| Abstract|| |
Background/Aims: To analyze the potential correlation of a positive family history of gastroesophageal reflux disease (GERD) and the history of headaches as a risk factor for and complication of the disease. Materials and Methods: Three thousand and six hundred subjects were selected by cluster random sampling from all seven districts of Shiraz city, who were invited for interview. In five months, 1956 subjects participated in this study. A questionnaire organized into three sections of demographic, signs and symptoms of GERD, headache and family history of GERD was completed for each patient. Social and demographic variables were also recorded. Results: The presence of GERD symptoms (72%) had a significant correlation with a positive family history of the disease ( P = 0.000). Patients showed a variable frequency of headache, ranging from once daily (16.7%), three to five times a week (5.6%), once-twice a week (26.7%), once to three times a month (15.0%) and less than once a month (8.3%). There was a significant correlation between the headaches and the GERD symptoms ( P = 0.000). Conclusion: A positive family history of GERD can be considered as a risk factor for the disease and the presence of headache at the time of diagnosis as a complication of this disease. Therefore, in the management of GERD, attention should be given to these factors.
Keywords: Family history, gastroesophageal reflux disease, headache, reflux
|How to cite this article:|
Saberi-Firoozi M, Yazdanbakhsh MA, Heidari ST, Khademolhosseini F, Mehrabani D. Correlation of gastroesophageal reflux disease with positive family history and headache in Shiraz city, Southern Iran. Saudi J Gastroenterol 2007;13:176-9
|How to cite this URL:|
Saberi-Firoozi M, Yazdanbakhsh MA, Heidari ST, Khademolhosseini F, Mehrabani D. Correlation of gastroesophageal reflux disease with positive family history and headache in Shiraz city, Southern Iran. Saudi J Gastroenterol [serial online] 2007 [cited 2020 Jun 2];13:176-9. Available from: http://www.saudijgastro.com/text.asp?2007/13/4/176/36748
Gastroesophageal reflux disease (GERD) is defined as the movement of gastric contents into the esophagus and is not associated with vomiting. It is frequently associated with heartburn, the sensation of burning discomfort in the retrosternal area that moves upward toward the throat. Gastroesophageal reflux disease is a chronic, relapsing condition with associated morbidity and adverse impact on the quality of life. However, 20-60% of patients with GERD have head and neck symptoms without any appreciable heartburn.  Frequent gastroesophageal reflux disease symptoms affect 21% of the population. Increasing body mass index, a family history of upper gastrointestinal disease, irritable bowel syndrome, south Asian origin, smoking, excess alcohol consumption, social deprivation and anticholinergic drugs are independently associated with GERD symptoms. 
GERD is a disease associated with a range of potentially serious esophageal complications and extraesophageal diseases.  This disease is a great burden for patients and has significant socioeconomic implications and a long-term follow-up period with further endoscopic and histological evaluations will help further us in understanding the natural course of the disease.  Psychological characteristics predict the likelihood of GERD symptoms  and it has a negative impact on the quality of life.  Similarly, family history is also a risk factor which suggests that there may be a genetic component to the disorder.  On the other hand, two patients with migraine have been described to have suffered from GERD symptoms. The reflux triggered headaches originated from the upper gum/teeth and these patients are reported to respond to specific reflux treatments.  One study demonstrated a high prevalence of GERD in patients with chronic rhinosinusitis (CRS). Among these patients, many of them experienced the improvement of modest sinus symptoms after the treatment with omeprazole for 3 months.  Spierings described three patients who presented with headache of gastrointestinal origin. In these patients, reflux, dyspepsia and constipation were the precipitating factors. The headache responded promptly to the treatment of the respective gastrointestinal disorders. 
This study was conducted to analyze the potential of a positive family history of GERD symptoms as a risk factor for and presence of headache as a complication of GERD.
| Materials and Methods|| |
This is a population-based study in which a total of 3600 subjects were selected by cluster random sampling from all the seven districts of Shiraz city. After a brief explanation and awareness program regarding the research project for every participant, they were invited to refer to Mottahari OPD Digestive Disease Clinic or the Gastroenterohepatology Research Center of Shiraz University of Medical Sciences based in Nemazi hospital. In 5 months, 1958 subjects participated in this study inclusion criteria includes were the age of more than 35 years old and residing in the city. A team of interviewers who had undergone an intensive training and had worked with our center completed a close-ended questionnaire survey; this questionnaire consisted of 53 multiple-choice questions including the demographic data (age, gender, place of residence and level of education), signs and symptoms of GERD, headache and family history of GERD. Heartburn, one of the major GERD symptoms, was defined as a burning feeling in epigastric area that rises through the chest in substernal area. Acid regurgitation, the other major GERD symptom, was defined as the returning of the liquid back into the mouth leaving a bitter or sour taste. A subject suffered from GERD when they reported heartburn and/or acid regurgitation in the preceding year with a frequency of at least once a week irrespective of its severity or duration. The reliability and validity of the questionnaire were determined by requesting 100 subjects to refer again to our clinic to be interviewed by the same trained interviewers and a gastroenterologist for the completion of the questionnaire. Statistical analysis was performed using the SPSS computer software package. A p value of 0.05 or less was considered to be statistically significant and all the reported P values were two-sided values obtained using Chi-square test.
| Results|| |
Among the 3600 households that were visited, the interview questionnaire survey was conducted for 1958 subjects (response rate: 54.3%; mean age: 49.90 ± 11.14 years). Among the subjects, 35.2% were male and 21.4% were illiterate. The reliability and validity of the questionnaire were 82 and 70%, respectively.
