Chronic migraine: risk factors, mechanisms and treatment

A Cox's hazard model for new development of medication overuse headache in pure chronic migraine patients under migraine prophylaxis

BACKGROUND

Medication Overuse Headache (MOH) occurrence during migraine preventive therapy is poorly known. The present study aims at identifying the rate and factors influencing MOH development in patients with Chronic Migraine (CM).

METHODS

Patients with a diagnosis of CM without MOH were consecutively recruited and followed at least three times for 1 year under preventive therapy. The number of headache days and the use of acute medication were recorded; the occurrence of MOH was considered as the main event. Kaplan-Meier curves were used to determine the time of the event. After the third follow-up patients were censored. Proportional hazards Cox regression was used to identify predictors of MOH among demographic variables (e,g. age), main comorbidities (e.g. sleep disorders, epilepsy, thyroid dysfunctions), migraine features (e.g. aura, number of previous preventive therapies, headache days and number of medications).

RESULTS

We recruited 260 first-visit patients with CM. 46 patients (17.70%) developed a new onset of MOH over 1 year, with 35 at the first follow-up. No difference in MOH occurrence was found among different pharmacological groups (Chi-square = 2.99, p = 0.70). About 1/3 of non-responders developed MOH. Monthly headache days, number of acute medications, thyroid dysfunction, epilepsy, and MIDAS score were associated with MOH (Chi-square = 14.08; p = 0.01). Headache days (Wald test: 6.0; p = 0.014) and MIDAS score (Wald test: 4.07, p = 0.04) were the only stand-alone significant factors.

CONCLUSIONS

The rate of new occurrence of MOH in patients without a previous history is 18%. Monthly number of headache days and MIDAS score are the most important predictors.

Disrupting Migraine Dynamics: A Narrative Review of the Consequences of Modern Anti-CGRP Monoclonal Antibody Therapies

This article provides an overview of a symposium held as part of the proceedings at the 10th European Academy of Neurology Congress in Helsinki, Finland, on 2 July 2024. Migraine is a common neurological disease and a leading cause of disability worldwide. Anti-calcitonin gene-related peptide (CGRP) therapies are the first to be specifically developed for migraine prevention and are recommended as a first-line option by the American Headache Society and European Headache Federation. Data on the effectiveness of anti-CGRP therapies are now available from clinical trials and real-world studies, and this article briefly reviews these data and discusses what they mean for people with migraine, and how healthcare professionals can take the conversation back to their clinics.

Dose-dependent association between proton pump inhibitor use and the risk of migraine: a nationwide matched case-control study

BACKGROUND

Proton pump inhibitors (PPIs) are widely prescribed, but their link to migraine risk, especially in Asian populations, remains unclear. This longitudinal study aimed to answer the following question: Does PPI exposure show a dose-dependent risk of migraine, varying by subtype and PPI indication in an Asian population?

METHOD

Using Taiwan's National Health Insurance Research Database (2000-15), we conducted a matched case-control study on PPI exposure. Adults prescribed PPIs for peptic ulcers, gastroesophageal reflux disease, or upper gastrointestinal bleeding were included, excluding those with prior migraines or incomplete data. Controls were matched 1:1 by age, sex, and residence. PPI exposure was measured in cumulative defined daily doses (cDDDs).

RESULT

The study included 22 834 PPI users (11 417 cases, 11 417 controls) with a mean follow-up of 4.1 ± 3.3 years. The study population comprised 65.6% females and 34.4% males, with no significant sex difference (P = 1.000). Mean age was 47.27 ± 15.16 years in cases and 47.42 ± 15.14 years in controls (P = .444). The average interval from PPI initiation to migraine diagnosis was 2.4 ± 1.9 years. Compared with those with the lowest PPI exposure (cDDD ≤30), migraine risk progressively increases with greater cumulative exposure: cDDD 31-120 [aOR = 1.22, 95% confidence interval (CI) = 1.15-1.30], cDDD 121-365 (aOR = 1.42, 95% CI = 1.32-1.52), and cDDD >365 (aOR = 1.60, 95% CI = 1.41-1.80). This dose-dependent relationship was consistent across migraine subtypes and PPI indications.

CONCLUSION

This large-scale Asian population study revealed a significant dose-dependent association between PPI exposure and increased migraine risk, emphasizing the need for cautious prescribing and monitoring of migraine symptoms in long-term PPI users, particularly in Asian populations.

A clinical guide for physiotherapists to assess and manage cervical musculoskeletal impairment and pain sensitivity in migraine patients

INTRODUCTION

Migraine is a complex neurological disorder characterized by different signs and symptoms, often presenting with an altered pain sensitivity and cervical musculoskeletal impairments. Thus, the management of migraine patients should include the assessment and eventually a specific treatment of these characteristics.

PURPOSE

Physiotherapists play a key role in identifying and managing cervical musculoskeletal impairments and altered pain sensitivity in migraine patients. This manuscript provides evidence-based guidance on assessment techniques and clinical reasoning strategies to help physiotherapists effectively evaluate and interpret these characteristics in clinical practice.

IMPLICATION

This manuscript serves as a practical guide for physiotherapists by: Outlining physiotherapy assessment techniques for migraine patients.Providing reference cutoff values to identify increased pain sensitivity and cervical dysfunctions.Supporting individualized clinical reasoning to understand these characteristics within each patient's overall condition.Clarifying the rationale behind physiotherapy interventions and integrating hands-on and hands-off therapeutic approaches based on patient-specific needs.

The role and interaction of hypothalamic-related neurotransmitters in migraine

Migraine is a complex neurological disorder frequently associated with hypothalamic dysfunction. This brain region is essential for maintaining homeostasis due to its regulation of autonomic, endocrine, and circadian systems. While the pathophysiology of migraine remains incompletely understood, clinical features such as the cyclic nature of attacks and symptoms, including nausea, vomiting, yawning, irritability, and sensitivity to light, indicate a significant role for the hypothalamus. Further, potential triggers of migraine, such as stress and disruption to feeding habits, also impact hypothalamic mechanisms. The higher prevalence of migraine in women compared to men suggests a link to hormonal fluctuations involving estrogen, progesterone, and prolactin. These hormones interact with the hypothalamus, potentially influencing the onset and severity of migraine episodes. Additionally, the hypothalamus synthesizes neuropeptides such as orexins, neuropeptide Y, PACAP, oxytocin, and vasopressin, which are all implicated in migraine mechanisms. Understanding the interplay between the hypothalamus, sex hormones, and neuropeptides offers valuable opportunities for endogenous targeted migraine therapies. In this review we discuss hypothalamic contributions to migraine pathophysiology, highlighting the mechanisms affected by hypothalamic connections, neuropeptides, and hormones, and their role as migraine triggers, particularly focusing on factors like stress, fasting, and changes in sleep patterns.

Effect of pain-related sodium channels SCN9A and SCN10A polymorphisms in migraine chronification

OBJECTIVE

Based on the frequency of attacks, migraine is classified into two subtypes: episodic (EM) and chronic (CM). Migraine progression from EM to CM is supposed to be affected by various factors, which is known as "migraine chronification. However, the pathophysiology of migraine chronification is multifactorial and still not fully understood. Ion channels are hypothesized to play a role in migraine pathophysiology and are essential for generating and suppressing action potentials, which lie under the pain and related symptoms. Two sodium channel genes, SCN9A and SCN10A, have been reported to be associated with various pain sensitivities. Studies have shown that patients with EM and CM are more sensitive to chronic pain and that pain sensitivity may be a risk factor for chronification. Thus, the current study aimed to determine whether pain sensitivity-related SCN9A and SCN10A polymorphisms affect the EM-to-CM transition.

METHODS

For this purpose, genotyping was performed using TaqMan SNP Assay for the (i) SCN9A rs7595255, rs12622743, and rs11898284, (ii) SCN10A rs6795970, rs6801957 SNPs in Turkish EM and CM patients.

