Next Article in Journal
Co-Production at Work: The Process of Breaking Up Sitting Time to Improve Cardiovascular Health. A Pilot Study
Previous Article in Journal
Contamination of Fresh Produce with Antibiotic-Resistant Bacteria and Associated Risks to Human Health: A Scoping Review
 
 
Search for Articles:
Title / Keyword
Author / Affiliation / Email
Journal
Article Type
 
 
Advanced Search
 
Section
Special Issue
Volume
Issue
Number
Page
 
Journals
IJERPH
Volume 19
Issue 1
10.3390/ijerph19010362
ijerph-logo
Submit to this Journal Review for this Journal Propose a Special Issue
► Article Menu

Article Menu

share Share announcement Help format_quote Cite question_answer Discuss in SciProfiles thumb_up
...
Endorse textsms
...
Comment
first_page
settings
Order Article Reprints
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:
Background:
Article

Migraine Headaches after Major Surgery with General or Neuraxial Anesthesia: A Nationwide Propensity-Score Matched Study

by
Chung-Yi Liao
1,2,
Chun-Cheng Li
1,2,
Hsin-Yi Liu
1,2,
Jui-Tai Chen
1,2,
Yih-Giun Cherng
1,2,
Tzeng-Ji Chen
3,4,
Ying-Xiu Dai
4,5,
Hsiang-Ling Wu
4,6,
Wan-Chi Liu
1,2,* and
Ying-Hsuan Tai
1,2,*
1
Department of Anesthesiology, Shuang Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan
2
Department of Anesthesiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
3
Department of Family Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan
4
School of Medicine, National Yang Ming Chiao Tung University, Taipei 11221, Taiwan
5
Department of Dermatology, Taipei Veterans General Hospital, Taipei 11217, Taiwan
6
Department of Anesthesiology, Taipei Veterans General Hospital, Taipei 11217, Taiwan
*
Authors to whom correspondence should be addressed.
Int. J. Environ. Res. Public Health 2022, 19(1), 362; https://doi.org/10.3390/ijerph19010362
Submission received: 16 November 2021 / Revised: 22 December 2021 / Accepted: 28 December 2021 / Published: 30 December 2021
(This article belongs to the Section Public Health Statistics and Risk Assessment)
Browse Figure
Versions Notes

Abstract

:
Migraine headaches can be provoked by surgical stress and vasoactive effects of anesthetics of general anesthesia in the perioperative period. However, it is unclear whether general anesthesia increases the migraine risk after major surgery. Incidence and risk factors of postoperative migraine are also largely unknown. We utilized reimbursement claims data of Taiwan’s National Health Insurance and performed propensity score matching analyses to compare the risk of postoperative migraine in patients without migraine initially who underwent general or neuraxial anesthesia. Multivariable logistic regressions were applied to calculate the adjusted odds ratio (aOR) and 95% confidence interval (CI) for migraine risk. A total of 68,131 matched pairs were analyzed. The overall incidence of migraine was 9.82 per 1000 person-years. General anesthesia was not associated with a greater risk of migraine compared with neuraxial anesthesia (aORs: 0.93, 95% CI: 0.80–1.09). This finding was consistent across subgroups of different migraine subtypes, uses of migraine medications, and varying postoperative periods. Influential factors for postoperative migraine were age (aOR: 0.99), sex (male vs. female, aOR: 0.50), pre-existing anxiety disorder (aOR: 2.43) or depressive disorder (aOR: 2.29), concurrent uses of systemic corticosteroids (aOR: 1.45), ephedrine (aOR: 1.45), and theophylline (aOR: 1.40), and number of emergency room visits before surgery. There was no difference in the risk of postoperative migraine between surgical patients undergoing general and neuraxial anesthesia. This study identified the risk factors for postoperative migraine headaches, which may provide an implication in facilitating early diagnoses and treatment.

1. Introduction

Migraine is a complex neurovascular disorder that affects an estimated 15% of people worldwide [1,2]. Despite the recent advances in diagnosis and treatment, migraine remains the second leading cause of disability globally and accounts for the financial costs of USD 23 billion and more than EUR 50 billion in the USA and Europe, respectively [1,2].
Surgical patients are predisposed to migraine headaches due to stress, mental tension, and bright lights in the perioperative period [3,4]. Postoperative migraine headaches can cause emotional distress, induce sleep disorders, and impair health-related quality of life in surgical patients [1,2]. In addition, studies showed that patients with migraine have increased risks of some perioperative complications, including postoperative nausea and vomiting, ischemic stroke, and rehospitalization [5,6]. A prospective cohort study showed that the diagnosis of migraine was significantly associated with increased long-term risks of major cardiovascular diseases and cardiovascular mortality in women [7]. More efforts are needed to implement and improve migraine diagnosis and care in the postoperative period.
One of the theories of migraine pathogenesis is stimuli from vasodilation in intracranial arteries (mainly the branches of the middle meningeal artery), which are innervated by trigeminal nerve, to nociceptors in arterioles [8,9]. In animal studies, volatile anesthetics were found to have a vasodilatory effect on meningeal arterioles [10,11], and this effect may serve as a trigger of migraine after general anesthesia. By contrast, some studies reported the use of Propofol as the treatment of refractory migraine [12,13]. The overall effect of general anesthesia on the precipitation of migraine is poorly understood so far.
Cases studies have proposed that general anesthesia and opioids may be related to the development of postoperative migraine headaches [14,15,16,17,18]. Although several risk factors were reported for postoperative headache, it remains unclear whether general anesthesia increases the risk of postoperative migraine compared with other forms of anesthesia [3,19,20,21]. In addition, risk factors for postoperative migraine episodes are also largely unknown in current literature. The diagnosis of perioperative migraine can be difficult and complicated to establish if clinicians are unable to identify high-risk patients [14,16,17].
Accordingly, we utilized Taiwan’s National Health Insurance (NHI) research database to conduct the nationwide population-based cohort study. There are two objectives in this study. First, we aimed to compare the risk of postoperative migraine headaches between patients undergoing general and neuraxial anesthesia. Second, we sought to determine the risk factors for postoperative migraine headaches. Based on the current evidence [10,11,14,15,16,17,18], we hypothesized that general anesthesia was associated with a higher risk of postoperative migraine headaches compared with neuraxial anesthesia.

