in
the control group (541.61±149.64 vs. 605.39±117.85 mm) (p=0.048). However, the eyes-open
and eyes-closed area values established that there was no significant difference between
the episodic group (321.97±300.53 and 672.47±701.33 mm2, respectively) and the control group (265.03±131.76 and 425.94±404.95 mm2, respectively) (p>0.05 for both). On the other hand, these value were significantly
higher in the episodic group than in the control group ([Table 1]).
Table 1
Comparison of eyes-open and eyes-closed static balance measurements between the episodic
and control groups.
|
EPISODIC
|
CONTROL
|
p-value
|
|
Mean
|
±SD
|
Median
|
Mean
|
±SD
|
Median
|
|
Eyes-open AP SD
|
4.69
|
±2.12
|
4.00
|
4.61
|
±1.71
|
4.00
|
0.725
|
|
Eyes-closed AP SD
|
6.11
|
±2.99
|
5.00
|
5.58
|
±2.90
|
5.00
|
0.566
|
|
Eyes-open ML SD
|
3.47
|
±1.76
|
3.00
|
3.25
|
±1.11
|
3.00
|
0.817
|
|
Eyes-closed ML SD
|
5.08
|
±2.73
|
4.00
|
3.78
|
±1.17
|
4.00
|
0.017*
|
|
Eyes-open average AP speed (mm/s)
|
6.06
|
±2.18
|
5.50
|
6.58
|
±1.54
|
7.00
|
0.040*
|
|
Eyes-closed average AP speed (mm/s)
|
8.83
|
±2.98
|
8.00
|
10.33
|
±3.76
|
10.00
|
0.056
|
|
Eyes-open average ML speed (mm/s)
|
4.81
|
±1.28
|
5.00
|
5.53
|
±1.38
|
6.00
|
0.021*
|
|
Eyes-closed average ML speed (mm/s)
|
7.33
|
±2.98
|
7.00
|
8.08
|
±3.08
|
8.00
|
0.312
|
|
Eyes-open average CoP-Y
|
−30.42
|
±26.88
|
−37.00
|
−15.81
|
±17.31
|
−17.00
|
<0.001*
|
|
Eyes-closed average CoP-Y
|
−27.78
|
±25.60
|
−31.00
|
−14.86
|
±18.64
|
−20.00
|
0.002*
|
|
Eyes-open average CoP-X
|
−1.56
|
±6.08
|
−1.50
|
−0.61
|
±5.49
|
−1.00
|
0.491
|
|
Eyes-closed Average CoP-X
|
0.39
|
±6.78
|
0.00
|
−0.42
|
±5.11
|
−1.00
|
0.571
|
|
Eyes-open trunk AP SD
|
5.63
|
±7.16
|
2.57
|
2.50
|
±2.11
|
1.66
|
0.149
|
|
Eyes-closed trunk AP SD
|
5.59
|
±7.04
|
2.41
|
2.45
|
±2.11
|
1.69
|
0.128
|
|
Eyes-open trunk ML SD
|
12.71
|
±10.69
|
10.19
|
10.09
|
±8.98
|
6.65
|
0.299
|
|
Eyes-closed trunk ML SD
|
12.83
|
±10.61
|
9.20
|
10.10
|
±9.32
|
6.21
|
0.225
|
|
Eyes-open trunk total SD
|
14.63
|
±12.01
|
10.41
|
10.76
|
±8.79
|
6.72
|
0.153
|
|
Eyes-closed trunk total SD
|
14.66
|
±11.92
|
9.75
|
10.79
|
±9.10
|
6.58
|
0.112
|
|
Eyes-open perimeter (mm)
|
541.61
|
±149.64
|
502.50
|
605.39
|
±117.85
|
614.00
|
0.048*
|
|
Eyes-closed perimeter (mm)
|
790.00
|
±253.86
|
720.00
|
889.25
|
±298.24
|
872.50
|
0.133
|
|
Eyes-open area (mm2)
|
321.97
|
±300.53
|
222.50
|
265.03
|
±131.76
|
253.50
|
0.906
|
|
Eyes-closed area (mm2)
|
672.47
|
±701.33
|
397.00
|
425.94
|
±404.95
|
291.00
|
0.093
|
|
Ratio of eyes-closed area to eyes-open area
|
255.75
|
±246.65
|
189.50
|
155.89
|
±83.88
|
133.50
|
0.031*
|
|
Ratio of eyes-closed perimeter to eyes-open perimeter
|
152.08
|
±47.59
|
136.00
|
146.25
|
±33.60
|
135.00
|
0.831
|
AP: anteroposterior; ML: mediolateral; SD: standard deviation; CoP: center of pressure.