RESULTS

The results showed that SCN9A and SCN10A polymorphisms did not play a role in the development of chronicity. However, the results indicated that the SCN10A rs6795970 polymorphism was associated with osmophobia (p = 0.036).

CONCLUSION

SCN10A rs6795970 polymorphism may be necessary to predict the EM-to-CM transition and identify therapeutic targets. However, further studies are required to confirm the osmophobia association of the SCN10A rs6795970 polymorphism and to investigate the role of these SNPs in chronification.

Neuromodulation in Chronic Migraine: Evidence and Recommendations from the GRADE Framework

Chronic migraine (CM) affects approximately 2% of the general population and is defined by the persistence of migraine symptoms for at least 15 days per month for at least 3 months. CM is often refractory to common drug treatments and is associated with a significant burden in functions of daily life during ictal phases, productivity loss, and direct costs. Modulation of pain is considered pivotal to reduce its impact and to improve the quality of life among patients with CM. In recent years, neuromodulation in CM has received growing attention; however, there remains no consensus regarding the effectiveness and safety of these procedures. Previous invasive methods such as occipital nerve neurolysis and interruption of the trigeminal dorsal root are not indicated due to high rates of relapsing pain and frequent procedural complications. Although emerging neuromodulation methods, both noninvasive, such as vagus nerve stimulation (VNS), transcranial magnetic stimulation (TMS), remote electrical neuromodulation (REM), and invasive, such as deep brain stimulation (DBS), occipital nerve stimulation (ONS), and high-frequency 10-Hz spinal cord stimulation (HF-10 SNS) have demonstrated promising outcomes in early clinical trials, their use has yet to be integrated into routine clinical practice. In this review, study evidence and strength of recommendations are assessed by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system. Other conditions such as therapeutic risk/benefit, direct and indirect costs, use of resources, and patient/clinician preferences are also evaluated.

"I am now on 'speaking terms' with my migraine monster" - patient experiences in acceptance-based cognitive behavioral therapy delivered via the internet for migraine: a randomized controlled pilot study using a mixed-method approach

Migraine is a common neurological disorder globally. Migraines, with or without aura, are episodic and recurring with symptom-free periods. Frequent and prolonged attacks can lead to chronic migraine. This pilot randomized controlled trial (RCT) aimed to evaluate feasibility of therapist-guided, acceptance-based internet cognitive behavioral therapy (iCBT) as an adjunct to standard medical care for migraine patients in Swedish primary healthcare settings using a mixed methods approach. Participants (treatment n = 15, control n = 14) underwent qualitative and quantitative assessments to evaluate feasibility, acceptance, and initial treatment effects. Interviews with participants (n = 7) indicate that most participants had struggled with migraines for decades and expressed dissatisfaction with the limited medical care. They found the flexible, digital format particularly helpful, praising its accessibility and structured learning. While they appreciated the comprehensive content, some faced challenges with the psychological language and the program pace. Post-treatment, participants reported emotional and behavioral changes, and better migraine management. Seventy-two percent of the 29 participants completed both baseline and 3-month follow-up measures. On average, participants completed 7.7 modules, with 60% completing all 10 modules. Promising effect size indicated a reduction in migraine days during the three-month follow-up. Both qualitative and quantitative data support the feasibility and acceptability of the intervention in primary care settings.

Metabolic Dysfunction and Dietary Interventions in Migraine Management: The Role of Insulin Resistance and Neuroinflammation-A Narrative and Scoping Review

INTRODUCTION

Migraine is a prevalent neurological disorder characterized by recurrent headaches with autonomic and neurological symptoms, significantly impacting quality of life globally. Its pathogenesis involves genetic, neurological, inflammatory, and metabolic factors, with insulin resistance and metabolic dysfunction increasingly recognized as important contributors. Historically, it has been known that certain foods can trigger migraine attacks, which led for many years to the recommendation of elimination diets-now understood to primarily target histamine-rich foods. Over the past two decades, attention has shifted toward underlying metabolic disturbances, leading to the development of dietary approaches specifically aimed at addressing these dysfunctions.

METHODS

A scoping literature review was conducted using PubMed and Embase to evaluate the relationships among migraine, insulin-related mechanisms, neurogenic inflammation, and dietary interventions. Initial searches focused on "MIGRAINE AND (neurogenic inflammation)" (2019-15 April 2025), followed by expanded searches from 1950 onward using terms such as "MIGRAINE AND (insulin, insulin resistance, hyperinsulinism)", and "MIGRAINE AND (diet, dietary, nutrition, nutritional)". A specific search also targeted "(INSULIN OR insulin resistance OR hyperinsulinism) AND (neurogenic inflammation)". Abstracts were screened, full texts were retrieved, and duplicates or irrelevant publications were excluded. No filters were applied by article type or language. Systematic reviews and meta-analyses were prioritized when available.

RESULTS

Migraine pathogenesis involves trigeminovascular system activation, neurogenic inflammation mediated by CGRP and PACAP, immune dysregulation, mast cell activation, and cortical spreading depression (CSD). Emerging evidence highlights significant associations between migraine, insulin resistance, and hyperinsulinism. Hyperinsulinism contributes to migraine through TRPV1 sensitization, increased CGRP release, oxidative stress, mitochondrial dysfunction, and systemic inflammation. Metabolic dysfunction, including obesity and insulin resistance, exacerbates migraine severity and frequency. Dietary interventions, particularly anti-inflammatory, Mediterranean, and ketogenic diets, show promise in reducing migraine frequency and severity through mechanisms involving reduced inflammation, oxidative stress, improved mitochondrial function, and glucose metabolism stabilization.

CONCLUSIONS

The interplay between insulin resistance, metabolic dysfunction, and neuroinflammation is crucial in migraine pathophysiology. Targeted dietary interventions, including ketogenic and Mediterranean diets, demonstrate significant potential in managing migraines, emphasizing the need for personalized nutritional strategies to optimize therapeutic outcomes.

Overview of migraine care, impact of the disease, and patient experience in France through patient voices: a cross-sectional and participatory survey study

BACKGROUND

This study aims to improve the understanding of the patient journey via the perspectives of patients with migraine.

METHODS

The questionnaire was created by patients. It was based on the experiences of 24 patients with migraine and 4 members of the patient advocacy organization La Voix des Migraineux. Two focus groups were held to assess the various dimensions of the patient journey. This survey was accessible on the MoiPatient online platform between March 19th and May 17th, 2022.

RESULTS

Out of the 683 participants (average age: 41.8 years; female: 92.4%; average age at first migraine attack: 16.2 years), 95.9% had received a formal migraine diagnosis from a physician. Migraine had a significant impact on most participants (96.0% had a severe HIT-6 score and 70.7% had severe disability on the MIDAS). Unmet patients' needs highlighted in this study included diagnosis delay (mean 7.5 years), treatment delay, limited access to neurologists and/or headache specialists, long trial-and-error process of different medications (participants had tried an average of 5.6 acute treatments and 5.0 preventive treatments), numerous (7.2 side effects per participants on average) and often inadequately addressed side effects, suboptimal patient education, and the need for a therapeutic, empathic, and supportive relationship between patients and healthcare professionals. Participants had a negative perception of the care journey and experience with healthcare professionals: 36.2% described their care journey as an uphill battle ("parcours du combatant"). More than half of patients did not feel heard nor supported by healthcare professionals.

CONCLUSION

Patients with migraine have to face a multitude of complex obstacles trying to get the care they deserve. The burden of disease is amplified by the complexity of the migraine patient's journey, both in terms of diagnosis and treatment. This study highlights specific areas in need for improvement.

Rates and risk factors for migraine progression using multiple definitions of progression: Results of the longitudinal OVERCOME (US) study

OBJECTIVE

To estimate rates of migraine progression and assess predictors of progression in a large, longitudinal cohort study using the traditional definition and two alternative definitions of migraine progression.