2. Materials and Methods

2.1. Source of Data

The present study was approved by the Institutional Review Board of Taipei Medical University in Taiwan (TMU-JIRB-N202101005). Written informed consent was waived by the Institutional Review Board. All methods of this study were performed in accordance with the STROBE guidelines and regulations. Taiwan’s National Health Insurance program was launched in March 1995 and provided insurance to more than 99% of Taiwan’s 23.4 million residents at the end of 2013. The NHI research database contains comprehensive data of the insured individuals, including demographic attributes (date of birth, sex, and residential location) and claims data (outpatient and inpatient care, medical diagnoses, prescriptions, and procedures). To protect personal privacy, a unique identification number is assigned to each beneficiary and enciphered before the data are released for research purposes. The NHI research database has been widely used in numerous epidemiological studies [22,23,24,25]. The present study used three Longitudinal Health Insurance Databases (LHID2000, LHID2005, and LHID2010), which randomly sampled 1 million beneficiaries from the original NHI research database in the years 2000, 2005, and 2010, respectively. The LHIDs contain the most updated medical claims of sampled beneficiaries since 1997. The representativeness of LHIDs has been validated by Taiwan’s National Health Research Institutes [26].

2.2. Study Population and Exposure Factors

We used the medical claims of 3 million insured beneficiaries to select patients who underwent their first surgical procedures requiring general or neuraxial anesthesia with a length of hospital stay ≥2 days in Taiwan between 1 January 2002 and 30 June 2013. We excluded surgeries which could only be performed with general anesthesia, patients who had any diagnoses of migraine in the outpatient or inpatient care within 24 months before the index surgery, and those who had a diagnosis of headache related to dural puncture or died within 180 days after the index surgery. Each subject with general anesthesia was randomly matched to a subject with neuraxial anesthesia in a ratio 1:1, using a frequency matched pair procedure.

2.3. Outcome of Interest

We identified patients who developed postoperative migraine headaches within 180 days after the index surgery by using the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes. (Supplementary Table S1) For sensitivity tests, migraine episodes in the varying postoperative periods (30, 60, 90, 120, and 150 days) were also compared between groups. The diagnosis of migraine was made by board-certified neurologists. Uses of acute migraine medications within 180 days after surgery were also examined, including sumatriptan, rizatriptan, ergotamine, and dihydroergotamine [27].

2.4. Covariates

Surgical procedures were classified into orthopedic (lower limbs), genitourinary, anal, obstetric, and hernia repair surgeries. We used the ICD-9-CM codes of physicians’ diagnoses within 24 months prior to surgery to ascertain the history of the following coexisting diseases, chosen based on data availability, physiological plausibility, and the existing literature: hypertension, diabetes mellitus, ischemic heart disease, atherosclerosis, heart failure, cerebrovascular disease, chronic kidney disease, chronic obstruction pulmonary disease, malignancy, anxiety disorder, depressive disorder, schizophrenia, and bipolar disorder [28]. Lifestyle factors included obesity, smoking disorder, alcohol use disorder, and malnutrition [28]. (Supplementary Table S1) Since adverse events after surgery may produce physical and emotional stress and trigger migraine headaches [3,4], we also analyzed the major complications that occurred within 30 days after the index surgery, including pneumonia, septicemia, acute renal failure, pulmonary embolism, deep vein thrombosis, stroke, urinary tract infection, surgical site infection, acute myocardial infarction, cardiac dysrhythmias, and postoperative bleeding. Perioperative uses of blood transfusion [29,30,31] and need for intensive care [32] during the index surgical admission were analyzed. Our analyses also adjusted for the commonly used sympathomimetic drugs prescribed within 180 days after the index surgery, which might affect cerebral blood flow and modify migraine risk, including systemic corticosteroids, ephedrine, and theophylline [33,34,35].

2.5. Statistical Analysis

A non-parsimonious multivariable logistic regression model was applied to estimate a propensity score for subjects undergoing general or neuraxial anesthesia. Each subject with general anesthesia was matched to a subject with neuraxial anesthesia using a greedy matching algorithm within a tolerance limit of 0.05 and without replacement to adjust for age, sex, insurance premium, types of surgery, comorbidities, lifestyle factors, concurrent sympathomimetic drugs, number of hospitalizations, and number of emergency room visits within 24 months before the index surgery. Categorical variables were expressed using frequency and percentage, and continuous variables were summarized using mean and standard deviation. The distributions of baseline attributes in propensity-score matched samples were compared between groups by using standardized difference [36]. Multivariable logistic regressions models were used to calculate the adjusted odds ratio (aOR) and 95% confidence interval (CI) of postoperative migraine headaches. We considered a two-sided level of 0.05 statistically significant. All the statistical analyses were conducted using Statistics Analysis System (SAS), Version 9.4 (SAS Institute Inc., Cary, NC, USA).

3. Results

3.1. Baseline Patient Characteristics

After meeting the patient selection criteria, the matching procedure generated 68,131 matched pairs with 66,989 person-years of follow-up for analyses. (Figure 1) Table 1 shows the baseline characteristics of the included subjects undergoing general or neuraxial anesthesia. The distributions of demographics, types of surgery, comorbidities, lifestyle factors, concurrent sympathomimetic drugs, number of hospitalizations, and number of emergency room visits were well balanced after matching.

3.2. Risk of Postoperative Migraine Headaches

In the matched cohort, 658 patients developed a new-onset migraine during the half-year follow-up, and 318 and 340 after general and neuraxial anesthesia, respectively. The overall incidence of migraine was 9.82 per 1000 person-years, and 9.49 and 10.15 for patients undergoing general and neuraxial anesthesia, respectively.
Table 2 shows the results of univariate and multivariable logistic regression models for the risk of postoperative migraine headaches. There was no significant difference in the migraine risk between general and neuraxial anesthesia, aOR: 0.93 (95% CI: 0.80–1.09). Independent influential factors for migraine were age (aOR: 0.99), sex (male vs. female, aOR: 0.50), pre-existing anxiety disorder (aOR: 2.43), depressive disorder (aOR: 2.29), concurrent uses of systemic corticosteroids (aOR: 1.45), ephedrine (aOR: 1.45), and theophylline (aOR: 1.40), and number of emergency room visits before surgery (1 vs. 0, aOR: 1.12; 2 vs. 0, aOR: 1.14; ≥3 vs. 0, aOR: 1.68).

