Postural control impairment in patients with headaches - A systematic review and meta-analysis
Creators: name: Carvalho, Gabriela
name: Becnel, Alena
name: Miske, Carolin
name: Szikszay, Tibor
name: Luedtke, Kerstin
Publisher: name: Open Science Framework
Year: 2022
Subjects: subject: Diseases
subject: Medicine and Health Sciences
subject: Rehabilitation and Therapy

description: Background Headache disorders are very prevalent, being experienced at least once by up to 90% of adults in a lifetime.(1,2) According to the World Health Organization (WHO), headaches are listed among the 10 most disabling conditions, and among the five among women.(3) They are generally benign and of short duration. However, when recurrent, they affect significantly the quality of life and productivity.(2) For this reason, the WHO considers headaches an underestimated, underrecognized and undertreated condition all through the world.(4) In 2018, the 3rd version of the International Headache Classification was published, describing over 200 headache types.(5) They are grouped in primary or secondary headaches, according to the symptom etiology. Primary headaches are considered the disease itself, where no defined etiology is defined. This includes migraine, tension-type headache, cluster and trigeminal autonomic headaches. Secondary headaches are defined as a symptom of a pre-existing condition, with remission of the headache concomitant with the pathology remission. They occur often due to a head or neck trauma, vessel complications in the head area, non-vascular intracranial complications, substance abuse or its withdrawal, infection, imbalance of homeostasis in the body, other pain conditions, and psychiatric complications.(5) A clear differentiation between headache types is not always possible, due to symptoms overlapping and because patients can experience more than one headache type at once. According to the Global Burden of Disease 2010, tension-type headache was established as the second most prevalent condition in the world (22%) and migraine close behind as the third (15%).(6) Comorbidities such as neck pain, vestibular symptoms and balance alterations are common among headaches.(7) It is estimated that more than half of migraineurs experience attacks associated with vertigo, dizziness or balance disturbances.(8) These symptoms are also described in cervicogenic (9) and tension type headaches(10, 11) arising from peripheral or central origin.(12) In migraine, it is speculated dizziness and balance impairment are due to the overlap between trigeminal and vestibular pathways(13,14,15) and cerebellar dysfunction.(16,17) In other headache types, such as cervicogenic and tension type headache, these symptoms may be related to the altered proprioceptive afferents from the neck to the brain.(18,19) Despite the emerging number of publications in the topic and potential clinical relevance in the management of headaches, the pooled evidence of balance impairment in this population has not been summarized so far. The purpose of this study is to systematically assess balance dysfunction among headache patients in comparison to controls. Methods This systematic review is conducted according to the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions(20) and reported according to the criteria of the PRISMA Statement.(21) Databases and search strategy Relevant computerized databases will be searched including CINAHL, Web of Science, and PubMed. Furthermore, the publications of scientific professional societies and reference lists will be used to verify possible further potentially eligible publications. The searches will not be limited by time-constraints. Two researchers will perform the search independently according to a defined MEDLINE strategy, in which MeSH keywords combinations are included (see below). Disagreement regarding included studies will be resolved through consulting a discussion until a third reviewer. The search results will be sorted and duplicates will be removed using Zotero. The structured search results will be presented in a flow diagram, as described by PRISMA-P guidelines.(21) Example of the utilized search strategy: (((Headache[Mesh]) OR Migraine Disorders[Mesh]) AND (((((Postural Balance[Mesh]) OR Musculoskeletal Equilibrium[Mesh]) OR Postural Control[Mesh]) OR Postural Equilibrium[Mesh]) OR Posture Control[Mesh]) OR Posturography[Mesh]). Eligibility Criteria Eligible studies will be selected according to the following inclusion and exclusion criteria, based on the PICO criteria. The target population of studies should be adults aging greater than 18 years old with headache diagnosed according to the International Classification of Headache Disorders, the Cervicogenic Headache International Study Group, or the Bárány Society. The studies must compare the target population to a headache-free control group. Any study