*Represents statistical significance.
No significant difference was observed in terms of eyes-open and eyes-closed area
values between the chronic migraine group (308.72±209.05 and 536.41±508.28 mm2, respectively) and the control group (265.00±131.76 and 425.94±404.95 mm2, respectively) (p>0.05 for both). However, these values were significantly higher
in the chronic migraine group than in the control group ([Table 2]).
Table 2
Comparison of eyes-open and eyes-closed static balance measurements between the chronic
and control groups.
|
CHRONIC
|
CONTROL
|
p-value
|
|
Mean
|
±SD
|
Median
|
Mean
|
±SD
|
Median
|
|
Eyes-open AP SD
|
4.34
|
±1.26
|
4.00
|
4.61
|
±1.71
|
4.00
|
0.620
|
|
Eyes-closed AP SD
|
5.72
|
±2.49
|
5.00
|
5.58
|
±2.90
|
5.00
|
0.716
|
|
Eyes-open ML SD
|
3.59
|
±1.62
|
3.00
|
3.25
|
±1.11
|
3.00
|
0.471
|
|
Eyes-closed ML SD
|
4.66
|
±2.25
|
4.00
|
3.78
|
±1.17
|
4.00
|
0.086
|
|
Eyes-open average AP speed (mm/s)
|
6.03
|
±1.33
|
6.00
|
6.58
|
±1.54
|
7.00
|
0.151
|
|
Eyes-closed average AP speed (mm/s)
|
10.56
|
±3.21
|
10.00
|
10.33
|
±3.76
|
10.00
|
0.729
|
|
Eyes-open average ML speed (mm/s)
|
5.28
|
±1.30
|
5.00
|
5.53
|
±1.38
|
6.00
|
0.538
|
|
Eyes-closed average ML speed (mm/s)
|
8.47
|
±2.79
|
8.00
|
8.08
|
±3.08
|
8.00
|
0.473
|
|
Eyes-open average CoP-Y
|
−36.03
|
±18.79
|
−35.00
|
−15.81
|
±17.31
|
−17.00
|
<0.001*
|
|
Eyes-closed average CoP-Y
|
−32.22
|
±20.37
|
−33.50
|
−14.86
|
±18.64
|
−20.00
|
0.001*
|
|
Eyes-open average CoP-X
|
−1.06
|
±5.59
|
0.00
|
−0.61
|
±5.49
|
−1.00
|
0.738
|
|
Eyes-closed average CoP-X
|
−0.34
|
±6.79
|
0.00
|
−0.42
|
±5.11
|
−1.00
|
0.960
|
|
Eyes-open trunk AP SD
|
9.22
|
±10.50
|
4.14
|
2.50
|
±2.11
|
1.66
|
0.001*
|
|
Eyes-closed trunk AP SD
|
10.31
|
±13.29
|
4.64
|
2.45
|
±2.11
|
1.69
|
<0.001*
|
|
Eyes-open trunk ML SD
|
19.22
|
±10.36
|
18.11
|
10.09
|
±8.98
|
6.65
|
<0.001*
|
|
Eyes-closed trunk ML SD
|
19.37
|
±10.41
|
19.03
|
10.10
|
±9.32
|
6.21
|
<0.001*
|
|
Eyes-open trunk total SD
|
22.64
|
±12.54
|
25.63
|
10.76
|
±8.79
|
6.72
|
<0.001*
|
|
Eyes-closed trunk total SD
|
22.91
|
±12.70
|
26.12
|
10.79
|
±9.10
|
6.58
|
<0.001*
|
|
Eyes-open perimeter (mm)
|
567.12
|
±114.13
|
567.00
|
605.39
|
±117.85
|
614.00
|
0.180
|
|
Eyes-closed perimeter (mm)
|
901.44
|
±306.44
|
854.50
|
889.25
|
±298.24
|
872.50
|
0.869
|
|
Eyes-open area (mm2)
|
308.72
|
±209.05
|
272.00
|
265.03
|
±131.76
|
253.50
|
0.414
|
|
Eyes-closed area (mm2)
|
536.41
|
±508.28
|
371.00
|
425.94
|
±404.95
|
291.00
|
0.241
|
|
Ratio of eyes-closed area to eyes-open area
|
176.75
|
±95.37
|
165.00
|
155.89
|
±83.88
|
133.50
|
0.280
|
|
Ratio of eyes-closed perimeter to eyes-open perimeter
|
166.16
|
±45.52
|
159.00
|
146.25
|
±33.60
|
135.00
|
0.058
|
AP: anteroposterior; ML: mediolateral; SD: standard deviation; CoP: center of pressure.