3.3. Subgroup Analyses

There was no significant difference in the migraine risk between patients undergoing general or neuraxial anesthesia across the subgroups of different migraine subtypes, uses of migraine medications, or varying postoperative periods. (Table 3) There was no difference between general and neuraxial anesthesia in migraine risk across the subgroups of age ≥ or <65 years, sex, anxiety disorder, depressive disorder, concurrent uses of systemic corticosteroids, ephedrine, theophylline, postoperative complications, or admission to intensive care unit, either (Table 4).

4. Discussion

In this study, we found that there was no significant difference in the risk of postoperative migraine headaches between patients undergoing general or neuraxial anesthesia. The results were consistent across subgroups of different migraine subtypes, uses of migraine medications, and varying postoperative periods. Importantly, our analyses identified several risk factors for postoperative migraine headaches, including younger age, female, pre-existing anxiety disorder, depressive disorder, and a greater number of preoperative emergency visits. The perioperative uses of systemic corticosteroid, ephedrine, and theophylline were associated with increased risks of migraine after surgery. To our knowledge, this is the first large-scale study to evaluate the overall incidence and potential risk factors for migraine headaches after major surgery. These findings provide evidence for the diagnosis, risk-stratification, and treatment of migraine headaches after major surgery.
Epidemiological study has reported that overall incidence of migraine was estimated at 8.1 per 1000 person-years in people without migraine initially [37]. In our study, the incidence of postoperative migraine headaches was 9.82 per 1000 person-years in the half-year follow-up, which was 21% higher than that of previous reports in general population [37]. Patients in our cohort were under the stress of surgery, which has been identified as the most important trigger of migraine [3,4,38]. Moreover, the present study showed that patients with pre-existing anxiety or depressive disorder had a greater risk of developing postoperative migraine. Emotional disturbances were found commonly comorbid with migraine in the general population [39,40]. The causation between anxiety/depressive disorders and migraine was unclear in the perioperative period. It is also uncertain whether the stress of surgery modifies the migraine risk among patients with mental health disorders. Our analyses revealed that more emergency room visits prior to surgery were associated with a higher risk of postoperative migraine. Two observational studies demonstrated a relationship between emergency room visits and severity of migraine [41,42]. In our study, preoperative frequency of emergency visits might reflect disease severity and surgical urgency, which potentially underlay the higher risk of postoperative migraine.
Our results refuted the primary hypothesis that general anesthesia was associated with a higher risk of postoperative migraine compared with neuraxial anesthesia. Until now, there are only few case studies reporting migraine headaches after general anesthesia and fentanyl sedation [14,15,16,17,18]. The association between general anesthesia and postoperative migraine episodes has been hypothesized, but there is still no study to compare the migraine risk between general anesthesia and other types of anesthesia. We raised the following possible explanations for our results. First, although the vasodilatory effect of volatile anesthetics on meningeal arterioles has been proposed to trigger migraine headaches [10,11], this neurovascular effect may be outweighed by Propofol used in general anesthesia. Propofol is an agonist of gamma-aminobutyric acid receptors, which inhibit the activity of central serotonergic neurons in the raphe nuclei and theoretically exert anti-migraine effects [12,13]. In addition, Propofol reduces both cerebral blood flow and cerebral metabolic rate, which may prevent the development of migraine [12,13]. Future studies are needed to investigate the potential impact of different regimens of general anesthesia on the risk of postoperative migraine, such as Propofol-based total intravenous anesthesia and opioid-free general anesthesia.
Our results suggested that uses of systemic corticosteroid, ephedrine, and theophylline were correlated with increased migraine risks. First, systemic corticosteroid has been used as an acute migraine treatment, and it is particularly effective for patients with refractory migraine, a history of recurrent headaches, and status migrainosus [43,44,45]. In our study, the use of systemic corticosteroid may represent a rescue therapy for migraine in these patients. Second, ephedrine is a non-selective beta agonist with alpha-1 activity [46,47]. In the current practice guideline, beta blockers without intrinsic sympathomimetic activity are used to prevent recurrent migraine headaches [46]. In a previous study conducted on healthy males, intravenous infusion of ephedrine caused an increase in blood flow of external carotid artery [47]. We reasoned that the increased blood flow of external carotid artery may increase the blood flow and induce vasodilation in the branches of middle meningeal artery, causing stimuli to trigeminal nerve and thereby triggering migraine [8,9]. Third, theophylline is a phosphodiesterase inhibiting agent used as the therapy for chronic obstructive pulmonary disease and asthma [48]. Theophylline has a narrow therapeutic window and its overdose can stimulate the central nervous system and cause headaches, insomnia, and seizure [49]. Besides, previous studies have shown that patients with asthma had a higher prevalence and incidence of migraine [50,51]. However, the mechanism is still unknown. Future studies are warranted to investigate the potential neurophysiological effects of theophylline on migraine headaches.
The present study discovered some potentially modifiable factors for migraine headaches after surgery, including systemic corticosteroids, ephedrine, and theophylline. Whether avoiding these drugs prevents the occurrence of migraine remains to be seen. It is also unclear what proportion of postoperative migraine progresses to chronic migraine. To date, the proven effective treatment for chronic migraine includes oral medications, neuromodulation, and nerve blockade [28,52]. Meta-analyses showed that acupuncture as a treatment modality was associated with a significant reduction in both headache frequency and response compared with routine care only and with prophylactic drugs at 2 months [53]. However, these results were potentially limited by the heterogeneity across studies and placebo effects [53]. Future studies are warranted to better evaluate the potential benefits and adverse effects of acupuncture in the prevention and treatment of chronic migraine.
There were some limitations to our study. First, our data did not contain information about physical measures (e.g., blood pressure), biochemical laboratory tests (e.g., stress hormone levels), socioeconomic factors (e.g., education level), and clinical data on detailed surgical (elective, urgent or emergent surgery, and duration of surgery) and anesthetic management (uses of vasoconstrictors or vasodilators, types and doses of anesthetics and opioids) that were not covered by NHI database. Second, our analyses have excluded patients who had a diagnosis of chronic migraine before surgery and therefore it is unclear whether types of anesthesia affect the precipitation of migraine headaches in this population. Third, surgeries that could only be performed with general anesthesia (e.g., brain surgery and ear, nose, and throat surgery) were excluded from analyses, which might decrease the generalizability of study results [32]. Fourth, a recent study reported that pre-existing migraine was a risk factor for postoperative nausea and vomiting [5]. However, primary care physicians rarely used diagnosis codes to document postoperative nausea and vomiting in the NHI research database probably due to its transient and mild symptoms compared with active surgical problems. This precluded meaningful analyses of the relationship between migraine headaches and postoperative nausea and vomiting in this study. Fifth, our dataset did not include patients with migraine who did not seek conventional medical care due to mild symptoms. Sixth, we did not evaluate the risk of migraine among people who did not undergo surgery or anesthesia. Finally, our cohort was only followed up until the end of 2013, due to the regulations of the NHI research database.

