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Behavior of Ambulatory Blood Pressure Surrounding Episodes of Headache in Mildly Hypertensive Patients
Miguel Gus, MD, PhD;
Flávio Danni Fuchs, MD, PhD;
Maurício Pimentel, MD;
Daniela Rosa, MD;
Alex Gules Melo, MD;
Leila Beltrami Moreira, MD, PhD
Arch Intern Med. 2001;161:252-255.
ABSTRACT
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Background Headache is usually associated with high blood pressure (BP) despite
the lack of evidence of such an association in most observational studies.
Ambulatory BP monitoring provides an opportunity to analyze this relation
because it permits measurement of BP before, during, and after episodes of
headache.
Methods We evaluated 76 patients with mild hypertension who underwent clinical
evaluation, ambulatory BP monitoring, and questioning about the occurrence
of headache and its characteristics during monitoring. The 24-hour BP curves
of patients with and without headache during monitoring were compared using
analysis of variance for multiple factors and repeated measurements. Hourly
averages of BP surrounding the episode and 24-hour mean BP of patients with
headache were compared using paired sample t tests.
Results Twenty-five participants (33%) experienced headache during monitoring.
Their 24-hour BP curves did not differ from those of participants without
headache. Mean 24-hour BP was not different from BP registered during the
episode of headache (mean ± SD systolic BP: 137.0 ± 17.3 vs
139.4 ± 21.1; P = .13; diastolic BP: 83.3
± 12.8 vs 85.0 ± 18.2; P = .30). Blood
pressure values registered during the episode of headache and in the hours
before and after the episode were not different from each other. Analysis
restricted to 8 patients with migrainelike headache showed a similar pattern.
Conclusions In patients with mild hypertension, there is no association between
the occurrence of headache and variation of BP. Health professionals must
discourage patients with hypertension from believing that they can rely on
the presence of such a symptom to know about their BP levels.
INTRODUCTION
THE 1997 report from the Joint National Committee1
identified a decline in the identification, treatment, and control of hypertension
in the United States in recent years, a situation that may have a worldwide
dimension.2, 3, 4 Identification
of individuals unaware of the diagnosis of hypertension or of its degree of
control by patients with hypertension persists as a challenge to policies
about cardiovascular disease prevention. The characterization that a symptom
is associated with the elevation of blood pressure (BP) before the development
of signs of target organ damage would be useful for the recognition of individuals
with undiagnosed or uncontrolled hypertension. Of various symptoms, headache
is still the most frequently associated with high BP levels,5, 6, 7
despite the absence of such an association in most studies.8, 9, 10, 11, 12, 13
The design of these studies, however, does not rule out an association between
the occurrence of headache and elevation of BP because they measure cross
sectionally the symptom and BP levels11, 13
or are based on a retrospective history of headache10, 12
or BP levels.8, 9 The direction
of an eventual association is not established because BP could cause the symptom
or vice versa. Despite these controversial issues, mechanisms linking the
elevation of BP to the occurrence of headache are still reported.14
Ambulatory BP (ABP) monitoring provides a unique opportunity to analyze
the relation between headache and variation of BP because it can register
BP before, during, and after episodes of headache. In this study we demonstrate
that BP does not differ significantly between hypertensive patients with and
without headache during 24-hour ABP monitoring and does not vary in the period
surrounding episodes of tension-type or migrainelike headache.
PATIENTS AND METHODS
A prospectively planned cohort study of patients with hypertension is
under way in the hypertension clinic of the Divisions of Cardiology and Clinical
Pharmacology of the Hospital de Clínicas de Porto Alegre, Porto Alegre,
Brazil. Some results have been reported elsewhere.15, 16, 17, 18
During baseline evaluation, patients answer an extensive questionnaire and
undergo a detailed physical examination. Classification of their BP is based
on the average of 6 BP measurements taken at 3 different visits. The diagnosis
of hypertension and its classification are established during the first visit
when BP is within the reference range, in patients with severe hypertension,
and in patients with clinical consequences of high BP.
