Chronic Migraine (CM) Patients Should Be Screened For Pseudobulbar Affect (PBA)

Presented at the International Headache Congress, hosted by the International Headache Society and the American Headache Society (June 27 - 30, 2013 in Boston, MA):

Chronic Migraine (CM) Patients Should Be Screened For Pseudobulbar Affect (PBA)

Daniel Kantor, MD

Objectives:

To report a case series of pseudobulbar affect (PBA) in patients with chronic migraine (CM).

Background:

Pseudobulbar affect (PBA) is an under-recognized neurologic condition characterized by uncontrollable, inappropriate outbursts of laughing and/or crying that are incongruous or disproportionate to the patient’s emotional state; PBA occurs secondary to a variety of neurologic conditions, but it has not previously been reported in patients with chronic migraine (CM).  CM shares many pathophysiological features with other diseases affecting the central nervous system, yet it was not included in the recent point-prevalence epidemiological data from the PBA Registry Series (PRISM) of 5,290 neurologic patients. PBA is screened for using the Center for Neurologic Studies – Lability Scale (CNS-LS), the first self-report measure of PBA to be established and validated; it consists of subscales for laughter (4 items) and for crying (3 items), with each item scored on a 5-point scale (1 = applies never; 5 = applies most of the time) for a total score ranging from 7 (no symptoms) to 35 (maximum). In the clinical trials leading to the FDA approval of fixed dose combination dextromethorphan/quinidine (DM/Q) for the treatment of PBA, more patients treated with placebo had headache than patients treated with DM/Q (15.6% vs 14.0%). This led to our use of DM/Q for the treatment of headache; we previously reported a patient with >20 year history of refractory chronic migraine who responded dramatically (reduction of headache frequency and severity) to DM/Q. It is unclear, however, whether the therapeutic effect of DM/Q in CM is due to its efficacy in PBA.

Methods:

Retrospective analysis of 5 consecutive chronic migraine (CM) patients, all of whom completed both the CNS-LS to screen for PBA symptoms and the Beck Depression Inventory -II (BDI-II) to screen for depression. The CNS-LS subscores for laughing and crying were also analyzed separately, as was the crying specific question of the BDI-II.

Results:

All 5 CM patients were women, between the age of 40 and 65 years (mean/median age = 50 years). The mean number of headache days per month was 26 and 4 patients met criteria for PBA (CNS-LS≥13), while the other patient had a CNS-LS = 12. Mean CNS-LS was 15 and median was 14. Mean BDI-II was 15 and median was 13. There appeared to be some correlation (Pearson coefficient, 0.54) between CNS-LS and BDI-II scores, but depression alone did not explain the presence of PBA. 

Conclusions:

PBA has not previously been described in patients with chronic migraine (without other underlying neurologic conditions, such as multiple sclerosis, amyotrophic lateral sclerosis, stroke, traumatic brain injury, parkinson’s diseases or Alzheimer’s dementia). This case series suggests that PBA (in addition to depression) should be screened for in patients with CM. Further research should be conducted to estimate the prevalence of PBA in CM patients and to ascertain whether the response of CM to DM/Q is independent of the effect of DM/Q on PBA.

References:

Kantor D. Dextromethorphan Plus Quinidine For Headache Prophylaxis: The First Case Report. Poster presented at: 137th Annual Meeting of the American Neurological Association; 2012 Oct 9-12; Boston, MA.

Moore SR, Gresham LS, Bromberg MB, et al.  A Self Report Measure of Affective Liability. J Neruol Neurosurg Psychol 1997;63:89-93.

Pioro EP, Brooks BR, Cummings J, et al; Safety, Tolerability, and Efficacy Results Trial of AVP-923 in PBA Investigators. Dextromethorphan plus ultra low-dose quinidine reduces pseudobulbar affect. Ann Neurol. 2010; 68:693-702

Smith RA, Berg JE, Pope LE, Callahan JD, Wynn D, Thisted RA. Validation of the CNS emotional lability scale for pseudobulbar affect (pathological laughing and crying) in multiple sclerosis patients. Mult Scler. 2004;10:1-7.