5. Conclusions

There was no significant difference in the incidence of postoperative migraine headaches in patients undergoing general or neuraxial anesthesia for surgeries that could be performed with both techniques. Several risk factors for migraine were determined, including younger age, female, pre-existing depressive and anxiety disorders, concurrent uses of systemic corticosteroids, ephedrine, and theophylline and number of emergency room visits before surgery. These findings may provide an implication for early diagnoses and prompt interventions of postoperative migraine headaches. More studies are needed to diagnose and evaluate postoperative migraines among patients receiving different anesthetics in the immediate postoperative period.

Supplementary Materials

The following are available online at https://www.mdpi.com/article/10.3390/ijerph19010362/s1, Table S1: ICD-9-CM codes of covariates and outcomes.

Author Contributions

Conceptualization, C.-Y.L., C.-C.L. and Y.-H.T.; methodology, Y.-H.T.; software, Y.-H.T.; validation, H.-Y.L., H.-L.W. and W.-C.L.; formal analysis, Y.-H.T.; investigation, W.-C.L. and Y.-H.T.; resources, J.-T.C. and Y.-G.C.; data curation, T.-J.C. and Y.-X.D.; writing—original draft preparation, C.-Y.L. and C.-C.L.; writing—review and editing, H.-Y.L., J.-T.C., Y.-G.C., T.-J.C., Y.-X.D., H.-L.W. and Y.-H.T.; visualization, Y.-H.T.; supervision, W.-C.L. and Y.-H.T.; project administration, Y.-H.T.; and funding acquisition, Y.-H.T., W.-C.L. and Y.-H.T. contributed equally to this work. All authors have read and agreed to the published version of the manuscript.

Funding

This research was funded by Taipei Medical University, Taiwan, grant number TMU110-AE1-B11. The APC was funded by Shuang Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.

Institutional Review Board Statement

The study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Institutional Review Board of Taipei Medical University (TMU-JIRB-N202101005).

Informed Consent Statement

Patient consent was waived by the Institutional Review Board.

Data Availability Statement

The data presented in this study are available on request from the corresponding author.

Conflicts of Interest

The authors declare no conflict of interest.