BACKGROUND

Traditionally, migraine progression is defined as moving from episodic migraine (EM) with ≤ 14 monthly headache days (MHD) to chronic migraine (CM) with ≥ 15 MHDs of which 8 are attributable to migraine. This definition does not take into account changes in the full range of potential headache days, disability, or impact on function.

METHODS

The Observational Survey of the Epidemiology, Treatment, and Care of Migraine (OVERCOME) study identified, characterized, and followed a representative sample of adults with migraine in the United States. Migraine was defined based on the International Classification of Headache Disorders, 3rd edition (ICHD-3) criteria. We estimated rates of migraine progression at 1 year of follow-up using three definitions: (1) traditional EM-to-CM transition, (2) increase of ≥ 5 MHDs (MHD progression), and (3) increase of ≥ 5 points on the Migraine Disability Assessment (MIDAS) scale (MIDAS progression). The analysis identified sociodemographic, clinical, and migraine-related characteristics associated with each definition of progression from a set of 67 candidates and then determined the association with progression for each candidate predictor and each definition of progression.

RESULTS

A total of 11,634 participants met ICHD-3 criteria for migraine at baseline and completed the 1-year follow-up survey. The average age was 48.2 years, and average years living with migraine was 22.8 years. The sample was 75.6% female (8793/11,634), 84.4% White (9814/11,634), 6.5% Black (757/11,634), and 7.6% Hispanic (889/11,634). The majority (89.2%, 10,374/11,634) had EM at baseline, and among these, 4.7% progressed to CM over 1 year of follow-up. Rates of progression at 1 year were higher using other definitions of progression, with 9.6% (1087/11,329) reporting an increase in ≥ 5 MHDs and 21.7% (2519/11,630) reporting an increase of ≥ 5 MIDAS points. Across all three definitions of progression, ever taking preventive medications for migraine placed people at lower odds of progressing (odds ratio [95% confidence interval]: EM-to-CM transition, 0.7 [0.57-0.85]; MHD progression, 0.9 [0.75-1.00]; MIDAS progression, 0.8 [0.73-0.91]), while the presence of depression placed people at higher odds of progressing (odds ratio [95% confidence interval]: EM-to-CM transition, 1.3 [1.05-1.69]; MHD progression, 1.4 [1.21-1.67]; MIDAS progression, 1.2 [1.04-1.34]).

CONCLUSION

This work expands the concept of migraine progression, exploring two alternative definitions that modify the potential range of MHD changes and take disability into account. This analysis identified never having used preventive medications for migraine and presence of depression as risk factors across all three definitions of progression. This work may more accurately identify persons with progression and at risk of migraine progression, setting the stage for trials of preventive intervention and ultimately more effective practice.

Association of periodontitis and periodontal parameters with migraine and mortality in people with migraine disease: A nationally representative observational study

OBJECTIVE

To investigate the association of periodontitis and clinical periodontal parameters with migraine as well as mortality among people with migraine disease.

BACKGROUND

Periodontitis has been shown to increase the systemic inflammatory burden thereby promoting various systemic health outcomes; however, the evidence regarding the relationship between periodontitis and migraine is scarce.

METHODS

A cross-sectional study was performed, and it included 13,108 participants from the National Health and Nutrition Examination Survey (1999-2004). Weighted logistic regression analysis was used to evaluate the association between periodontitis/clinical periodontal parameters and migraine. Mediation analysis was performed to explore the potential mediating role of inflammatory response. A cohort study including 1909 participants with migraine disease was further conducted to assess the associations between periodontitis/clinical periodontal parameters and mortality from all causes, cardiovascular disease (CVD), and cancer in participants with migraine disease using Cox proportional hazards models. Death outcomes were ascertained by linkage to National Death Index records through December 31, 2018.

RESULTS

Periodontitis was positively associated with migraine (odds ratio [OR] 1.29, 95% confidence interval [CI] 1.01-1.65). Each 1-unit rise in attachment loss and pocket depth was linked to a 17.5% (OR 1.18, 95% CI 1.08-1.29) and 28.1% (OR 1.28, 95% CI 1.08-1.51) increase in migraine risk, respectively. Mediation analyses revealed that leukocyte, monocyte, and lymphocyte counts mediated 17.9%, 7.3%, and 20.1%, respectively, of the association between periodontitis and migraine. During a median follow-up of 17.7 years among 1909 participants with migraine disease, periodontitis was associated with greater all-cause mortality (hazard ratio 1.82, 95% CI 1.25-2.66), but was not significantly associated with mortality from CVD or cancer among participants with migraine disease. Similar association patterns were also observed for attachment loss and pocket depth.

CONCLUSIONS

This study provides evidence that periodontitis and clinical periodontal parameters were significantly associated with migraine as well as all-cause mortality in people with migraine disease. These findings underscore the importance of considering periodontal health in the prevention and management strategies for migraine disease.

Clinical comparisons between post-traumatic headache and migraine: A cross-sectional study

ObjectiveTo compare clinical characteristics, treatment patterns, and patient-reported outcome measures (PROMs) in persons with persistent post-traumatic headache (PTH) and those with episodic or chronic migraine (with and without medication-overuse headache).MethodsThis cross-sectional study included adults with persistent PTH following mild traumatic brain injury and adults with episodic or chronic migraine. Information on headache features, treatment patterns, and PROMs were collected via semi-structured interviews and standardized questionnaires, including the HIT-6, MIDAS, HADS, ASC-12, CSI, WHODAS-2.0, NDI, and ODI.ResultsA total of 132 participants with persistent PTH and 751 with migraine were enrolled. On average, participants with persistent PTH reported 27.2 ± 9.3 monthly headache days, and 93.9% had a migraine-like phenotype. Compared with episodic migraine, the persistent PTH group had higher MIDAS scores (72.5 [IQR, 28.0-156.0] vs. 40.0 [IQR, 20.0-62.8]; P < 0.001), HADS-Anxiety (6.0 [IQR, 3.3-9.0] vs. 5.0 [IQR, 3.0-7.0]; P = 0.003), higher HADS-Depression scores (6.0 [IQR, 3.0-9.0] vs. 3.0 [IQR, 1.0-5.0]; P < 0.001), CSI (67.2 [SD, 15.0] vs. 57.4 [SD, 12.5]; P = 0.002), WHODAS-2.0 (41.0 [IQR, 15.5-68.5] vs. 22.0 [IQR, 10.0-35.0]; P < 0.001), and NDI (21.0 [IQR, 16.0-27.0] vs. 14.5 [IQR, 8.0-22.0]; P = 0.007). No marked differences were noted between the PTH group and chronic migraine groups.ConclusionsPersons with persistent PTH show similar disability and headache profiles to those with chronic migraine. These findings underscore the need for targeted management strategies, similar to those used in chronic migraine care.

The challenge of diagnosing intracranial pressure elevations as an otolaryngologist

PURPOSE

This article addresses the complex clinical scenario where patients present to otolaryngologists with symptoms typically ascribed to chronic rhinosinusitis (CRS) or migraines which may in fact stem from elevations in intracranial pressure. We aim to clarify the diagnostic challenges and emphasize the importance of considering elevated intracranial pressure (eICP) as its symptoms overlap with both CRS and migraines.

METHODS

This narrative review synthesizes clinical experiences and literature to discuss the differential diagnoses involving CRS, facial pain/pressure, migraines, and eICP. Key discussion points include symptomatology of eICP and its management in otolaryngological practice.

RESULTS

Patients presenting with symptoms of CRS or migraine may exhibit overlapping signs that makes diagnosis challenging. Patients with symptoms of facial pain and pressure, or other findings such as ear fullness, muffled hearing, and tinnitus, that do not resolve with conventional topical intranasal therapies or migraine management should be worked up for eICP.