*Represents statistical significance.
No significant difference was found in terms of eyes-closed perimeter values between
the chronic and episodic migraine groups (901.44±306.44 and 790.00±253.86, respectively)
(p>0.05). However, these values were significantly higher in the chronic migraine
group than in the episodic migraine group.
No significant difference was found between the episodic and control groups with regard
to right-leg perimeter (1800.56±535.20 and 1739.50±402.27 mm, respectively), left-leg
perimeter (1854.28±665.12 and 1755.81±486.49 mm, respectively) and left-leg area (889.75±647.27
and 807.33±370.06 mm2, respectively). However, these values were found to be relatively higher in the episodic
group than in the control group ([Table 3]).
Table 3
Comparison of right and left-leg static balance measurements between the episodic
and control groups.
|
EPISODIC
|
CONTROL
|
p-value
|
|
Mean
|
±SD
|
Median
|
Mean
|
±SD
|
Median
|
|
Right-leg average CoP-X
|
5.19
|
±7.55
|
3.50
|
4.69
|
±5.77
|
6.00
|
0.753
|
|
Left-leg average CoP-X
|
−10.92
|
±16.29
|
−7.50
|
−7.17
|
±5.93
|
−7.00
|
0.580
|
|
Right-leg average CoP-Y
|
−18.47
|
±23.66
|
−17.50
|
−7.94
|
±22.79
|
−10.00
|
0.059
|
|
Left-leg average CoP-Y
|
−25.50
|
±27.47
|
−32.50
|
−24.67
|
±18.87
|
−24.50
|
0.881
|
|
Right-leg AP SD
|
8.06
|
±2.63
|
8.00
|
8.42
|
±2.29
|
8.00
|
0.562
|
|
Left-leg AP SD
|
8.94
|
±3.63
|
8.00
|
8.89
|
±2.45
|
8.00
|
0.554
|
|
Right-leg ML SD
|
4.75
|
±1.20
|
4.50
|
4.64
|
±0.87
|
5.00
|
0.838
|
|
Left-leg ML SD
|
5.06
|
±1.37
|
5.00
|
4.78
|
±1.35
|
5.00
|
0.377
|
|
Right-leg average AP speed (mm/s)
|
18.78
|
±5.99
|
19.00
|
18.97
|
±4.83
|
17.50
|
0.879
|
|
Left-leg average AP speed (mm/s)
|
19.42
|
±7.35
|
18.50
|
19.22
|
±5.95
|
18.00
|
0.991
|
|
Right-leg average medium-lateral speed (mm/s)
|
19.39
|
±6.32
|
17.50
|
18.03
|
±4.33
|
18.00
|
0.433
|
|
Left-leg average ML speed (mm/s)
|
19.33
|
±7.66
|
18.00
|
18.22
|
±5.02
|
18.00
|
0.852
|
|
Right-leg trunk AP SD
|
6.98
|
±7.33
|
4.06
|
3.70
|
±2.89
|
2.62
|
0.066
|
|
Left-leg trunk AP SD
|
6.58
|
±6.51
|
3.88
|
3.29
|
±1.66
|
3.09
|
0.102
|
|
Right-leg trunk ML SD
|
12.32
|
±9.92
|
8.77
|
8.49
|
±7.49
|
5.02
|
0.056
|
|
Left-leg trunk ML SD
|
13.03
|
±10.09
|
9.47
|
9.05
|
±8.57
|
5.37
|
0.034*
|
|
Right-leg trunk total SD
|
14.80
|
±11.53
|
10.84
|
9.84
|
±7.29
|
7.09
|
0.051
|
|
Left-leg trunk total SD
|
14.79
|
±10.95
|
11.19
|
10.34
|
±7.87
|
6.85
|
0.035*
|
|
Right-leg perimeter (mm)
|
1800.56
|
±535.20
|
1771.50
|
1739.50
|
±402.27
|
1691.50
|
0.554
|
|
Left-leg perimeter (mm)
|
1854.28
|
±665.12
|
1854.00
|
1755.81
|
±486.49
|
1698.50
|
0.558
|
|
Right-leg area (mm2)
|
725.44
|
±333.78
|
711.00
|
729.22
|
±261.70
|
688.00
|
0.857
|
|
Left-leg area (mm2)
|
889.75
|
±647.27
|
782.50
|
807.33
|
±370.06
|
720.00
|
0.910
|