References

  1. Ashina, M.; Katsarava, Z.; Do, T.P.; Buse, D.C.; Pozo-Rosich, P.; Özge, A.; Krymchantowski, A.V.; Lebedeva, E.R.; Ravishankar, K.; Yu, S.; et al. Migraine: Epidemiology and systems of care. Lancet 2021, 397, 1485–1495. [Google Scholar] [CrossRef]
  2. Burch, R.C.; Buse, D.C.; Lipton, R.B. Migraine: Epidemiology, Burden, and Comorbidity. Neurol. Clin. 2019, 37, 631–649. [Google Scholar] [CrossRef] [PubMed]
  3. Faithfull, N.S. Post-operative headache—A multifactorial analysis. Eur. J. Anaesthesiol. 1991, 8, 59–63. [Google Scholar]
  4. Ulrich, V.; Olesen, J.; Gervil, M.; Russell, M.B. Possible Risk Factors and Precipitants for Migraine with Aura in Discordant Twin-Pairs: A Population-Based Study. Cephalalgia 2000, 20, 821–825. [Google Scholar] [CrossRef]
  5. Kim, J.-H.; Lim, M.-S.; Lee, S.-H.; Kwon, Y.-S.; Lee, J.J.; Sohn, J.-H. Consideration of Migraines among Risk Factors for Postoperative Nausea and Vomiting. J. Clin. Med. 2020, 9, 3154. [Google Scholar] [CrossRef]
  6. Timm, F.P.; Houle, T.; Grabitz, S.D.; Lihn, A.-L.; Stokholm, J.B.; Eikermann-Haerter, K.; Nozari, A.; Kurth, T.; Eikermann, M. Migraine and risk of perioperative ischemic stroke and hospital readmission: Hospital based registry study. BMJ 2017, 356, i6635. [Google Scholar] [CrossRef] [Green Version]
  7. Kurth, T.; Winter, A.C.; Eliassen, A.H.; Dushkes, R.; Mukamal, K.J.; Rimm, E.B.; Willett, W.C.; E Manson, J.; Rexrode, K. Migraine and risk of cardiovascular disease in women: Prospective cohort study. BMJ 2016, 353, i2610. [Google Scholar] [CrossRef] [Green Version]
  8. Levy, D.; Ramírez, A.L.; MaassenVanDenBrink, A. Current understanding of meningeal and cerebral vascular function underlying migraine headache. Cephalalgia 2018, 39, 1606–1622. [Google Scholar] [CrossRef] [PubMed]
  9. Ashina, M. Migraine. N. Engl. J. Med. 2020, 383, 1866–1876. [Google Scholar] [CrossRef]
  10. Iida, H.; Ohata, H.; Iida, M.; Watanabe, Y.; Dohi, S. Isoflurane and Sevoflurane Induce Vasodilation of Cerebral Vessels via ATP-sensitive K+ Channel Activation. Anesthesiol. 1998, 89, 954–960. [Google Scholar] [CrossRef]
  11. Inoue, S.; Kawaguchi, M.; Kurehara, K.; Sakamoto, T.; Kishi, K.; Einaga, T.; Kitaguchi, K.; Furuya, H. Mild hypothermia can enhance pial arteriolar vasodilation induced by isoflurane and sevoflurane in cats. Crit. Care Med. 2002, 30, 1863–1869. [Google Scholar] [CrossRef]
  12. Dhir, A. Propofol in the treatment of refractory migraine headaches. Expert Rev. Neurother. 2016, 16, 1007–1011. [Google Scholar] [CrossRef] [PubMed]
  13. Piatka, C.; Beckett, R.D. Propofol for Treatment of Acute Migraine in the Emergency Department: A Systematic Review. Acad. Emerg. Med. 2020, 27, 148–160. [Google Scholar] [CrossRef] [PubMed]
  14. Thurlow, J.A. Hemiplegia following general anaesthesia: An unusual presentation of migraine. Eur. J. Anaesthesiol. 1998, 15, 610–612. [Google Scholar] [CrossRef]
  15. Gil-Gouveia, R.; Wilkinson, P.A.; Kaube, H. Severe hemiplegic migraine attack precipitated by fentanyl sedation for esophagogastroscopy. Neurology 2004, 63, 2446–2447. [Google Scholar] [CrossRef]
  16. Lin, L.; Adey, C. Presentation of Hemiplegic Migraine—Hemiplegia and Hemi-Sensory Loss following General Anaesthesia. Anaesth. Intensiv. Care 2007, 35, 418–422. [Google Scholar] [CrossRef]
  17. Pianezza, A.; Barthélémy, R.; Minville, V.; Martin, F.; Faggianelli, M. Migraine with Atypical Aura in the Recovery Room: A Sometimes Complicated Diagnosis! Anesth. Analg. 2008, 106, 1844–1846. [Google Scholar] [CrossRef]
  18. Willson, J.; Kapur, S. Apnoeic spells following general anaesthesia in a patient with familial hemiplegic migraine. Anaesthesia 2007, 62, 956–958. [Google Scholar] [CrossRef] [PubMed]
  19. Levo, H.; Blomstedt, G.; Hirvonen, T.; Pyykko, I. Causes of persistent postoperative headache after surgery for vestibular schwannoma. Clin. Otolaryngol. 2001, 26, 401–406. [Google Scholar] [CrossRef]
  20. Munkvold, B.K.R.; Sagberg, L.M.; Jakola, A.S.; Solheim, O. Preoperative and Postoperative Headache in Patients with Intracranial Tumors. World Neurosurg. 2018, 115, e322–e330. [Google Scholar] [CrossRef] [PubMed]
  21. Venkatraghavan, L.; Li, L.; Bailey, T.; Manninen, P.H.; Tymianski, M. Sumatriptan improves postoperative quality of recovery and reduces postcraniotomy headache after cranial nerve decompression. Br. J. Anaesth. 2016, 117, 73–79. [Google Scholar] [CrossRef] [Green Version]
  22. Dai, Y.-X.; Tai, Y.-H.; Chang, Y.-T.; Chen, T.-J.; Chen, M.-H. Bidirectional Association between Psoriasis and Atopic Dermatitis: A Nationwide Population-Based Cohort Study. Dermatology 2021, 237, 521–527. [Google Scholar] [CrossRef]
  23. Chen, M.-H.; Dai, Y.-X.; Tai, Y.-H.; Chang, Y.-T.; Chen, T.-J. Increased risk of alopecia areata among patients with endometriosis: A longitudinal study in Taiwan. Dermatol. Sin. 2021, 39, 41. [Google Scholar] [CrossRef]
  24. Chung, Y.-H.; Kuo, H.-C.; Liu, H.-Y.; Wu, M.-Y.; Chang, W.-J.; Chen, J.-T.; Cherng, Y.-G.; Chen, T.-J.; Dai, Y.-X.; Wu, H.-L.; et al. Association between Dental Scaling and Reduced Risk of End-Stage Renal Disease: A Nationwide Matched Cohort Study. Int. J. Environ. Res. Public Health 2021, 18, 8910. [Google Scholar] [CrossRef]
  25. Wu, Y.-M.; Kuo, H.-C.; Li, C.-C.; Wu, H.-L.; Chen, J.-T.; Cherng, Y.-G.; Chen, T.-J.; Dai, Y.-X.; Liu, H.-Y.; Tai, Y.-H. Preexisting Dementia Is Associated with Increased Risks of Mortality and Morbidity Following Major Surgery: A Nationwide Propensity Score Matching Study. Int. J. Environ. Res. Public Health 2020, 17, 8431. [Google Scholar] [CrossRef]
  26. National Health Insurance Research Database. Data Subsets. Available online: https://nhird.nhri.org.tw/en/Data_Subsets.html (accessed on 15 November 2021).
  27. Mayans, L.; Walling, A. Acute Migraine Headache: Treatment Strategies. Am. Fam. Physician 2018, 97, 243–251. [Google Scholar] [PubMed]
  28. May, A.; Schulte, A.M.L.H. Chronic migraine: Risk factors, mechanisms and treatment. Nat. Rev. Neurol. 2016, 12, 455–464. [Google Scholar] [CrossRef]
  29. Tai, Y.-H.; Wu, H.-L.; Mandell, M.S.; Lin, S.-P.; Tsou, M.-Y.; Chang, K.-Y. The association of non–small cell lung cancer recurrence with allogenic blood transfusion after surgical resection: A propensity score analysis of 1,803 patients. Eur. J. Cancer 2020, 140, 45–54. [Google Scholar] [CrossRef]
  30. Tai, Y.H.; Wu, H.L.; Mandell, M.S.; Tsou, M.Y.; Chang, K.Y. The association of allogeneic blood transfusion and the recurrence of hepatic cancer after surgical resection. Anaesthesia 2020, 75, 464–471. [Google Scholar] [CrossRef] [PubMed]
  31. Wu, H.-L.; Tai, Y.-H.; Lin, S.-P.; Chan, M.-Y.; Chen, H.-H.; Chang, K.-Y. The Impact of Blood Transfusion on Recurrence and Mortality Following Colorectal Cancer Resection: A Propensity Score Analysis of 4030 Patients. Sci. Rep. 2018, 8, 13345. [Google Scholar] [CrossRef] [Green Version]
  32. Dhakal, L.P.; Harriott, A.; Capobianco, D.J.; Freeman, W.D. Headache and Its Approach in Today’s NeuroIntensive Care Unit. Neurocrit. Care 2016, 25, 320–334. [Google Scholar] [CrossRef]
