title: Reduction in perceived stress as a migraine trigger: testing the "let-down headache" hypothesis.
abstract: OBJECTIVE
  To test whether level of perceived stress and reductions in levels of perceived stress (i.e., "let-down") are associated with the onset of migraine attacks in persons with migraine.
  
  
  METHODS
  Patients with migraine from a tertiary headache center were invited to participate in a 3-month electronic diary study. Participants entered data daily regarding migraine attack experience, subjective stress ratings, and other data. Stress was assessed using 2 measures: the Perceived Stress Scale and the Self-Reported Stress Scale. Logit-normal, random-effects models were used to estimate the odds ratio for migraine occurrence as a function of level of stress over several time frames.
  
  
  RESULTS
  Of 22 enrolled participants, 17 (median age 43.8 years) completed >30 days of diaries, yielding 2,011 diary entries including 110 eligible migraine attacks (median 5 attacks per person). Level of stress was not generally associated with migraine occurrence. However, decline in stress from one evening diary to the next was associated with increased migraine onset over the subsequent 6, 12, and 18 hours, with odds ratios ranging from 1.5 to 1.9 (all p values < 0.05) for the Perceived Stress Scale. Decline in stress was associated with migraine onset after controlling for level of stress for all time points. Findings were similar using the Self-Reported Stress Scale.
  
  
  CONCLUSIONS
  Reduction in stress from one day to the next is associated with migraine onset the next day. Decline in stress may be a marker for an impending migraine attack and may create opportunities for preemptive pharmacologic or behavioral interventions.
authors.affiliation: From the Saul B. Korey Department of Neurology (R.B.L., D.C.B., C.B.H., T.A.D., T.M.B., B.M.G., S.R.H.) and Department of Epidemiology and Population Health (R.B.L., C.B.H.), Albert Einstein College of Medicine, Bronx; Montefiore Headache Center (R.B.L., D.C.B., T.A.D., B.M.G.), Bronx, NY; and Department of Community Medicine (H.T.), University of Connecticut School of Medicine, Farmington, CT.
authors.forename: Richard B
authors.initials: RB
authors.lastname: Lipton
authors.forename: Dawn C
authors.initials: DC
authors.lastname: Buse
authors.forename: Charles B
authors.initials: CB
authors.lastname: Hall
authors.forename: Howard
authors.initials: H
authors.lastname: Tennen
authors.forename: Tiffani A
authors.initials: TA
authors.lastname: Defreitas
authors.forename: Thomas M
authors.initials: TM
authors.lastname: Borkowski
authors.forename: Brian M
authors.initials: BM
authors.lastname: Grosberg
authors.forename: Sheryl R
authors.initials: SR
authors.lastname: Haut
mesh_terms: D000223:Adaptation, Psychological / Q000502:physiology; D001143:Arousal / Q000502:physiology; D001921:Brain / Q000503:physiopathology; D055991:Health Records, Personal; D006801:Humans; D007030:Hypothalamo-Hypophyseal System / Q000503:physiopathology; D008279:Magnetic Resonance Imaging; D008881:Migraine Disorders / Q000453:epidemiology* / Q000209:etiology* / Q000503:physiopathology / Q000523:psychology; D010913:Pituitary-Adrenal System / Q000503:physiopathology; D012307:Risk Factors; D013315:Stress, Psychological / Q000150:complications* / Q000453:epidemiology* / Q000503:physiopathology / Q000523:psychology