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Lee Peterlin, DO

Lee Peterlin received a medical degree from the Philadelphia College of Osteopathic Medicine in Pennsylvania. She completed a neurology residency and a neurophysiology fellowship at Pennsylvania State University College of Medicine’s Milton S. Hershey Medical Center in Hershey, Pennsylvania and a headache fellowship at Dartmouth-Hitchcock Medical Center in Lebanon, New Hampshire. Before joining the faculty at Johns Hopkins, Dr. Peterlin served as Director of the Drexel University College of Medicine’s Headache Clinic in Philadelphia, Pennsylvania.

Dr. Peterlin has published over 75 articles in the scientific literature, authored several book chapters, co-edited a handbook for primary care physicians on migraine (Menstrual Migraine, Oxford University Press, 2008), serves as an associate editor for Headache and is a member of the editorial board of Neurology. As a researcher, Dr. Peterlin has focused on advancing our understanding of the factors that influence the generation and progression of migraine and the identification of potential migraine biomarkers and drug targets. Her work has received grant support from the National Institutes of Health, the American Headache Society, and the Landenberger Foundation. Dr. Peterlin has lectured at multiple national and international medical conferences on topics related to headache. Additionally, she has been interviewed for articles in several magazines—including Cosmopolitan, Prevention, Shape, Weight Watchers, Reader’s Digest, and Women’s Day—as well as for television, radio and online outlets.

Dr. Peterlin is an active member of the American Headache Society (AHS), the International Headache Society, and the National Headache Foundation (NHF). She is the chair of the Southern Headache Society’s Education Committee, and the past chair of the Women’s Special Interest Section of the AHS. In 2009, Dr. Peterlin was awarded the NHF lectureship for her work on the relationship between migraine and obesity, and in 2013 was named one of Baltimore’s Top Doctors in Baltimore Magazine.

OVERVIEW

Migraine is comorbid with obesity. The prevalence of both episodic and chronic migraine is increased in individuals who are obese as compared to normal weight. In addition, the risk of migraine in those with obesity increases with increasing obesity status (ie. from overweight to obese to morbidly obese) and is strongest in those of reproductive age, (i.e. teens to 50 years of age).

There are several potential mechanisms for the migraine-obesity relationship. The hypothalamus controls the drive to feed and is activated during acute migraine attacks. Further, multiple bioactive substances, with receptors located in the hypothalamus and which regulate the drive to feed, are targeted by effective migraine therapies (e.g. serotonin). Additionally, several inflammatory proteins which are produced in adipocytes and which are modulated by weight changes, have been implicated in migraine pathophysiology (e.g. interleukin-6, adiponectin).

Both nonsurgical (e.g. diet, aerobic activity) and surgical weight loss strategies have been evaluated for migraine prevention. Limited data supports that a ketogenic diet or a diet high in omega 3 and low omega may be effective for migraine prevention. The evidence is stronger that supports aerobic exercise for migraine prevention. Finally several uncontrolled studies support that bariatric surgery is associated with a reduction in headache frequency in morbidly obese migraineurs. It remains unclear if any of these weight loss strategies are effective due to weight loss specifically.

Current recommendations for clinicians treating those with migraine include advocating that patients maintain a healthy weight and healthy lifestyle choices in terms of diet and exercise and to take particular care in the choice of medications prescribed to their patients, as many of these drugs can impact weight. While not indicated due to migraine, early data suggests bariatric surgery may provide headache relief in morbidly obese migraineurs who fulfill indications for bariatric surgery for other health reasons.

FULL REVIEWS

Chai NC, Scher AI, Moghekar A, Bond DS, Peterlin BL. Obesity and headache: Part I--a systematic review of the epidemiology of obesity and headache. Headache 2014, 54(2), 219-234.

Chai NC, Bond DS, Moghekar A, Scher AI, Peterlin BL. Obesity and headache: Part II--potential mechanism and treatment considerations. Headache 2014 Mar;54(3):459-71

Evans RW, Williams MA, Rapoport AM, Peterlin BL. The association of obesity with episodic and chronic migraine. Headache. 2012 Apr;52(4):663-71.

Peterlin BL, Rapoport AM, Kurth T. Migraine and obesity: epidemiology, mechanisms, and implications. Headache 2010;50:631–648.

Oakley CB, Scher AI, Recober A, Peterlin BL. Headache and obesity in the pediatric population. Curr Pain Headache Rep. 2014 May;18(5):416.

EPIDEMIOLOGY OF MIGRAINE AND OBESITY

Epidemiology Reviews

Chai NC, Scher AI, Moghekar A, Bond DS, Peterlin BL. Obesity and headache: Part I--a systematic review of the epidemiology of obesity and headache. Headache. 2014 54(2), 219-234.