AP: anteroposterior; ML: mediolateral; SD: standard deviation; CoP: center of pressure.
*Represents statistical significance.
No significant difference was observed between the chronic and control groups with
regard to right-leg perimeter (1830.78±596.59 and 1739.50±402.27 mm, respectively)
and right-leg area (855.59±477.59 and 729.22±261.70 mm2, respectively). However, these values were significantly higher in the chronic group
than in the control group ([Table 4]).
Table 4
Comparison of right and left-leg static balance measurements between the chronic and
control groups.
|
CHRONIC
|
CONTROL
|
p-value
|
|
Mean
|
±SD
|
Median
|
Mean
|
±SD
|
Median
|
|
Right-leg average CoP-X
|
8.12
|
±7.34
|
9.50
|
4.69
|
±5.77
|
6.00
|
0.035*
|
|
Left-leg average CoP-X
|
−5.50
|
±7.30
|
−3.50
|
−7.17
|
±5.93
|
−7.00
|
0.155
|
|
Right-leg average CoP-Y
|
−11.91
|
±25.06
|
−9.00
|
−7.94
|
±22.79
|
−10.00
|
0.497
|
|
Left-leg average CoP-Y
|
−19.06
|
±22.00
|
−21.50
|
−24.67
|
±18.87
|
−24.50
|
0.262
|
|
Right-leg AP SD
|
8.84
|
±3.25
|
8.00
|
8.42
|
±2.29
|
8.00
|
0.901
|
|
Left-leg AP SD
|
8.03
|
±2.09
|
8.00
|
8.89
|
±2.45
|
8.00
|
0.268
|
|
Right-leg ML SD
|
4.97
|
±1.43
|
5.00
|
4.64
|
±.87
|
5.00
|
0.588
|
|
Left-leg ML SD
|
5.03
|
±1.06
|
5.00
|
4.78
|
±1.35
|
5.00
|
0.201
|
|
Right-leg average AP speed (mm/s)
|
19.84
|
±7.15
|
18.50
|
18.97
|
±4.83
|
17.50
|
0.887
|
|
Left-leg average AP speed (mm/s)
|
19.81
|
±5.88
|
18.00
|
19.22
|
±5.95
|
18.00
|
0.749
|
|
Right-leg average medium-lateral speed (mm/s)
|
18.97
|
±6.06
|
18.00
|
18.03
|
±4.33
|
18.00
|
0.810
|
|
Left-leg average ML speed (mm/s)
|
18.94
|
±5.05
|
18.00
|
18.22
|
±5.02
|
18.00
|
0.584
|
|
Right-leg trunk AP SD
|
9.61
|
±10.16
|
5.76
|
3.70
|
±2.89
|
2.62
|
0.007*
|
|
Left-leg trunk AP SD
|
9.10
|
±9.11
|
5.28
|
3.29
|
±1.66
|
3.09
|
0.001*
|
|
Right-leg trunk ML SD
|
15.82
|
±11.00
|
15.07
|
8.49
|
±7.49
|
5.02
|
0.003*
|
|
Left-leg trunk ML SD
|
16.42
|
±11.26
|
16.05
|
9.05
|
±8.57
|
5.37
|
0.008*
|
|
Right-leg trunk total SD
|
19.91
|
±13.19
|
16.34
|
9.84
|
±7.29
|
7.09
|
0.001*
|
|
Left-leg trunk total SD
|
19.79
|
±12.89
|
18.42
|
10.34
|
±7.87
|
6.85
|
0.002*
|
|
Right-leg perimeter (mm)
|
1830.78
|
±596.59
|
1764.00
|
1739.50
|
±402.27
|
1691.50
|
0.749
|
|
Left-leg perimeter (mm)
|
1768.81
|
±582.60
|
1627.00
|
1755.81
|
±486.49
|
1698.50
|
0.868
|
|
Right-leg area (mm2)
|
855.59
|
±477.59
|
748.50
|
729.22
|
±261.70
|
688.00
|
0.597
|
|
Left-leg area (mm2)
|
790.69
|
±316.07
|
749.50
|
807.33
|
±370.06
|
720.00
|
0.975
|
AP: anteroposterior; ML: mediolateral; SD: standard deviation; CoP: center of pressure.
*Represents statistical significance.
No significant difference was observed between the episodic and chronic migraine groups
with regard to right and left-leg static balance measurements.