CONCLUSION

The overlap in clinical presentations among patients with concern for CRS, migraines, and ICP elevations poses a diagnostic challenge. It is crucial for otolaryngologists and neurologists to collaborate closely to ensure accurate diagnoses and appropriate management. Enhanced awareness and understanding of the broader spectrum of symptoms associated with eICP can prevent misdiagnosis and promote better patient outcomes.

Transcutaneous occipital nerve stimulation alleviated migraine related pain by regulating synaptic plasticity and CGRP expression in the periaqueductal gray of male rats

BACKGROUND

Clinical observations have shown that transcutaneous occipital nerve stimulation (tONS) is effective in treating migraine. However, the underlying mechanisms are poorly understood. This study employs a rodent model to investigate the therapeutic effects of tONS on migraine-related pain and to explore potential mechanisms.

METHODS

The SD rats were used to establish the migraine model by repeated epidural infusions of inflammatory soup (IS). Modified bilateral electrodes were attached noninvasively for tONS treatments. Periorbital mechanical thresholds were assessed using von-Frey filaments, and other pain-related nociceptive behaviors were analyzed through video recordings. The expressions of c-Fos, synaptophysin (Syp) and calcitonin gene-related peptide (CGRP) in the trigeminal nucleus caudalis (TNC) and/or periaqueductal gray (PAG) area were measured by immunofluorescence and western blotting analyses. The excitatory synaptic transmission in the PAG was detected by whole-cell patch-clamp recording among migraine rats.

RESULTS

The reduction in periorbital mechanical thresholds induced by repeated IS infusions was partially reversed by tONS treatments in migraine rats. Other pain-related behaviors, including exploration, rest, and unilateral grooming, consistently improved following tONS treatment. The TNC and PAG area were activated after IS modeling, and the CGRP expressions in the PAG significantly decreased after tONS treatments. tONS could inhibit the enhanced excitatory synaptic transmission in the PAG of migraine rats.

CONCLUSIONS

Our findings suggest that tONS has therapeutic potential in treating migraine, with the PAG excitability and CGRP expression playing a role in its mechanisms of action. tONS may represent a promising non-invasive neuromodulation approach for the management of migraine in the future.

Effect of migraine on suicide mortality in young adults: a nationwide cohort study in South Korea

BACKGROUND

Migraine is linked to increased suicidal behaviour, but its relationship with suicide mortality remains underexplored. In South Korea, suicide rates are among the highest in Organisation for Economic Co-operation and Development nations, particularly in young adults.

OBJECTIVE

To investigate the effect of migraine on suicide mortality in young Korean adults.

METHODS

Participants who underwent the Korean Health Examination from 2009 to 2012 were enrolled in this study and followed up until 2021. Participants aged 20-39 years (n=6 539 547) were categorised based on their migraine status. Cox proportional hazards regression models assessed the association between migraine and suicide mortality, adjusting for demographic factors, health behaviours and comorbidities.

FINDINGS

Among 6 539 547 participants, 113 681 (1.74%) had migraine (6620 (0.10%) with aura, 107 061 (1.64%) without aura). Over 11 years, there were 21 suicides (0.32%) in migraine with aura, 219 (0.20%) in migraine without aura and 13 040 (0.20%) in no migraine. All migraine was not linked to increased suicide risk (HR 1.07, 95% CI 0.94 to 1.21), but migraine with aura showed a higher risk (HR 1.61, 95% CI 1.05 to 2.47). Migraine without aura had no increased risk (HR 1.03, 95% CI 0.90 to 1.18). Depression modified the association across migraine subtypes.

CONCLUSION AND IMPLICATIONS

Although all migraine and migraine without aura were not significantly associated with a higher suicide risk compared with that in the absence of migraine, migraine with aura was associated with a higher risk of suicide mortality. Depression significantly modified this relationship, showing different associations across migraine subtypes.

Cognition, mental health, and quality of life in patients with chronic and episodic migraine during the interictal period

INTRODUCTION

Migraine is a highly prevalent and disabling condition, not only due to its painful symptoms but also because of its significant impact on mental health and cognitive functioning, leading to a considerable deterioration in quality of life. This study aimed to evaluate the cognitive profile, mental health, and quality of life in patients with chronic and episodic migraine during the interictal period, and to explore their relationship with sociodemographic and clinical variables.

METHOD

This observational, descriptive, cross-sectional analytical study included 60 patients diagnosed with chronic or episodic migraine, who were enrolled in a health program for headache patients between 2010 and 2016. Cognitive function, anxiety and/or depression symptoms, and quality of life during the interictal period were assessed. Descriptive analyses were conducted, and associations were evaluated by configuring primary (type of migraine) and alternative events (cognitive impairment, depression and/or anxiety, and poor quality of life).

RESULTS

The mean age of the participants was 45 years (SD ± 8), with 83.3% being women and 93.3% belonging to middle and low socioeconomic strata. Of the 60 patients, 83.3% (50) were diagnosed with chronic migraine, while the remaining had episodic migraine. The use of one or more cognition-altering medications was observed in 90% of patients with chronic migraine and 60% of those with episodic migraine (p = 0.02). Anxiety was more prevalent in patients with episodic migraine, whereas depression was more common among those with chronic migraine. Female gender, middle socioeconomic status, and longer disease duration were significantly associated with chronic migraine. Among the 57 patients who completed the Mini-Mental State Examination, 38.6% had cognitive impairment, which decreased with longer migraine duration and better social interaction. Memory and selective attention were the most affected cognitive domains in both groups. No significant associations were found for the other variables after adjusting for confounders.

CONCLUSIONS

Chronic migraine significantly impacts mental health, cognition, and quality of life, with depression and cognitive impairments being prevalent. Social interaction and longer disease duration may protect against cognitive decline, highlighting the need for multidisciplinary, personalized interventions addressing neurological and psychosocial challenges.

Profiling chronic migraine patients according to clinical characteristics: a cluster analysis approach

Background

To group the characteristics of chronic migraine (CM) by headache characteristics.

Methods

We performed a retrospective analysis of the medical records of 821 adult CM patients who visited a specialized outpatient clinic for headaches. Using the headache characteristics, we performed Density-Based Spatial Clustering of Applications with Noise (DBSCAN) clustering to group CM patients. The burdens to their lives, monthly headache days (MHD), monthly acute medication intake days (AMD), and treatment outcomes were evaluated among the clusters.

Results

Through a cluster analysis based on headache characteristics, our findings indicated the potential existence of three distinct types of CM: cluster 1 (predominantly female with CM resembling migraine), cluster 2 (higher age, higher BMI, smoker), and cluster 3 (mostly female with CM that have fewer migraine characteristics). The impact on quality of life was significant in cluster 1 compared to cluster 3. However, there were no differences in treatment outcomes, initial MHD, AMD, the years of migraine, or treatment sensitivity among these three clusters.

Conclusion

Cluster analysis mathematically divided CM patients into three groups, with predominant differences in the degree of disruption to their lives and their characteristics; further research is needed on the diagnostic criteria for CM and its characteristics.

A Randomized, Double-Blind, Controlled Trial Protocol for Therapeutic Neuroscience Education in Chronic Migraine Patients: A Clinical-Neurophysiological Combined Study Design

Chronic migraine (CM) is a highly disabling condition, affecting about 2% of the global population. Non-pharmacological treatments can be optimal for their non-invasive nature. This prospective, randomized, double-blind, controlled trial aimed to test the efficacy of therapeutic neuroscience education (TNE) in CM. Early response biomarkers were also evaluated. A total of 80 CM patients were consecutively enrolled and randomly allocated to TNE or a general education program. Treatment effectiveness was evaluated at baseline (T1) and 2 months after the end of treatment (T4). We collected the responses to disability and comorbidity questionnaires at the start (T1) and end of treatment (T3, 10 weeks after start). Early response biomarkers were evaluated at screening (T0) and mid-way through the process (T2, 5 weeks after start). We expected that TNE would provide a greater benefit than the general education program, which served as the primary outcome of this study. We also expected that a change in clinical and neurophysiological measures could potentially occur, reflecting plasticity-induced reorganization and predicting clinical response. This is the first study selectively exploring the effect of TNE as a standalone treatment for CM. A new, effective treatment regime without interactions with other medication could be of great interest as an addition to migraine therapeutic strategies.