Epidemiological Studies

Of Predominantly Reproductive Age (<50 years) Individuals

Peterlin BL, Rosso AL, Rapoport AM, Scher AI. Obesity and migraine: the effect of age, gender and adipose tissue distribution. Headache. 2010 Jan;50(1):52-62.

Vo M, Ainalem A, Qiu C, Peterlin BL, Aurora SK, Williams MA. Body mass index and adult weight gain among reproductive age women with migraine. Headache 2011;51:559–569.

Brown WJ, Mishra G, Kenardy J, Dobson A. Relationships between body mass index and well-being in young australian women. International Journal of Obesity and Related Metabolic Disorders. 2000. 24(10), 1360-1368.

Scher AI, Stewart WF, Ricci JA, Lipton RB. Factors associated with the onset and remission of chronic daily headache in a population-based study. Pain. 2003. 106(1-2), 81-89.

Bigal ME, Liberman JN, Lipton RB. Obesity and migraine: a population study. Neurology. 2006 Feb 28;66(4):545-50.

Bigal ME, Lipton RB Obesity is a risk factor for transformed migraine but not chronic tension-type headache. Neurology. 2006. 67(2), 252-257.

Ford ES, Li C, Pearson WS, Zhao G, Strine TW, Mokdad, AH. Body mass index and headaches: Findings from a national sample of US adults. Cephalalgia. 2008. 28(12), 1270-1276

Peterlin BL , Rosso AL,Williams MA, Rosenberg JR , Haythornthwaite JA , Merikangas KR , Gottesman RF , Bond DS,He JP, Zonderman AB . Episodic migraine and obesity and the influence of age, race, and sex. Neurology. 2013. 81(15), 1314-1321.

Robberstad L, Dyb G, Hagen K, Stovner LJ, Holmen TL, Zwart JA. An unfavorable lifestyle and recurrent headaches among adolescents: The HUNT study. Neurology. 2010. 75(8), 712-717.

Ornello R, Ripa P, Pistoia F, Degan D, Tiseo C, Carolei A, Sacco S. Migraine and body mass index categories: A systematic review and meta-analysis of observational studies. The Journal of Headache and Pain. 2015. 16, 27-015-0510-z.

Winsvold BS, Hagen K, Aamodt AH, Stovner LJ, Holmen J, Zwart JA. (2011). Headache, migraine and cardiovascular risk factors: The HUNT study. European Journal of Neurology, 18(3), 504-511.

Of Predominantly Older Individuals (50+ years) Individuals

Peterlin BL, Rosso AL, Rapoport AM, Scher AI. Obesity and migraine: the effect of age, gender and adipose tissue distribution. Headache. 2010 Jan;50(1):52-62.

Mattsson P. Migraine headache and obesity in women aged 40-74 years: a population-based study. Cephalalgia. 2007 Aug;27(8):877-80. Epub 2007 Jul 17.

Keith SW, Wang C, Fontaine KR, Cowan CD, Allison DB. BMI and headache among women: Results from 11 epidemiologic datasets. Obesity. 2008. 16(2), 377-383.

Peterlin BL , Rosso AL,Williams MA, Rosenberg JR , Haythornthwaite JA , Merikangas KR , Gottesman RF , Bond DS,He JP, Zonderman AB. Episodic migraine and obesity and the influence of age, race, and sex. Neurology. 2013. 81(15), 1314-1321.

Winter AC, Berger K, Buring JE, Kurth T. Body mass index, migraine, migraine frequency and migraine features in women. Cephalalgia. 2009 Feb;29(2):269-78

Winter AC, Wang L, Buring JE, Sesso HD, Kurth T. Migraine, weight gain and the risk of becoming overweight and obese: A prospective cohort study . Cephalalgia. 2012. 32(13), 963-971.

POTENTIAL MECHANISMS

Reviews

Peterlin BL, Sacco S, Bernecker C, Scher AI. Adipokines and Migraine: A Systematic Review. Headache. 2016 Apr;56(4):622-44.

Chai NC, Bond DS, Moghekar A, Scher AI, Peterlin BL. Obesity and headache: Part II--potential mechanism and treatment considerations. Headache. 2014 Mar;54(3):459-71

Recober A, Peterlin BL. Migraine and obesity: moving beyond BMI. Future Neurol. 2014 Jan 1;9(1):37-40.

Peterlin BL, Bigal ME, Tepper SJ, Urakaze M, Sheftell FD, Rapoport, AM. Migraine and adiponectin: Is there a connection? Cephalalgia. 2007. 27(5), 435-446.