No significant correlation was detected between eyes-open and eyes-closed static balance
measurements and VAS, MIDAS and disease duration, whereas a moderate negative correlation
was found between MIDAS and left-leg perimeter (p=0.022; r: −0.381), whereby the left-leg
perimeter value decreased as the MIDAS score increased. Similarly, MIDAS also established
a moderate negative correlation with eyes-open perimeter (p=0.022; r: −0.403) and
right-leg perimeter (p=0.043; r: −0.360), whereby the eyes-closed and right-leg perimeters
decreased as the MIDAS score increased.
DISCUSSION
Migraine patients often present with balance control disorders, besides vestibular
anomalies, auras and subclinical ischemic-like lesions[11],[12],[13]. The exact mechanism of balance disorders in migraine patients remains unknown.
Moreover, although balance disorders have been associated with subclinical cerebellar
or brainstem dysfunction[11],[14] and central vestibular dysfunction[11],[15],[16], migraine patients are considered to have a normal peripheral vestibular system[6]. On the other hand, central vestibular dysfunction may be associated with ischemia
of the labyrinth caused by vasospasm[17]. The CAMERA study (cerebral abnormalities in migraine, an epidemiological risk analysis)
reported that silent posterior circulation infarcts increased the prevalence of hyperintense
ischemic lesions in the brain stem and cerebellum in migraine patients, compared with
control subjects[12]. We emphasize that, in our view, coexistence of balance control disorders and the
pain associated with migraine episodes can have an adverse effect on the functional
abilities of patients.
In our study, the average number of laps in the dynamic balance test was lower among
migraine patients than among control subjects, which suggests that migraine patients
may have lower balance performance. Additionally, the average number of laps among
chronic migraine patients was lower than that of episodic migraine patients, which
implies that chronic migraine patients may have lower balance performance than episodic
migraine patients. On the other hand, no significant difference was found between
the patient groups and the control group, which does not support the balance disorder
hypothesis for migraine patients. To our knowledge, our study is the first of its
kind in the literature to investigate ATE in migraine patients.
No significant differences were found among our groups with regard to eyes-open and
eyes-closed area values. However, the area values were relatively higher in the episodic
and chronic migraine group than in the control group, which suggests that migraine
patients may have lower balance performance. Accordingly, we consider that larger
number of subjects are needed in order to obtain significant results for these parameters
in static balance tests.