  33. Singhal, A.B.; Topcuoglu, M.A. Glucocorticoid-associated worsening in reversible cerebral vasoconstriction syndrome. Neurology 2017, 88, 228–236. [Google Scholar] [CrossRef] [Green Version]
  34. Koch, K.U.; Mikkelsen, I.K.; Aanerud, J.; Espelund, U.S.; Tietze, A.; Oettingen, G.V.; Juul, N.; Nikolajsen, L.; Østergaard, L.; Rasmussen, M. Ephedrine versus Phenylephrine Effect on Cerebral Blood Flow and Oxygen Consumption in Anesthetized Brain Tumor Patients. Anesthesiology 2020, 133, 304–317. [Google Scholar] [CrossRef]
  35. Bath, P.M. Theophylline, aminophylline, caffeine and analogues for acute ischaemic stroke. Cochrane Database Syst. Rev. 2004, 2004, CD000211. [Google Scholar] [CrossRef]
  36. Austin, P.C. Balance diagnostics for comparing the distribution of baseline covariates between treatment groups in propensity-score matched samples. Stat. Med. 2009, 28, 3083–3107. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  37. Lyngberg, A.C.; Rasmussen, B.K.; Jørgensen, T.; Jensen, R. Incidence of Primary Headache: A Danish Epidemiologic Follow-up Study. Am. J. Epidemiol. 2005, 161, 1066–1073. [Google Scholar] [CrossRef]
  38. Pellegrino, A.B.W.; E Davis-Martin, R.; Houle, T.; Turner, D.P.; Smitherman, T. Perceived triggers of primary headache disorders: A meta-analysis. Cephalalgia 2017, 38, 1188–1198. [Google Scholar] [CrossRef]
  39. Jette, N.; Patten, S.; Williams, J.; Becker, W.; Wiebe, S. Comorbidity of Migraine and Psychiatric Disorders—A National Population-Based Study. Headache J. Head Face Pain 2008, 48, 501–516. [Google Scholar] [CrossRef] [PubMed]
  40. Breslau, N.; Lipton, R.B.; Stewart, W.F.; Schultz, L.R.; Welch, K.M. Comorbidity of migraine and depression: Investigating potential etiology and prognosis. Neurology 2003, 60, 1308–1312. [Google Scholar] [CrossRef]
  41. Silberstein, S.D.; Lee, L.; Gandhi, K.; Ma, T.F.; Bell, J.; Cohen, J.M. Health care Resource Utilization and Migraine Disability Along the Migraine Continuum Among Patients Treated for Migraine. Headache J. Head Face Pain 2018, 58, 1579–1592. [Google Scholar] [CrossRef]
  42. Sumelahti, M.-L.; Sumanen, M.; Sumanen, M.S.; Tuominen, S.; Vikkula, J.; Honkala, S.M.; Rosqvist, S.; Korolainen, M.A. My Migraine Voice survey: Disease impact on healthcare resource utilization, personal and working life in Finland. J. Headache Pain 2020, 21, 118. [Google Scholar] [CrossRef]
  43. Woldeamanuel, Y.W.; Rapoport, A.M.; Cowan, R.P. What Is the Evidence for the Use of Corticosteroids in Migraine? Curr. Pain Headache Rep. 2014, 18, 464. [Google Scholar] [CrossRef]
  44. Orr, S.; Friedman, B.W.; Christie, S.; Minen, M.T.; Bamford, C.; Kelley, N.E.; Tepper, D. Management of Adults With Acute Migraine in the Emergency Department: The American Headache Society Evidence Assessment of Parenteral Pharmacotherapies. Headache J. Head Face Pain 2016, 56, 911–940. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  45. Kelley, N.E.; Tepper, D.E. Rescue Therapy for Acute Migraine, Part 3: Opioids, NSAIDs, Steroids, and Post-Discharge Medications. Headache J. Head Face Pain 2012, 52, 467–482. [Google Scholar] [CrossRef] [PubMed]
  46. Sprenger, T.; Viana, M.; Tassorelli, C. Current Prophylactic Medications for Migraine and Their Potential Mechanisms of Action. Neurotherapeutics 2018, 15, 313–323. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  47. Sørensen, H.; Rasmussen, P.; Sato, K.; Persson, S.; Olesen, N.D.; Nielsen, H.B.; Olsen, N.V.; Ogoh, S.; Secher, N.H. External carotid artery flow maintains near infrared spectroscopy-determined frontal lobe oxygenation during ephedrine administration. Br. J. Anaesth. 2014, 113, 452–458. [Google Scholar] [CrossRef] [Green Version]
  48. Devereux, G.; Cotton, S.; Fielding, S.; McMeekin, N.; Barnes, P.J.; Briggs, A.; Burns, G.; Chaudhuri, R.; Chrystyn, H.; Davies, L.; et al. Effect of Theophylline as Adjunct to Inhaled Corticosteroids on Exacerbations in Patients With COPD: A Randomized Clinical Trial. JAMA 2018, 320, 1548–1559. [Google Scholar] [CrossRef] [PubMed]
  49. Shannon, M. Life-Threatening Events after Theophylline Overdose. Arch. Intern. Med. 1999, 159, 989–994. [Google Scholar] [CrossRef] [PubMed] [Green Version]
  50. Sayyah, M.; Saki-Malehi, A.; Javanmardi, F.; Forouzan, A.; Shirbandi, K.; Rahim, F. Which came first, the risk of migraine or the risk of asthma? A systematic review. Neurol. Neurochir. Polska 2018, 52, 562–569. [Google Scholar] [CrossRef] [PubMed]
  51. Martin, V.T.; Fanning, K.M.; Serrano, D.; Buse, D.C.; Reed, M.L.; Lipton, R.B. Asthma is a risk factor for new onset chronic migraine: Results from the American migraine prevalence and prevention study. Headache J. Head Face Pain 2015, 56, 118–131. [Google Scholar] [CrossRef]
  52. Maniaci, A.; Merlino, F.; Cocuzza, S.; Iannella, G.; Vicini, C.; Cammaroto, G.; Lechien, J.R.; Calvo-Henriquez, C.; La Mantia, I. Endoscopic surgical treatment for rhinogenic contact point headache: Systematic review and meta-analysis. Eur. Arch. Oto-Rhino-Laryngol. 2021, 278, 1743–1753. [Google Scholar] [CrossRef]
  53. Coeytaux, R.R.; Befus, D. Role of Acupuncture in the Treatment or Prevention of Migraine, Tension-Type Headache, or Chronic Headache Disorders. Headache J. Head Face Pain 2016, 56, 1238–1240. [Google Scholar] [CrossRef]
Ijerph 19 00362 g001 550
Figure 1. Flow diagram for patient selection.
Figure 1. Flow diagram for patient selection.
Ijerph 19 00362 g001
Table
Table 1. Baseline characteristics of patients undergoing general and neuraxial anesthesia.
Table 1. Baseline characteristics of patients undergoing general and neuraxial anesthesia.
Baseline CharacteristicGeneral Anesthesia
n = 68,131		Neuraxial Anesthesia
n = 68,131		SDD
Age (years), mean (SD)51.419.851.119.50.0153
Sex, male, n (%)36,89054.237,00354.3−0.0037
Insurance premium (USD/month), n (%) 0.0028
0–50029,88843.930,18244.3
501–80022,81033.522,37532.8
≥80115,43322.715,57422.9
Type of surgery, n (%)
Orthopedic, lower limbs29,82443.829,62943.50.0064
Genitourinary18,01826.517,69226.00.0136
Anal737310.8761311.2−0.0198
Obstetric697210.2696610.20.0005
Hernia repair61689.165069.6−0.0324
Lifestyle factors, n (%)
Obesity3710.53810.6−0.0147
Smoking disorder4340.64370.6−0.0038
Alcohol use disorder9451.49251.40.0120
Malnutrition4770.74860.7−0.0104
Comorbidity, n (%)
Hypertension20,41630.020,14929.60.0103
Diabetes mellitus971914.3954214.00.0118
Ischemic heart disease736310.8735710.80.0005
Atherosclerosis6040.95940.90.0093
Heart failure22423.322123.30.0077
Cerebrovascular disease54538.054298.00.0026
Chronic kidney disease37085.436925.40.0025
COPD56638.356858.3−0.0023
Malignancy44786.644466.50.0042
Anxiety disorder712710.5713110.5−0.0003
Depressive disorder7231.17341.1−0.0084
Schizophrenia3830.63740.60.0132
Bipolar disorder2680.42810.4−0.0262
Concurrent sympathomimetic drugs, n (%)
Systemic corticosteroids11,43916.811,29116.60.0086
Ephedrine11,96117.612,09917.8−0.0077
Theophylline66239.767029.8−0.0072