outcome related to postural control and balance will be included. The following study designs will be considered in the present systematic review: case-control studies, observational studies and baseline data of cohort studies and clinical trials. Previously written systematic reviews, meta-analyses, literature reviews will be excluded from this review. Furthermore, exclusion criteria encompass the following: animal studies, case studies, population with concomitant headaches and comorbidities such as diagnosis of vestibular disease (i.e. Menière disease, BPPV, or basilar migraine). Studies where data is not available even after contacting the authors and papers not written in English will also be excluded. Risk of Bias Assessment The methodological quality of studies will be assessed through an adapted version of the Downs and Black Risk of Bias Checklist. (22) This scale will be adapted in order to exclude the items related to assess interventions. This procedure will be performed by two independent reviewers, with intercession of a third in case of disagreement. The level of bias will be calculated through a quality index, classifying the studies in low, moderate, or high-quality index. The quality index (QI) is calculated by dividing the sum of scores by the number of items. A QI &gt;75% indicates a low risk of bias, a QI from 75% to 50% is considered a moderate risk of bias, and a QI &lt;50% indicates a high risk of bias. The Cohen’s kappa coefficient will be computed to assess the agreement between all reviewers. (22) Data extraction and synthesis The outcomes based on static and dynamic balance tests will include computerized and non-computerized posturography, stabilometry, romberg test, gait tests and mobility tests, such as the timed up and go, tandem walk, sit-to-stand test, and step-up-and-over test. Data will be extracted in excel sheets and organized according to the headache type and outcome. The postural control outcomes will include center of pressure (COP) displacement (in degrees, mm or cm), displacement area (squared millimeters or centimeters) sway velocity (in millimeters per second,) step length and width during gait (in centimeters), and gait speed (measured in seconds or in cm per second). In case of missing data we will contact the study corresponding authors. After 2 weeks without a response a reminder email will be sent; and after 4 weeks with no response, the study will not be included in the review. Analysis Once the studies have been included and the outcome data has been extracted, the analysis will be executed according to the PRISMA Checklist Guidelines. (21) The study features will be highlighted and sorted according to the headache population and balance outcomes. A descriptive synthesis is planned for all included studies. If there are sufficient and homogeneous studies, a meta-analysis will be performed. Subgroup analysis according to the headache type will be performed when possible. Results and figures will be pooled using a random-effects model through the software Review Manager 5.4 (23). Heterogeneity among studies will be calculated and low heterogeneity will be considered when I2 is lower than 40%; I2 values between 40% and 60% indicate moderate heterogeneity; between 60% and 75% indicate substantial heterogeneity; and values greater than 75%, considerable heterogeneity. (Shamseer 2015) Post-hoc sensitivity analyses will be performed excluding studies with a moderate or high risk of bias (QI was lower than 75%). Differences between headache and controls will be considered significant when a significant overall effect is found (p &lt;0.05 and an I2 &lt;40%). Expected Results After considering several studies and performing a meta-analysis, we expect to verify whether patients with headaches have balance impairment or not, considering the static and dynamic balance tests outcome. Furthermore, it will be possible to verify differences of headache subtypes in contrast to controls. These results will shed light into the topic, summarizing the current evidence and collaborating to the clinical management of balance disorders in headache patients. Bibliography 1. Rasmussen BK, Jensen R, Schroll M, Olesen J. Epidemiology of headache in a general population—A prevalence study. Journal of Clinical Epidemiology. Januar 1991;44(11):1147–57. 2. Stovner L, Hagen K, Jensen R, Katsarava Z, Lipton R, Scher A, u. a. The Global Burden of Headache: A Documentation of Headache Prevalence and Disability Worldwide. Cephalalgia. März 2007;27(3):193–210. 3. Uygunoglu U, Siva A. Epidemiology of Headache. In: Mitsikostas DD, Paemeleire K, Herausgeber. Pharmacological Management of Headaches [Internet]. Cham: Springer International Publishing; 2016 [zitiert 10. Februar 2021]. S. 7–18. (Headache). Verfügbar unter: https://doi.org/10.1007/978-3-319-19911-5_2 4. 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