This study revealed that, among the patients with GERD symptoms, a total of 132 patients (72%) reported a history of GERD in at least one member of the family. Our results showed a significant correlation between GERD symptoms and the positive family history of the disease (P = 0.000) [Table - 1].
Patients showed a variable frequency of headache, ranging from once daily (16.7%), three to five times a week (5.6%), once-twice a week (26.7%), once to three times a month (15.0%) and less than once a month (8.3%). Fifty patients (27.8%) with GERD symptoms did not report any complaints of headache. There was a significant correlation between the headache and the symptoms associated with GERD (P = 0.000) [Table - 2].
In addition, this study showed that some factors were significantly correlated with the presence of GERD symptoms. Regarding gender, reflux symptoms were more common in females than males (P < 0.001) [Table - 3]. GERD was also observed more frequently in subjects with lower levels of education and its prevalence appeared to decrease as literacy increased in the study population (P = 0.001) [Table - 3].
| Discussion|| |
GERD has been defined as the movement of gastric contents into the esophagus without the initiation of vomiting. It has a common clinical presentation of a burning discomfort in the retrosternal area, regurgitation and dysphagia, with 20-60% of patients with head and neck symptoms without heartburns.  Our study elaborates that, the patients may also possess associated factors that may provide a clearer picture of the disease and a unified therapeutic approach.
In this study, the cases aligned well to this clinical definition, although this may lead to the underestimation of the actual prevalence of the disease as the known symptoms do not include the atypical ones, particularly if these symptoms are not associated with the classic ones. Unfortunately, the frequency of atypical symptoms in patients suffering from GERD is not well known and the optimal management of such symptoms has not been well established.  It has been reported that almost 27.1% of patients with GERD present with dominant atypical symptoms.  There are consistent evidences to support the role of dietary fat in causing temporary episodes of reflux, where several physiological studies of human volunteers have shown increased frequency of the transient lower esophageal sphincter relaxation and increased esophageal acid exposure with high fat consumption.  This may partly explains the significant correlation between GERD and family history as the family groups are usually exposed to the same dietary and lifestyle patterns. Familial factors are important in the etiology of GERD; a number of reports describe families with multiple members affected by symptomatic, endoscopic or complicated GERD. Two case-control studies have revealed the aggregation of GERD symptoms in the families of patients with GERD. 
Given the possible relationship between GERD and chronic sinusitis, it may be a potential cofactor or initiating factor in patients with chronic sinusitis when no other etiology exists or in those whose symptoms are unresponsive to conventional therapies.  Other upper respiratory symptoms (URS) are also frequent among subjects with symptomatic GERD diagnosed by esophageal pH studies. The correlation of URS with reflux episodes supports an association of URS with symptomatic GERD.  A variety of pulmonary and ear, nose and throat (ENT) symptoms and disorders are also considered to be extraesophageal manifestations of GERD, including asthma, chronic cough, laryngeal disorders and various ENT symptoms. Recent studies have established that GERD underlies or contributes to chronic sinusitis, chronic otitis media, paroxysmal laryngospasm, excessive throat phlegm and postnasal drip.  All these may partially play a role in the pathophysiology of the headache that has been reported among our patients. Unfortunately, GERD is not clinically apparent in most patients with supraesophageal manifestations to which it is linked. Neither heartburn and regurgitation nor esophageal inflammation, the finding diagnostic for GERD, are always present.  This suggests that the screening methods used to distinguish patients with and without the disease are not adequate. The classical symptoms of GERD are well known, particularly that of indigestion and heartburn. Atypical symptoms, however, affect a variety of medical and dental specialties and are often chronic and insidious in nature. The presentation of atypical symptoms may occur in the absence of typical symptoms. Although there is a need for the improved understanding of the pathophysiology of atypical GERD and for the improved identification of the condition and its atypical manifestations, linking symptoms to esophageal causes, particularly GERD, is difficult and often poorly investigated.  The possible relationship between acid reflux, URS and migraine headaches has also been reported. ,, A number of patients with migraine headaches complain of the worsening of the headache with increased heartburn. In such cases, the symptoms should be clearly identified to determine whether they are GERD-related ones. This study did not attempt to classify migraine and non-migraine headaches; and future studies may be beneficial if a closer specific consideration may be given to all types of headaches in patients with GERD symptoms.
| Conclusion|| |
The positive family history of GERD and a history of headaches may be considered as the risk factors for the presence of GERD. The management of chronic headache and GERD presenting with atypical/unusual symptoms should be through a common protocol since these two entities appear to have the same origin but present differently.
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Gastroenterohepatology Research Center, Nemazee Hospital, Shiraz University of Medical Sciences, P.O.Box 71935-1311, Shiraz
Source of Support: None, Conflict of Interest: None
[Table - 1], [Table - 2], [Table - 3]