Number of hospitalizations, n (%) 0.0238
052,00776.352,99777.8
110,50215.4975014.3
232174.729344.3
≥324053.524503.6
Number of ER visits, n (%) −0.0004
039,55458.139,77258.4
116,20223.815,86423.3
264239.464219.4
≥359528.760748.9
Postoperative complications, n (%)853312.5910513.4−0.0411
Blood transfusion, n (%)9861.58151.20.1064
ICU admission, n (%)4300.63740.60.0774
Abbreviation: COPD = chronic obstruction pulmonary disease; ER = emergency room; ICU = intensive care unit; SD = standard deviation; SDD = standardized difference; and USD = United States dollar.
Table
Table 2. Univariate and multivariable analyses for the risk of postoperative migraine.
Table 2. Univariate and multivariable analyses for the risk of postoperative migraine.
UnivariateMultivariable
cOR95% CIpaOR95% CIp
General vs. neuraxial anesthesia0.940.80–1.090.39000.930.80–1.090.3578
Age (years)1.001.00–1.000.85730.990.99–1.000.0211
Sex, male0.510.44–0.60<0.00010.500.42–0.60<0.0001
Insurance premium (USD/month) 0.5394 0.7854
501–800 vs. 0–5000.980.83–1.170.64950.970.81–1.160.9443
≥801 vs. 0–5000.890.73–1.090.28150.930.75–1.150.5540
Type of surgery
Orthopedic, lower limbs0.880.75–1.030.11360.430.06–3.140.4079
Genitourinary0.950.80–1.130.56710.520.07–3.700.5096
Anal1.321.06–1.640.01430.620.09–4.490.6356
Obstetric1.200.95–1.520.13180.390.05–2.880.3592
Hernia repair0.890.67–1.170.40440.590.08–4.230.6000
Lifestyle factors
Obesity1.660.74–3.730.21641.300.58–2.930.5261
Smoking disorder1.440.64–3.220.37781.500.66–3.370.3327
Alcohol use disorder0.550.23–1.330.18230.510.21–1.240.1359
Malnutrition1.080.45–2.600.86550.840.35–2.050.7078
Comorbidity
Hypertension1.110.95–1.310.19660.920.75–1.140.4612
Diabetes mellitus1.120.90–1.380.31351.030.82–1.300.8100
Ischemic heart disease1.381.11–1.720.00411.120.87–1.450.3697
Atherosclerosis1.570.81–3.030.18201.260.65–2.470.4948
Heart failure1.320.90–1.930.15381.020.67–1.530.9442
Cerebrovascular disease1.311.02–1.690.03741.200.90–1.600.2110
Chronic kidney disease1.371.02–1.840.03521.040.76–1.430.8015
COPD1.381.08–1.760.01041.160.89–1.510.2772
Malignancy0.920.67–1.270.62520.930.67–1.300.6651
Anxiety disorder3.052.56–3.64<0.00012.432.01–2.95<0.0001
Depressive disorder4.182.85–6.12<0.00012.291.53–3.44<0.0001
Schizophrenia1.100.41–2.940.85630.860.31–2.330.7588
Bipolar disorder1.130.36–3.530.82960.510.16–1.630.2555
Concurrent sympathomimetic drugs
Systemic corticosteroids1.691.42–2.02<0.00011.451.21–1.74<0.0001
Ephedrine1.801.52–2.14<0.00011.451.21–1.75<0.0001
Theophylline1.841.50–2.26<0.00011.401.12–1.740.0036
Number of hospitalizations 0.1994 0.2011
1 vs. 01.241.01–1.520.23021.050.85–1.300.0668
2 vs. 01.160.82–1.650.71730.870.60–1.270.9935
≥3 vs. 01.020.67–1.560.65700.640.40–1.010.0676
Number of ER visits <0.0001 0.0012
1 vs. 01.130.93–1.370.12201.120.92–1.360.3045
2 vs. 01.200.92–1.560.59571.140.87–1.500.5517
≥3 vs. 01.891.51–2.37<0.00011.681.30–2.160.0004
Postoperative complications1.030.82–1.290.83000.920.73–1.170.5028
Blood transfusion0.690.31–1.540.36080.580.24–1.390.2217
ICU admission1.290.54–3.120.56861.550.59–4.060.3725
Abbreviation: aOR = adjusted odds ratio; COPD = chronic obstruction pulmonary disease; cOR = crude odds ratio; ER = emergency room; ICU = intensive care unit; USD = United States dollar.
Table
Table 3. Risk of postoperative migraine stratified by migraine subtypes, migraine medications, and varying postoperative periods.
Table 3. Risk of postoperative migraine stratified by migraine subtypes, migraine medications, and varying postoperative periods.
General AnesthesiaNeuraxial AnesthesiaMigraine Risk
EventRate (%)Crude Incidence
Rate/1000 PY		EventRate (%)Crude Incidence
Rate/1000 PY		Incidence Rate RatioaOR (95% CI) †p
All migraine3180.479.493400.5010.150.940.93 (0.80–1.09)0.3578
Migraine with aura320.050.96310.050.931.031.02 (0.62–1.68)0.9295
Migraine without aura580.091.73780.112.330.740.73 (0.52–1.03)0.0697
Migraine, unspecified2280.336.812310.346.900.990.99 (0.82–1.19)0.8857
Migraine with medications1020.153.05830.122.481.231.23 (0.92–1.64)0.1717
30-day migraine600.0910.73580.0910.371.031.03 (0.72–1.48)0.8706
60-day migraine1150.1710.281120.1610.021.031.02 (0.79–1.33)0.8793
90-day migraine1740.2610.381610.249.601.081.08 (0.87–1.34)0.4981
120-day migraine2180.329.762200.329.840.990.99 (0.82–1.19)0.8893
150-day migraine2760.419.882820.4110.100.980.97 (0.82–1.15)0.7570
Abbreviation: aOR = adjusted odds ratio; CI = confidence interval; PY = person-years. † Adjusted for age (continuous), sex, insurance premium (categorical), types of surgery, comorbidities, lifestyle factors, concurrent sympathomimetic drugs, number of hospitalizations, number of emergency room visits, postoperative complications, perioperative uses of blood transfusion, and intensive care unit care.
Table
Table 4. Subgroup analyses of postoperative migraine for patients undergoing general and neuraxial anesthesia.
Table 4. Subgroup analyses of postoperative migraine for patients undergoing general and neuraxial anesthesia.
Subgroup nEventRate (%)aOR (95% CI) †p
Age ≥ 65 yearsGA19,894770.390.94 (0.69–1.29)0.6985
NA20,074830.41reference
Age < 65 yearsGA48,2372410.500.93 (0.78–1.11)0.3972
NA48,0572570.53reference
MaleGA36,8901120.300.84 (0.65–1.08)0.1672
NA37,0031360.37reference
FemaleGA31,2412060.660.98 (0.81–1.20)0.8629
NA31,1282040.66reference
Anxiety disorderGA7127771.080.80 (0.59–1.08)0.1410
NA7131951.33reference
No anxiety disorderGA61,0042410.400.98 (0.82–1.18)0.8551
NA61,0002450.40reference
Depressive disorderGA723131.800.79 (0.34–1.83)0.5818
NA734152.04reference
No depressive disorderGA67,4083050.450.94 (0.80–1.10)0.4096
NA67,3973250.48reference
Use of systemic corticosteroidsGA11,439820.720.98 (0.72–1.33)0.8769
NA11,291840.74reference
No use of systemic corticosteroidsGA56,6922360.420.92 (0.77–1.09)0.3280
NA56,8402560.45reference
Use of ephedrineGA11,961840.700.86 (0.64–1.15)0.3119
NA12,099990.82reference
No use of ephedrineGA56,1702340.420.96 (0.80–1.15)0.6469
NA56,0322410.43reference
Use of theophyllineGA6623480.720.78 (0.53–1.14)0.1996
NA6702610.91reference
No use of theophyllineGA61,5082700.440.96 (0.81–1.14)0.6500
NA61,4292790.45reference
Postoperative complications complicationsGA8533410.480.94 (0.61–1.43)0.7581
NA9105460.51reference
No postoperative complicationsGA59,5982770.460.93 (0.79–1.10)0.3777
NA59,0262940.50reference
Admission to ICUGA43030.700.97 (0.08–12.33)0.9825
NA37420.53reference
No admission to ICUGA67,7013150.470.93 (0.79–1.08)0.3357
NA67,7573380.50reference
Abbreviation: aOR = adjusted odds ratio; CI = confidence interval; GA = general anesthesia; ICU = intensive care unit; NA = neuraxial anesthesia. † Adjusted for age (continuous), sex, insurance premium (categorical), types of surgery, comorbidities, lifestyle factors, concurrent sympathomimetic drugs, number of hospitalizations, number of emergency room visits, postoperative complications, perioperative uses of blood transfusion, and intensive care unit care.
Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Share and Cite

