title: Causality and headache triggers.
abstract: OBJECTIVE
  The objective of this study was to explore the conditions necessary to assign causal status to headache triggers.
  
  
  BACKGROUND
  The term "headache trigger" is commonly used to label any stimulus that is assumed to cause headaches. However, the assumptions required for determining if a given stimulus in fact has a causal-type relationship in eliciting headaches have not been explicated.
  
  
  METHODS
  A synthesis and application of Rubin's Causal Model is applied to the context of headache causes. From this application, the conditions necessary to infer that 1 event (trigger) causes another (headache) are outlined using basic assumptions and examples from relevant literature.
  
  
  RESULTS
  Although many conditions must be satisfied for a causal attribution, 3 basic assumptions are identified for determining causality in headache triggers: (1) constancy of the sufferer, (2) constancy of the trigger effect, and (3) constancy of the trigger presentation. A valid evaluation of a potential trigger's effect can only be undertaken once these 3 basic assumptions are satisfied during formal or informal studies of headache triggers.
  
  
  CONCLUSIONS
  Evaluating these assumptions is extremely difficult or infeasible in clinical practice, and satisfying them during natural experimentation is unlikely. Researchers, practitioners, and headache sufferers are encouraged to avoid natural experimentation to determine the causal effects of headache triggers. Instead, formal experimental designs or retrospective diary studies using advanced statistical modeling techniques provide the best approaches to satisfy the required assumptions and inform causal statements about headache triggers.
authors.affiliation: Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC 27157, USA. daturner@wakehealth.edu
authors.forename: Dana P
authors.initials: DP
authors.lastname: Turner
authors.forename: Todd A
authors.initials: TA
authors.lastname: Smitherman
authors.forename: Vincent T
authors.initials: VT
authors.lastname: Martin
authors.forename: Donald B
authors.initials: DB
authors.lastname: Penzien
authors.forename: Timothy T
authors.initials: TT
authors.lastname: Houle
mesh_terms: D006261:Headache / Q000209:etiology*; D006801:Humans; D008962:Models, Theoretical; D015985:Precipitating Factors
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