Extra-axial inflammatory signal and its relationship to peripheral and central immunity in depression

Although both central and peripheral inflammation have been observed consistently in depression, the relationship between the two remains obscure. Extra-axial immune cells may play a role in mediating the connection between central and peripheral immunity. This study investigates the potential roles of calvarial bone marrow and parameningeal spaces in mediating interactions between central and peripheral immunity in depression. PET was used to measure regional TSPO expression in the skull and parameninges as a marker of inflammatory activity. This measure was correlated with brain TSPO expression and peripheral cytokine concentrations in a cohort enriched for heightened peripheral and central immunity comprising 51 individuals with depression and 25 healthy controls. The findings reveal a complex relationship between regional skull TSPO expression and both peripheral and central immunity. Facial and parietal skull bone TSPO expression showed significant associations with both peripheral and central immunity. TSPO expression in the confluence of sinuses was also linked to both central and peripheral immune markers. Group-dependent elevations in TSPO expression within the occipital skull bone marrow were also found to be significantly associated with central inflammation. Significant associations between immune activity within the skull, parameninges, parenchyma and periphery highlight the role of the skull bone marrow and venous sinuses as pivotal sites for peripheral and central immune interactions.

Association between headache frequency and risk for fibromyalgia in patients with migraine

BACKGROUND

The present study aimed to evaluate the risk and impact of fibromyalgia in relation to headache frequency in migraine patients.

METHODS

This cross-sectional study involved migraine patients from a regional hospital and a tertiary medical center. Diagnoses of migraine and fibromyalgia were made according to the International Classification of Headache Disorders, 3rd edition, and the modified 2016 American College of Rheumatology diagnostic criteria, respectively. Clinical data, including Fibromyalgia Symptoms (FS) scale and revised Fibromyalgia Impact Questionnaire (FIQR), were collected systematically by questionnaires-based interviews. Patients were categorized based on monthly headache day (MHD) cut-offs derived from decision tree analysis based on the chi-squared automatic interaction detection algorithm.

RESULTS

The study involved 2082 migraine patients (1619 female/463 male, mean ± SD age 39.3 ± 12.0 years), including 132 with fibromyalgia (118 female/14 male, mean ± SD age 44.1 ± 12.7 years) (6.3%). Patients were divided into three groups: ≤9 MHDs (n = 924), 10-20 MHDs (n = 745) and ≥21 MHDs (n = 413). The percentage of fibromyalgia increased with headache frequency (p < 0.001). When compared with patients with ≤9 MHDs (2.8%), those with 10-20 MHDs (6.2%) (odds ratio (OR) = 1.90, 95% confidence interval (CI) = 1.11-3.23, p = 0.019) and ≥21 MHDs (14.5%) (OR = 3.68, 95% CI = 2.08-6.49, p < 0.001) were more likely to have fibromyalgia. Patients with more frequent headaches had higher FS and FIQR scores (all p < 0.001 between MHD categories).

CONCLUSIONS

There was an independent dose-response association between headache frequency and odds, severity, and impact of fibromyalgia in migraine patients. For migraine patients with a higher headache frequency, the potential risk of comorbid fibromyalgia should not be overlooked given its association with more severe clinical manifestations and greater disability.

Migraine and its major subtypes - with and without aura are associated with polygenic scores for autism

BACKGROUND

Individuals with autism spectrum disorder (ASD) experience a wide array of neurological, psychiatric and medical comorbidities, yet little attention has been given to the potential link between ASD and migraine, one of the most prevalent neurological disorders worldwide. This study aimed to investigate whether a genetic predisposition for ASD is linked to migraine and its major subtypes, with and without aura. Additionally, potential moderator and mediators of the association between ASD and migraine were explored.

METHODS

Polygenic scores (PGS) for ASD were constructed based on the genome-wide association study by the Psychiatric Genomics Consortium, on the UK Biobank cohort dataset comprising 337,386 participants using PRSice-2. Regression analyses were performed to investigate the association of ASD PGS with migraine and its major subtypes, with and without aura. Sex was explored as a potential moderating factor. The mediation analyses took into consideration variables such as education, personality trait neuroticism, body mass index (BMI) and four categories of comorbidities (psychiatric, vascular, neurologic and others).

RESULTS

ASD PGS were significantly and positively associated with migraine (odds ratio (OR) = 1.04, 95% confidence interval (CI) = 1.02-1.05, p < 0.002), migraine without aura (OR = 1.05, 95% CI = 1.02-1.07, p < 0.002) and migraine with aura (OR = 1.05, 95% CI = 1.02-1.07, p < 0.002). No moderating effect of sex on the association between ASD PGS and migraine was observed. As for potential mediators, only the personality trait neuroticism significantly mediated the association between ASD PGS and migraine, with the proportion of effect mediated 8.75% (95% CI = 4-18%).

CONCLUSIONS

Our study suggests that individuals genetically predisposed to autism are at higher risk of experiencing migraine, including the two major subtypes, with and without aura. While emphasizing the complex shared genetic and pathophysiological interactions of these conditions, the role of personality trait neuroticism as a mediator of this relationship is highlighted.

Impact of duration of chronic migraine on long-term effectiveness of monoclonal antibodies targeting the calcitonin gene-related peptide pathway-A real-world study

OBJECTIVE

We assessed whether the effectiveness of monoclonal antibodies (mAbs) targeting the calcitonin gene-related peptide (CGRP) pathway changes according to the duration of chronic migraine (CM) over 12 months.

BACKGROUND

In most patients, CM is a progressive disease starting with episodic migraine. Longer CM duration might be associated with more difficult treatment, probably because the mechanisms underlying chronicization are strengthened. Therefore, early treatment of CM could lead to better outcomes compared with later treatment.

METHODS

This cohort study included individuals with CM treated with anti-CGRP mAbs in two tertiary headache centers from April 2019 to May 2023. The primary outcome included a change in monthly migraine days (MMDs) from baseline to the third trimester of treatment, 10-12 months. Secondary outcomes established whether response to anti-CGRP mAbs has a more rapid onset in individuals with shorter CM duration compared with longer duration; they included change in MMDs, monthly headache days (MHDs), and days and number of intakes of acute medication during each trimester compared to baseline. Additional outcomes included persisting MMDs, MHDs, and days and number of intakes of acute medication during each trimester of treatment. Patients were compared across tertiles of the overall CM duration.

RESULTS

The study included 335 individuals with CM, with a median (interquartile range [IQR]) age of 48 (39-57) years; 270 (80.6%) were women. Patients in the highest tertile of CM duration (aged 18-60 years) were older than patients in the lower duration tertiles (0-7 years and 8-18 years, respectively), with a median (IQR) age of 56 (48-64) years compared with 42 (31-50) years, and 48 (39-56)years, respectively (p = 0.025); however, this difference was likely due to a correlation between age and disease duration. The change in MMDs from baseline to the last trimester of treatment (10-12 months) was comparable across tertiles of CM duration (median [IQR] -12 [-18 to -5] days, -12 [-17 to -6] days, and -12 [-18 to -4] days; p = 0.946). No difference emerged in secondary outcomes, suggesting a similar time to onset of anti-CGRP mAbs effect across all tertiles of CM duration.

CONCLUSIONS

Our data showed that anti-CGRP mAbs are effective and have a rapid onset of action in CM regardless of disease duration.

Association between serum cryptoxanthin levels and migraine in American adults: results from NHANES

BACKGROUND

Oxidative stress and neuroinflammation play critical roles in the pathogenesis of migraine, a neurovascular disease. Cryptoxanthin is a carotenoid known for its potent antioxidant and anti-inflammatory properties. However, the specific association between serum cryptoxanthin levels and migraine remains unclear. This study aims to evaluate the correlation between migraine and serum cryptoxanthin levels.