The study sample consists of patients who underwent the initial evaluation
plus 24-hour ABP monitoring and who answered a detailed questionnaire about
the occurrence and characteristics of headache during the examination. None
had secondary hypertension or evidence of severe target organ damage. Monitoring
of ABP was done with a SpaceLabs 90702 device (SpaceLabs Medical Inc, Redmond,
Wash). A large cuff was used on patients with an arm circumference greater
than 33 cm. For analysis, the daytime period was considered to be from 7 AM
to 11 PM (with measurements taken every 15 minutes), and the nighttime period
was from 11 PM to 7 AM (with measurements taken every 20 minutes). Patients
were oriented to go to bed around 11 PM. Participants were considered dippers
if they had a reduction in mean systolic and diastolic BP values of more than
10% from day to night. Blood pressure load was defined as the percentage of
measurements higher than 140/90 mm Hg during the daytime period and higher
than 120/80 mm Hg during the nighttime period.
The questionnaire about the occurrence of headache during BP monitoring
included identification of the moment of beginning, length, and characteristics
of the episodes. The symptom was considered to be a migrainelike headache
if there were at least 2 of the following characteristics: unilateral occurrence,
pulsating, moderate to severe intensity (disturbing or precluding daily activities),
or episodes aggravated by movement.19 If these
criteria were not fulfilled the episode was classified as tension-type headache.
Only episodes that lasted longer than 60 minutes were analyzed. The first
episode was considered for analysis when multiple episodes occurred during
monitoring. Other anthropometric and medical data were obtained from the baseline
database of the cohort.
Blood pressure and other continuous variables in patients with and without
headache were compared using the t test for independent
samples. Analysis of variance for multiple factors (presence or absence of
headache during monitoring) and repeated measurements (hourly averages) were
used to compare systolic and diastolic ABP in patients with and without headache
during the examination. Hourly average BP levels surrounding the episode of
headache (1 and 2 hours before, during, and 1 and 2 hours after the episode)
and 24-hour mean BP levels were compared using paired sample t tests.
RESULTS
Twenty-five (33%) of 76 patients reported the occurrence of headache
during 24-hour ABP monitoring. The average length of the episodes was 120
± 51 minutes. Three patients experienced the index episode during the
dawn, 10 in the morning, 6 in the afternoon, and 6 in the evening. Table 1 shows that the groups with and
without headache did not differ regarding several characteristics except that
more women had headaches. About 60% of patients in both groups were using
antihypertensive drugs. The 24-hour ABP curves did not differ significantly
between the 2 groups (Figure 1),
although patients with headache had higher absolute values in the periods
near installation and removal of the device. The proportion of dippers and
BP loads did not differ between the 2 groups.
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Table 1. Characteristics of 76 Patients With and Without Headache During
ABP Monitoring*
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Figure 1. The 24-hour ambulatory blood pressure
curves of patients with and without headache. Error bars represent SEM.
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Mean systolic and diastolic BP values during the 24-hour period and
during the episodes of headache in 25 patients with the symptom were not different
(Table 2). Hourly average BP values
1 hour before, during, and 1 hour after the symptom and the first measurement
taken during the symptom were not different from each other. The overall behavior
of systolic and diastolic BP in the hours surrounding the episode of headache
is shown in Figure 2.
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Table 2. Comparison of Blood Pressure Values in Different Periods Surrounding
an Episode of Headache During ABP Monitoring in 25 Patients*
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Figure 2. Systolic and diastolic blood pressure
headache before, during, and after episodes of headache (n = 20). Error bars
represent SEM.
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Eight patients (10% of the whole sample) had migrainelike headache.
Their BP during the episode and in the hour preceding it did not differ from
their 24-hour average BP (Table 3).
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Table 3. Comparison of Blood Pressure Values in Different Periods Surrounding
an Episode of Migrainelike Headache in 8 Patients*
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COMMENT
Most observational studies8, 9, 10, 11, 12, 13
have not confirmed the hypothesis that there is a relation between headache
and chronic hypertension. It seems that the association detected in a few
studies20, 21, 22 might
be artifactual because BP is more likely to be measured in patients with headache.23, 24
The possibility of any relation between headache and the variation of
BP seems to be low.25 Results of studies26 conducted for several years confirmed that the aura
phase of migraine is associated with a reduction in cerebral blood flow, although
the progression of oligemia across the cortex does not respect vascular territories,
and, therefore, it is unlikely to be primarily a vasospastic phenomenon. Recently,
images of positron emission tomography during a migraine attack without aura
open up the possibility that blood flow changes might occur in migraine with
and without aura.27 Vascular changes during
migraine are epiphenomena, secondary to neurogenic mechanisms. Depolarization
of trigeminal ganglion or its perivascular nerve terminals activates the trigeminovascular
system, giving rise to central transmission of nociceptive information and
retrograde perivascular release of powerful vasoactive neuropeptides. The
consequences would be dural vasodilation mediated by calcitonin gene-related
peptide and dural plasma extravasation mediated by neurokinin A and substance
P from trigeminal C-fibers.28
Tension type is the most common type of headache in population surveys.