Carvalho et al.[5] and Carvalho et al.[18] found significant differences between eyes-open and eyes-closed static balance measurements
conducted on a planar surface and those performed on a foam surface, with regard to
total area (cm2). These authors noted that the total area values measured on the foam surface were
found to be higher among migraine patients than among control subjects and were higher
among chronic migraine patients with aura than among migraine patients without aura.
In our study, the eyes-open and eyes-closed area values were significantly higher
among migraine patients than in the control group, while no significant difference
was found between patients with chronic and episodic migraine, with regard to total
area.
Ishizaki et al.[15] found no significant difference between patients with episodic tension-type headache
and control subjects, with regard to total distance (cm) of displacement of CoP measured
in static balance tests with eyes open and eyes closed. However, the total distance
of displacement with eyes closed was longer among migraine patients than in the control
group and the balance performances of the migraine patients were worse than those
of the control group. In our study, although no significant difference was found between
chronic and episodic migraine patients with regard to eyes-closed perimeter values,
the relatively higher perimeter values in the chronic group, compared with the episodic
group, suggests that chronic migraine patients might have exhibited lower balance
performance than the episodic migraine patients.
Carvalho et al. reported that total area values (cm2) measured in static balance tests using the right and left legs were both significantly
higher among migraine patients with aura than among migraine patients without aura[5]. In our study, however, no significant difference was found between the migraine
patients and the control group with regard to eyes-open right and left-leg area values,
while the left-leg area values were significantly higher among episodic migraine patients
than in the control group.
In our study, no significant correlation was found between VAS scores and eyes-open
and eyes-closed right and left-leg static balance measurements, among both the episodic
and the chronic migraine. Nevertheless, despite the absence of any significant correlation,
our study is of high value since, to our knowledge, no studies in the literature have
investigated the relationship between VAS scores and static balance measurements among
migraine patients.
Among our patients, MIDAS scores established a moderate negative correlation with
left-leg perimeter values in the episodic migraine group and established a moderate
negative correlation with right-leg perimeter values measured with eyes closed in
the chronic migraine group. In a similar way, our study is of high value since, to
our knowledge, no studies in the literature have investigated the relationship between
MIDAS scores and static balance measurements in migraine patients.
Carvalho et al. reported that the migraine patients had lower balance performance
than the control group and that the presence of aura and frequent migraine attacks
had an adverse effect on postural performance. These authors also noted that patients
with chronic migraine and aura exhibited lower balance performance, compared with
control subjects and migraine patients without aura[18]. Similarly, in our study, the eyes-closed right-leg perimeter values were significantly
higher among the chronic migraine patients than among the episodic migraine patients
and in the control group.
Akdal et al. evaluated 25 migraine patients without basilar migraine and vertigo (including
10 migraine patients with visual aura) and 25 control subjects and found significant
deterioration in balance parameters among migraine patients, compared with the control
group[14]. The same authors conducted a follow-up study with the same sample in the following
year and reported that the balance disorders had persisted among the migraine patients
and that some of the balance parameters had even deteriorated noticeably[16].
Our study was limited since it had a small patient population, the groups were not
sufficiently homogeneous, some patients were using prophylactic drugs that could have
affected their balance performance and the balance tests were performed during a pain-free
period rather than during a pain attack.
In conclusion, in the literature it is indicated that balance performance is typically
lower among migraine patients than among control subjects, and reviews of the literature
have indicated that no studies comparing balance performances between episodic and
chronic migraine patients had been conducted. In the present study, we made this comparison
of balance performances between episodic and chronic migraine patients. Although no
significant difference was found between chronic and episodic migraine patients and
control subjects, chronic migraine patients seemed to have lower balance performance
than episodic migraine patients. On the other hand, we also found that some of the
balance parameters examined in our study had not addressed in previous studies (i.e.
ATE, VAS and MIDAS). Further studies with larger numbers of patients are needed, in
order to investigate the relationship between these parameters and balance. We believe
that our results will shed light that future studies can build on.