METHODS

For this cross-sectional analysis, information was gathered from individuals ≥20 years who took part in the National Health and Nutrition Examination Survey from 2001 to 2004. Details information was collected on migraines, serum cryptoxanthin levels and various crucial factors. Multivariable logistic regression and restricted cubic spline regression analyses were performed to investigate the relationship between serum cryptoxanthin and the occurrence of migraines.

RESULTS

The study included 8,645 participants, of whom 20.00%(1734/8645) experienced migraine. There was a nonlinear relationship (p < 0.001) between serum cryptoxanthin levels and migraine, which was depicted as an L-shaped curve. The occurrence rate of individuals with serum cryptoxanthin levels below 26.64 nmol/dL experiencing migraine was 0.976 (95% CI: 0.965∼0.987, p<0.001).

CONCLUSION

In adults among the United States, increased levels of serum cryptoxanthin were associated with decreased risk of migriane with a turning point at around 26.64 nmol/dL in American adults. Further studys are needed to confirm our findings.

Alpha-asarone alleviates cutaneous hyperalgesia by inhibiting hyperexcitability and neurogenic inflammation via TLR4/NF-κB/NLRP3 signaling pathway in a female chronic migraine rat model

Migraine is a highly prevalent neurological disorder. Alpha-asarone (ASA), a major active component found in Acorus tatarinowii, plays a crucial role in analgesia and anti-inflammation for neuropathic pain. This study aimed to assess the efficacy of ASA against migraine and elucidate its potential mechanisms using a well-established inflammatory soup (IS) migraine female rat model. Mechanical pain thresholds were assessed daily before IS infusion, followed by post-infusion administration of ASA. Subsequently, spontaneous locomotor activities, exploratory behavior, short-term spatial memory, and photophobia were blindly evaluated after the final drug administration. The rats were then sacrificed for investigation into the underlying mechanisms of action. Network pharmacology was also employed to predict potential targets and pathways of ASA against migraine. The anti-inflammatory activity of ASA and pathway-related proteins were examined in BV2 cells stimulated with lipopolysaccharides (LPS). The results demonstrated that ASA ameliorated cutaneous hyperalgesia and photophobia while improving spatial memory and increasing exploratory behavior in IS rats. ASA attenuated central sensitization-related indicators and excessive glutamate levels while enhancing GABA synthesis. ASA rescued neuronal loss in the cortex and hippocampus of IS rats. Notably, the ability of ASA to improve spatial memory performance in the Y maze test was not observed with sumatriptan, a first-line treatment drug, suggesting the potential involvement of the TLR4 pathway. Moreover, ASA suppressed microglial activation, reduced pro-inflammatory factors, and downregulated TLR4, MyD88, p-NF-κB/NF-κB, NLRP3, caspase-1, IL-1β, and IL-18. Overall, ASA demonstrated its potential to alleviate hyperalgesia and improve behavioral performance in migraine rats by inhibiting hyperexcitability and microglia-related inflammation.

Metformin attenuates central sensitization by regulating neuroinflammation through the TREM2-SYK signaling pathway in a mouse model of chronic migraine

BACKGROUND

Chronic migraine (CM) is a serious neurological disorder. Central sensitization is one of the important pathophysiological mechanisms underlying CM, and microglia-induced neuroinflammation conduces to central sensitization. Triggering receptor expressed on myeloid cells 2 (TREM2) is presented solely in microglia residing within the central nervous system and plays a key role in neuroinflammation. Metformin has been shown to regulate inflammatory responses and exert analgesic effects, but its relationship with CM remains unclear. In the study, we investigated whether metformin modulates TREM2 to improve central sensitization of CM and clarified the potential molecular mechanisms.

METHODS

A CM mouse model was induced by administration of nitroglycerin (NTG). Behavioral evaluations were conducted using von Frey filaments and hot plate experiments. Western blot and immunofluorescence techniques were employed to investigate the molecular mechanisms. Metformin and the SYK inhibitor R406 were administered to mice to assess their regulatory effects on neuroinflammation and central sensitization. To explore the role of TREM2-SYK in regulating neuroinflammation with metformin, a lentivirus encoding TREM2 was injected into the trigeminal nucleus caudalis (TNC). In vitro experiments were conducted to evaluate the regulation of TREM2-SYK by metformin, involving interventions with LPS, metformin, R406, siTREM2, and TREM2 plasmids.

RESULTS

Metformin and R406 pretreatment can effectively improve hyperalgesia in CM mice. Both metformin and R406 significantly inhibit c-fos and CGRP expression in CM mice, effectively suppressing the activation of microglia and NLRP3 inflammasome induced by NTG. With the administration of NTG, TREM2 expression gradually increased in TNC microglia. Additionally, we observed that metformin significantly inhibits TREM2 and SYK expression in CM mice. Lv-TREM2 attenuated metformin-mediated anti-inflammatory responses. In vitro experiments, knockdown of TREM2 inhibited LPS-induced SYK pathway activation and alleviated inflammatory responses. After the sole overexpression of TREM2, the SYK signaling pathway is activated, resulting in the activation of the NLRP3 inflammasome and an increased expression of pro-inflammatory cytokines; nevertheless, this consequence can be reversed by R406. The overexpression of TREM2 attenuates the inhibition of SYK activity mediated by metformin, and this effect can be reversed by R406.

CONCLUSIONS

Our findings suggest that metformin attenuates central sensitization in CM by regulating the activation of microglia and NLRP3 inflammasome through the TREM2-SYK pathway.

Association between dietary vitamin C intake and migraine in adults: A cross-sectional study of the National Health and Nutrition Examination Survey

BACKGROUND

Previous studies indicate that vitamin C may decrease the occurrence and intensity of migraines, but the evidence is restricted due to small sample sizes. This study aimed to determine the magnitude of the association between dietary vitamin C intake and migraine in the general population.

METHODS

This cross-sectional study utilised data from the National Health and Nutrition Examination Survey (NHANES) conducted between 1999 and 2004. Participants who had severe headaches or migraines in the past 3 months were classified as experiencing migraines. Dietary vitamin C intake was evaluated using the 24-h dietary recall system. Logistic regression models, restricted cubic spline (RCS) regression and stratified analyses were employed to assess the association between dietary vitamin C intake and migraine.

RESULTS

The study included 4101 participants, of whom 702 (17.12%) experienced migraine. The study revealed an inverse association between dietary vitamin C intake and migraine (odds ratio [OR] = 0.89, 95% confidence intervals [CI] = 0.83-0.96, p = 0.002) after adjusting for demographic covariates, lifestyle covariates, laboratory tests, physical examinations, physical activity, dietary covariates and comorbidities. When vitamin C intake was categorised, the adjusted OR (95% CI) for migraine in Q4 (highest vitamin C intake) was 0.64 (95% CI = 0.49-0.84, p = 0.001) compared to Q1 (lowest vitamin C intake). The RCS regression showed a linear inverse relationship between dietary vitamin C intake and migraine (pnon-linearity = 0.449). The findings remained consistent, and no significant interactions were found among different groups.

CONCLUSIONS

Dietary vitamin C intake was inversely associated with migraine, and a linear negative relationship was found between vitamin C intake and migraine.