MDPI and ACS Style

Liao, C.-Y.; Li, C.-C.; Liu, H.-Y.; Chen, J.-T.; Cherng, Y.-G.; Chen, T.-J.; Dai, Y.-X.; Wu, H.-L.; Liu, W.-C.; Tai, Y.-H. Migraine Headaches after Major Surgery with General or Neuraxial Anesthesia: A Nationwide Propensity-Score Matched Study. Int. J. Environ. Res. Public Health 2022, 19, 362. https://doi.org/10.3390/ijerph19010362

AMA Style

Liao C-Y, Li C-C, Liu H-Y, Chen J-T, Cherng Y-G, Chen T-J, Dai Y-X, Wu H-L, Liu W-C, Tai Y-H. Migraine Headaches after Major Surgery with General or Neuraxial Anesthesia: A Nationwide Propensity-Score Matched Study. International Journal of Environmental Research and Public Health. 2022; 19(1):362. https://doi.org/10.3390/ijerph19010362

Chicago/Turabian Style

Liao, Chung-Yi, Chun-Cheng Li, Hsin-Yi Liu, Jui-Tai Chen, Yih-Giun Cherng, Tzeng-Ji Chen, Ying-Xiu Dai, Hsiang-Ling Wu, Wan-Chi Liu, and Ying-Hsuan Tai. 2022. "Migraine Headaches after Major Surgery with General or Neuraxial Anesthesia: A Nationwide Propensity-Score Matched Study" International Journal of Environmental Research and Public Health 19, no. 1: 362. https://doi.org/10.3390/ijerph19010362

Note that from the first issue of 2016, this journal uses article numbers instead of page numbers. See further details here.

Article Metrics

Back to TopTop