Rasmussen et al19 identified a prevalence of
79% of the symptom in adults lifelong. The relation between this kind of headache
and hypertension could be explained by a common pathophysiological mechanism.
Traditionally, tension-type headache was thought to be caused by contraction
of skeletal muscles of the head and neck that might induce ischemia, generating
a vascular component of headache,25 a hypothesis
that has been discharged.29 Electromyographic
studies have shown more muscle contraction with migraine than with tension-type
headache.25
The absence of a primary vascular pathophysiological mechanism that
could justify the relation between headache and the variation of BP is a consistent
explanation for our results. Blood pressure did not differ between mildly
hypertensive patients with and without headache during 24-hour ABP monitoring.
Systolic and diastolic BP values in the periods surrounding the episodes of
headache were not different from each other and from the 24-hour ABP average.
This happened in patients with tension-type and migrainelike headache, but
the small number of patients with migrainelike symptoms precludes a conclusive
interpretation about the relation between BP and migraine.
To our knowledge, this is the first time that the absence of an association
between variation of BP and the occurrence of episodes of headache was recorded
with this observational design. Among its strengths are the possibility to
measure, in a masked fashion, BP several times during the day and, especially,
to evaluate the behavior of BP in the hours preceding, accompanying, and following
the episode of headache. In general, our results agree with those obtained
in studies with other designs.8, 9, 10, 11, 12, 13
The nature of our sampling criteria should be taken in account before
generalizing our findings. Because we studied only patients with mild hypertension,
we cannot extend our findings to patients with more severe forms of hypertension.
Also, our data do not compare the incidence of headache in normotensive and
hypertensive individuals because all participants were hypertensive.
The fact that patients with headache tended to have higher BP levels
near the periods of installation and withdrawal of the device might be because
of an exaggerated alert reaction presented by them. Anxiety could be the common
mechanism to explain the occurrence of headache and the alert reaction in
these patients.
Textbooks and reviews5, 6, 7, 30
still present headache as a symptom of hypertension or of some of its presentation.
The Headache Classification Committee of the International Headache Society31 states that chronic arterial hypertension of mild
or moderate degrees does not cause headache but does not comment about whether
this is the case in patients with severe hypertension. The classification
considers that headache can be caused by elevation of BP in 4 situations:
acute pressure response to an exogenous agent, pheochromocytoma, malignant
hypertension, and preeclampsia and eclampsia.
The inconsistency in the literature about the relation of these 2 prevalent
situations, hypertension and headache, has created some myths among patients.
Cantillon et al32 reported that at least 50%
of 102 patients with hypertension believed that they could tell when their
BP was elevated based in the presence of symptoms, such as headache. Most
of them (86%), however, could not accurately predict their BP.
In conclusion, our findings show that in patients with mild hypertension
there is no association between headache, classified as tension type or migrainelike,
and BP. Health professionals must discourage patients with hypertension from
believing that they can rely on the presence of such a symptom to know about
their BP levels.
AUTHOR INFORMATION
Accepted for publication July 20, 2000.
This work was supported in part by grants from Fundação
de Amparo a Pesquisa do Rio Grande do Sul (98/1628.9), Porto Alegre, and Conselho
Nacional de Pesquisa (300458/98-3), Brasília, Brazil.
From the Divisions of Cardiology (Drs Gus and Fuchs) and Clinical Pharmacology
(Drs Fuchs, Pimental, Rosa, Melo, and Moreira), Hospital de Clínicas
de Porto Alegre; and Instituto de Cardiologie (Dr Gus), Porto Alegre, Brazil.
Reprints: Flávio Danni Fuchs, MD, PhD, Serviço de Cardiologia,
Hospital de Clínicas de Porto Alegre, Ramiro Barcelos, 2350, 90.035-003,
Porto Alegre, RS, Brazil.
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