Transcriptomic changes in the hypothalamus of mice with chronic migraine: Activation of pathways associated with neuropathic inflammation and central sensitization

Chronic migraine is a common central nervous system disorder characterized by recurrent, pulsating headaches. However, the extent and mechanisms of hypothalamic involvement in disease progression have not been thoroughly investigated. Herein, we created a chronic migraine mouse model using repeated intraperitoneal injections of nitroglycerin. We performed transcriptomic sequencing on the hypothalamus of mice with chronic migraine and control mice under normal physiological conditions, followed by differential gene set enrichment and functional analysis of the data. Additionally, we examined the intrinsic connection between chronic migraine and sleep disorders using transcriptomic sequencing data from sleep-deprived mice available in public databases. We identified 39 differentially expressed genes (DEGs) in the hypothalamus of a mouse model of chronic migraine. Functional analysis of DEGs revealed enrichment primarily in signaling transduction, immune-inflammatory responses, and the cellular microenvironment. A comparison of the transcriptomic data of sleep-deprived mice revealed two commonly expressed DEGs. Our findings indicate that the hypothalamic DEGs are primarily enriched in the PI3K/AKT/mTOR pathway and associated with the NF-κB/NLRP3/IL-1 β pathway activation to maintain the central sensitization of the chronic migraine. Chronic migraine-induced gene expression changes in the hypothalamus may help better understand the underlying mechanisms and identify therapeutic targets.

Real-world clinical results of CGRP monoclonal antibody treatment for medication overuse headache of migraine without abrupt drug discontinuation and no hospitalization

Background

Abrupt discontinuation of overused medications is standard treatment for medication overuse headache (MOH), but discontinuation is difficult to maintain. The aim was to evaluate the real-world clinical results of anti-calcitonin gene-related peptide monoclonal antibody (CGRP-mAb) treatment for migraine with MOH without abrupt drug discontinuation and no hospitalization.

Methods

Data were collected before starting CGRP-mAb injections (baseline) and 1 month after each injection. The following items were compared between baseline and after the first, second, and third CGRP-mAb injections, monthly headache days (MHD), monthly migraine days (MMD), monthly acute medication use (AMU) days, monthly total amount of AMU tablets, headache impact test-6 (HIT-6), and the migraine-specific quality of life questionnaire (MSQ). Achieving reduction rates ≥50 % in the frequency of each headache and migraine was defined as a good response. Achieving reduction rates of both AMU days and tablets ≥50 % was defined as effective in reducing AMU.

Results

This study included 33 patients with migraine with MOH. After the third CGRP-mAb injection, MHD and MMD were significantly decreased from median 30.0 to 9.5 days, and 10.0 to 1.5 days, respectively. In addition, monthly AMU days and tablets were significantly decreased from median 28.0 to 8.0 days, and 30.0 to 9.5 tablets, respectively. After the third CGRP-mAb injection, the good MHD and MMD responder rates were 75.0 % and 85.7 %, respectively. The rate of reducing AMU was 78.6 %. HIT-6 and MSQ scores decreased significantly from baseline to after each CGRP-mAb injection.

Conclusions

When CGRP-mAb was administered to migraine with MOH, frequency of headache symptoms and AMU were reduced without abrupt drug discontinuation and no hospitalization.

Disrupted topologic efficiency of white matter structural connectome in migraine: a graph-based connectomics study

OBJECTIVE

To delineate the structural connectome alterations in patients with chronic migraine (CM), episodic migraine (EM), and healthy controls (HCs).

BACKGROUND

The pathogenesis of migraine chronification remains elusive, with structural brain network changes potentially playing a key role. However, there is a paucity of research employing graph theory analysis to explore changes in the whole brain structural networks in patients with CM and EM.

METHODS

The individual structural brain connectome of 60 patients with CM, 34 patients with EM, and 39 healthy control participants were constructed by using deterministic diffusion-tensor tractography. Graph metrics including global efficiency, characteristic path length, local efficiency, clustering coefficient, and small-world parameters were evaluated to describe the topologic organization of the white matter structural networks. Additionally, nodal clustering coefficient and efficiency were considered to assess the regional characteristics of the brain connectome. A graph-based statistic was used to assess brain network properties across the groups.

RESULTS

Graph theory analysis revealed significant disruptions in the structural brain networks of CM patients, characterized by reduced global efficiency, local efficiency, and increased characteristic path length compared to HCs. Additionally, CM patients exhibited significantly lower local efficiency than EM patients. Notably, the CM group demonstrated marked reductions in local clustering coefficient and nodal local efficiency in the frontal and temporal regions compared with the healthy control group and EM group. Nodal local efficiency can effectively distinguish CM from EM and HCs. Moreover, the disrupted topologic efficiency was significantly associated with attack frequency and MIDAS score in patients with migraine after Bonferroni correction.

CONCLUSION

Decreased structural connectivity in the frontal and temporal regions may serve as a neuroimaging marker for migraine chronification and disease progression, providing valuable insights into the pathophysiology of chronic migraine.

α7nAChR-mediated astrocytic activation: A novel mechanism of Xiongzhi Dilong decoction in ameliorating chronic migraine

ETHNOPHARMACOLOGICAL RELEVANCE

Alpha 7 nicotinic acetylcholine receptor (α7nAChR)-mediated astrocytic activation is closely related to central sensitization of chronic migraine (CM). Xiongzhi Dilong decoction (XZDL), originated from Xiongzhi Shigao decoction of Yi-zong-jin-jian, has been confirmed to relieve CM in experiment and clinic. However, its underlying mechanism for treating CM has not been elucidated.

AIM OF THE STUDY

To reveal the underlying mechanisms of XZDL to alleviate CM in vivo focusing mainly on α7nAChR-mediated astrocytic activation and central sensitization in TNC.

MATERIALS AND METHODS

CM rat model was established by subcutaneous injection of nitroglycerin (NTG) recurrently, and treated with XZDL simultaneously. Migraine-like behaviors of rats (ear redness, head scratching, and cage climbing) and pain-related reactions (mechanical hind-paw withdrawal threshold) of rats were evaluated before and after NTG injection and XZDL administration at different points in time for nine days. The immunofluorescence single and double staining were applied to detect the levels of CGRP, c-Fos, GFAP and α7nAChR in NTG-induced CM rats. ELISA kits were employed to quantify levels of TNF-α, IL-1β, and IL-6 in medulla oblongata of CM rats. The expression levels of target proteins were examined using western blotting. Finally, methyllycaconitine citrate (MLA, a specific antagonist of α7nAChR) was applied to further validate the mechanisms of XZDL in vivo.

RESULTS

XZDL significantly attenuated the pain-related behaviors of the NTG-induced CM rats, manifesting as constraints of aberrant migraine-like behaviors including elongated latency of ear redness and decreased numbers of head scratching and cage climbing, and increment of mechanical withdrawal threshold. Moreover, XZDL markedly lowered levels of CGRP and c-Fos, as well as inflammatory cytokines (IL-1β, IL-6 and TNF-α) in CM rats. Furthermore, XZDL significantly enhanced α7nAChR expression and its co-localization with GFAP, while markedly inhibited the expression of GFAP and the activation of JAK2/STAT3/NF-κB pathway in the TNC of CM rats. Finally, blocking α7nAChR with MLA reversed the effects of XZDL on astrocytic activation, central sensitization, and the pain-related behaviors in vivo.

CONCLUSION

XZDL inhibited astrocytic activation and central sensitization in NTG-induced CM rats by facilitating α7nAChR expression and suppressing JAK2/STAT3/NF-κB pathway, implying that the regulation of α7nAChR-mediated astrocytic activation represents a novel mechanism of XZDL for relieving CM.

Regulatory T cells require peripheral CCL2-CCR2 signaling to facilitate the resolution of medication overuse headache-related behavioral sensitization

BACKGROUND

Medication overuse headache (MOH) is the most common secondary headache disorder, resulting from chronic and excessive use of medication to treat headaches, for example, sumatriptan. In a recent study, we have shown that the peripheral C-C motif ligand 2 (CCL2), C-C motif chemokine receptor 2 (CCR2) and calcitonin-gene-related peptide (CGRP) signaling pathways interact with each other and play critical roles in the development of chronic migraine-related behavioral and cellular sensitization. In the present study, we investigated whether CCL2-CCR2 and CGRP signaling pathways play a role in the development of sumatriptan overuse-induced sensitization, and whether they are involved in its resolution by the low-dose interleukin-2 (LD-IL-2) treatment.