Hypothalamus

Denuelle M, Fabre N, Payoux P, Chollet F, Geraud G. Hypothalamic activation in spontaneous migraine attacks. Headache. 2007 Nov-Dec;47(10):1418-26

Fox AW, Davis RL. Migraine Chronobiology. Headache. 1998;38:436-441.

Kellman L. The triggers or precipitants of the acute migraine attack. Cephalalgia 2007;27:394-402

Turner DP, Smitherman TA, Penzien DB, Porter JA, Martin VT, Houle TT. Nighttime snacking, stress, and migraine activity. J of Clin NeuroSci 2014;21:638-643

Adipocytokines

Peterlin BL, Sacco S, Bernecker C, Scher AI. Adipokines and Migraine: A Systematic Review. Headache. 2016 Apr;56(4):622-44.

Berilgen MS, Bulut S, Gonen M, Tekatas A, Dag E, Mungen B. Comparison of the effects of amitriptyline and flunarizine on weight gain and serum leptin, C peptide and insulin levels when used as migraine preventive treatment. Cephalalgia. 2005. 25(11), 1048-1053.

Guldiken B, Guldiken S, Demir M, Turgut N, Tugrul A. Low leptin levels in migraine: A case control study. Headache. 2008., 48(7), 1103-1107.

Peterlin BL, Tietjen GE, Gower BA, Ward TN, Tepper SJ, White LW, Dash PD, Hammond ER, Haythornthwaite JA. Ictal adiponectin levels in episodic migraineurs: a randomized pilot trial. Headache. 2013 Mar;53(3):474-90

Chai NC, Gelaye B, Tietjen GE, Dash PD, Gower BA, White LW, Ward TN, Scher AI, Peterlin BL. Ictal adipokines are associated with pain severity and treatment response in episodic migraine. Neurology. 2015. 84(14), 1409-1418.

Duarte H, Teixeira AL, Rocha NP, Domingues RB. Increased serum levels of adiponectin in migraine. Journal of the Neurological Sciences. 2014. 342(1-2), 186-188.

Hirfanoglu T, Serdaroglu A, Gulbahar O, Cansu A. Prophylactic drugs and cytokine and leptin levels in children with migraine. Pediatr Neurol. 2009;41:281-287.

Ligong Z, Jinjin Q, Chunfu C, Congcong L, Xiaojun D. Effect of obesity and leptin level on migraineurs. Med Sci Monit. 2015; 21:3270-3274.

Peterlin BL, Alexander G, Tabby D, Reichenberger, E. Oligomerization state-dependent elevations of adiponectin in chronic daily headache. Neurology. 2008. 70(20), 1905-1911.

Cytokines

Rozen T, Swidan SZ. Elevation of CSF tumor necrosis factor alpha levels in new daily persistent headache and treatment refractory chronic migraine. Headache. 2007. 47(7), 1050-1055.

Sarchielli P, Alberti A, Baldi A, Coppola F, Rossi C, Pierguidi L, Floridi A, Calabresi P. Proinflammatory cytokines, adhesion molecules, and lymphocyte integrin expression in the internal jugular blood of migraine patients without aura assessed ictally. Headache . 2006 Feb;46(2):200-7.

Orexin

Holland PR, Akerman S, Goadsby PJ. Orexin 1 receptor activation attenuates neurogenic dural vasodilation in an animal model of trigeminovascular nociception. The Journal of Pharmacology and Experimental Therapeutics. 2005. 315(3), 1380-1385.

Holland PR, Akerman S, Goadsby PJ. Modulation of nociceptive dural input to the trigeminal nucleus caudalis via activation of the orexin 1 receptor in the rat. The European Journal of Neuroscience. 2006. 24(10), 2825-2833.

Sarchielli P, Rainero I, Coppola F, Rossi C, Mancini M, Pinessi L, Calabresi P. Involvement of corticotrophin-releasing factor and orexin-A in chronic migraine and medication-overuse headache: Findings from cerebrospinal fluid. Cephalalgia. 2008. 28(7), 714-722.

TREATMENT CONSIDERATONS

Diet

Bic Z, Blix GG, Hopp HP, Leslie FM, Schell MJ. The influence of a low-fat diet on incidence and severity of migraine headaches. Journal of Women's Health & Gender-Based Medicine. 1999. 8(5), 623-630.

Di Lorenzo C, Coppola G, Sirianni G, Di Lorenzo G, Bracaglia M, Di Lenola D, Siracusano A, Rossi P, Pierelli F. Migraine improvement during short lasting ketogenesis: a proof-of-concept study. Eur J Neurol . 2015 Jan;22(1):170-7.

Kossoff EH, Huffman J, Turner Z, Gladstein J. Use of the modified Atkins diet for adolescents with chronic daily headache. Cephalalgia. 2010 Aug;30(8):1014-6

Maggioni F, Margoni M, Zanchin G. Ketogenic diet in migraine treatment: A brief but ancient history. Cephalalgia. 2011. 31(10), 1150-1151.

Ramsden CE, Faurot KR, Zamora D, Suchindran CM, Macintosh BA, Gaylord S, Mann JD. Targeted alteration of dietary n-3 and n-6 fatty acids for the treatment of chronic headaches: A randomized trial. Pain. 2013. 154(11), 2441-2451.

Peterlin BL. Diet and Migraine. In: The Ketogenic and Modified Atkins Diets:Treatments for Epilepsy and Other Disorders. Eds. Kossof EH, Turner Z, Doerr, Cervenka MC, Henry BJ. Demos medical Publishing NY, NY 2016; p 265-272 (Note: This book chapter is geared towards patients.)

Exercise

Varkey E, Cider A, Carlsson J, Linde M. A study to evaluate the feasibility of an aerobic exercise program in patients with migraine. Headache. 2009. 49(4), 563-570.

Bond DS, Thomas JG, O'Leary KC, Lipton RB, Peterlin BL, Roth J, Wing RR. Objectively measured physical activity in obese women with and without migraine. Cephalalgia. 2015. 35(10), 886-893.

Darabaneanu S, Overath CH, Rubin D, Lüthje S, Sye W, Niederberger U, Gerber WD, Weisser B. Aerobic exercise as a therapy option for migraine: a pilot study. Int J Sports Med. 2011; 32(6):455–460.

Dittrich SM, Gunther V, Franz G, Burtscher M, Holzner B, Kopp M. Aerobic exercise with relaxation: Influence on pain and psychological well-being in female migraine patients. Clin J Sport Medical. 2008;18:363-365.

Koseoglu E, Akboyraz A, Soyuer A, Ersoy AO. Aerobic exercise and plasma beta endorphin levels in patients with migrainous headache without aura. Cephalalgia. 2003. 23(10), 972-976.

Narin SO, Pinar L, Erbas D, Ozturk V, Idiman F. The effects of exercise and exercise-related changes in blood nitric oxide level on migraine headache. Clin Rehabil. 2003; 17(6):624–630.

Robberstad L, Dyb G, Hagen K, Stovner LJ, Holmen TL, Zwart JA. An unfavorable lifestyle and recurrent headaches among adolescents: The HUNT study. Neurology. 2010;75:712-717

Verrotti A, Agostinelli S, D'Egidio C, Di Fonzo A, Carotenuto M, Parisi P, Battistella PA. Impact of a weight loss program on migraine in obese adolescents. European Journal of Neurology. 2013. 20(2), 394-397.

Wöber C, Brannath W, Schmidt K, Kapitan M, Rudel E, Wessely P, Wöber-Bingöl C; PAMINA Study Group. Prospective analysis of factors related to migraine attacks: The PAMINA study. Cephalalgia. 2007;27:304-314.

Bariatric Surgery

Peterlin BL. Bariatric surgery in obese migraineurs: mounting evidence but important questions remain. Cephalalgia. 2011 Oct;31(13):1333-5

Bond DS, Vithiananthan S, Nash JM, Thomas JG, Wing RR. Improvement of migraine headaches in severely obese patients after bariatric surgery. Neurology. 2011; 76(13):1135–1138.

Gunay Y, Jamal M, Capper A, Eid A, Heitshusen D, Samuel I. Rouxen-Y gastric bypass achieves substantial resolution of migraine headache in the severely obese: 9-year experience in 81 patients. Surg Obes Relat Dis. 2013; 9(1):55–62.

Novack V, Fuchs L, Lantsberg L, Kama S, Lahoud U, Horev A, Ifergane G. (2011). Changes in headache frequency in premenopausal obese women with migraine after bariatric surgery: A case series. Cephalalgia. 2011. 31(13), 1336-1342.

Behavioural/Psychiatric Consideratons

Bond DS , Buse DC,Lipton RB,Thomas JG,Rathier L,Roth J,Pavlovic JM,Evans EW, Wing RR. Clinical Pain Catastrophizing in Women With Migraine and Obesity. Headache. 2015 Jul-Aug;55(7):923-33.

Pharmacological Considerations

Schutt M, Brinkhoff J, Drenckhan M, Lehnert H, Sommer C. Weight reducing and metabolic effects of topiramate in patients with migraine--an observational study. Experimental and Clinical Endocrinology & Diabetes : Official Journal, German Society of Endocrinology [and] German Diabetes Association. 2010. 118(7), 449-452.

Taylor FR. Weight change associated with the use of migraine-preventive medications. Clinical Therapeutics. 2008. 30(6), 1069-1080.

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