METHODS

Mice received daily sumatriptan administration for 12 days. MOH-related behavioral sensitization was assessed by measuring changes of periorbital mechanical thresholds for 3 weeks. CCL2-CCR2 and CGRP signaling pathways were inhibited by targeted gene deletion or with an anti-CCL2 antibody. Ca2+-imaging was used to examine whether repetitive sumatriptan treatment enhances CGRP and pituitary adenylate cyclase-activating polypeptide (PACAP) signaling in trigeminal ganglion (TG) neurons. LD-IL-2 treatment was initiated after the establishment of sumatriptan-induced sensitization. Immunohistochemistry and flow cytometry analyses were used to examine whether CCL2-CCR2 signaling controls regulatory T (Treg) cell proliferation and/or trafficking.

RESULTS

CCL2, CCR2 and CGRPα global KO mice exhibited robust sumatriptan-induced behavioral sensitization comparable to wild-type controls. Antibody neutralization of peripheral CCL2 did not affect sumatriptan-induced behaviors either. Repeated sumatriptan administration did not enhance the strength of CGRP or PACAP signaling in TG neurons. Nevertheless, LD-IL-2 treatment, which facilitated the resolution of sumatriptan-induced sensitization in wild-type and CGRPα KO mice, was completely ineffective in mice with compromised CCL2-CCR2 signaling. In CCL2 KO mice, we observed normal LD-IL-2-induced Treg expansion in peripheral blood, but the increase of Treg cells in dura and TG tissues was significantly reduced in LD-IL-2-treated CCL2 KO mice relative to wild-type controls.

CONCLUSIONS

These results indicate that the endogenous CCL2-CCR2 and CGRP signaling pathways are not involved in sumatriptan-induced behavioral sensitization, suggesting that distinct molecular mechanisms underlie chronic migraine and MOH. On the other hand, peripheral CCL2-CCR2 signaling is required for LD-IL-2 to reverse chronic headache-related sensitization.

The Impact of COVID-19 on Migraine: The Patients' Perspective

The COVID-19 pandemic represents a global health phenomenon that will sadly remain part of our history. It had innumerable consequences for society and people's lives. With different mechanisms, COVID-19 has been pointed out as a factor in the pathophysiology of several secondary disorders or the deterioration of pre-existing conditions. Migraine is a frequent disorder that can be influenced by several conditions, including psychologically stressful conditions or infectious diseases. The purpose of the present study is to gain insight into the influence of COVID-19 on the clinical characteristics of patients with migraine. A self-administrable questionnaire has been developed, asking for migraine features before and after COVID-19 infection. One hundred and two patients who had been infected at least once were included. After COVID-19 infection, 54 reported the worsening of migraine, 45 noticed no variation, and 3 reported an improvement. After the infection, 21 patients changed preventive therapy due to the loss of efficacy of the previous one. The most effective treatments in this subpopulation were gene-related peptide monoclonal antibodies. The presented data confirm that the influence of COVID-19 is heterogeneous in patients with migraine, but new treatments may be effective in controlling the symptoms among those who report a worsening of the disease.

Exploring the Two-Way Link between Migraines and Venous Thromboembolism: A Bidirectional Two-Sample Mendelian Randomization Study

BACKGROUND

 The objective of this study is to utilize Mendelian randomization to scrutinize the mutual causality between migraine and venous thromboembolism (VTE) thereby addressing the heterogeneity and inconsistency that were observed in prior observational studies concerning the potential interrelation of the two conditions.

METHODS

 Employing a bidirectional Mendelian randomization approach, the study explored the link between migraine and VTE, incorporating participants of European descent from a large-scale meta-analysis. An inverse-variance weighted (IVW) regression model, with random-effects, leveraging single nucleotide polymorphisms (SNPs) as instrumental variables was utilized to endorse the mutual causality between migraine and VTE. SNP heterogeneity was evaluated using Cochran's Q-test and to account for multiple testing, correction was implemented using the intercept of the MR-Egger method, and a leave-one-out analysis.

RESULTS

 The IVW model unveiled a statistically considerable causal link between migraine and the development of VTE (odds ratio [OR] = 96.155, 95% confidence interval [CI]: 4.342-2129.458, p = 0.004), implying that migraine poses a strong risk factor for VTE development. Conversely, both IVW and simple model outcomes indicated that VTE poses as a weaker risk factor for migraine (IVW OR = 1.002, 95% CI: 1.000-1.004, p = 0.016). The MR-Egger regression analysis denoted absence of evidence for genetic pleiotropy among the SNPs while the durability of our Mendelian randomization results was vouched by the leave-one-out sensitivity analysis.

CONCLUSION

 The findings of this Mendelian randomization assessment provide substantiation for a reciprocal causative association between migraine and VTE within the European population.

Hallmarks of primary headache: part 1 - migraine

BACKGROUND AND AIM

Migraine is a common disabling conditions which, globally, affects 15.2% of the population. It is the second cause of health loss in terms of years lived with disability, the first among women. Despite being so common, it is poorly recognised and too often undertreated. Specialty centres and neurologists with specific expertise on headache disorders have the knowledge to provide specific care: however, those who do not regularly treat patients with migraine will benefit from a synopsis on the most relevant and updated information about this condition. This paper presents a comprehensive view on the hallmarks of migraine, from genetics and diagnostic markers, up to treatments and societal impact, and reports the elements that identify migraine specific features.

MAIN RESULTS

The most relevant hallmark of migraine is that it has common and individual features together. Besides the known clinical manifestations, migraine presentation is heterogeneous with regard to frequency of attacks, presence of aura, response to therapy, associated comorbidities or other symptoms, which likely reflect migraine heterogeneous genetic and molecular basis. The amount of therapies for acute and for prophylactic treatment is really wide, and one of the difficulties is with finding the best treatment for the single patient. In addition to this, patients carry out different daily life activities, and might show lifestyle habits which are not entirely adequate to manage migraine day by day. Education will be more and more important as a strategy of brain health promotion, because this will enable reducing the amount of subjects needing specialty care, thus leaving it to those who require it in reason of refractory condition or presence of comorbidities.

CONCLUSIONS

Recognizing the hallmarks of migraine and the features of single patients enables prescribing specific pharmacological and non-pharmacological treatments. Medical research on headaches today particularly suffers from the syndrome of single-disease approach, but it is important to have a cross-sectional and joint vision with other close specialties, in order to treat our patients with a comprehensive approach that a heterogeneous condition like migraine requires.

Associations between the waist-to-height ratio index and migraine: A cross-section study of the NHANES 1999-2004

BACKGROUND

The importance of obesity as a factor that increases the probability of migraine episodes is increasingly acknowledged. Thus, this study aimed to explore the potential correlation between central obesity and migraine, emphasizing the waist-to-height ratio (WHtR) as a key measure in assessing this relationship.

METHODS

This cross-sectional analysis included 13,344 individuals who participated in the National Health and Nutrition Examination Survey (NHANES) from 1999-2004. To investigate the association associations between WHtR and migraine, we utilized refined multivariate logistic regression models, smoothing curve fitting methods, subpopulation analysis, and interactive testing.

RESULTS

Of the 13,344 participants, 2,764 (20.72%) had migraines. A significant positive correlation was observed between the WHtR and migraine incidence in both the partially adjusted model (3.08 [95% CI: 1.92-4.94]) and the crude model (1.95 [95% CI: 1.23-3.08]). The participants in the highest quartile of the WHtR had a 13% greater incidence of migraine than those in the lowest quartile [1.13(0.99,1.28)]. The interaction analysis revealed a statistically significant difference (p<0.01) in this relationship among the subgroups. Notably, the correlation between WHtR and migraine risk was not significant and negative in patients ≥60 years, indicating that obesity has a mitigating role in preventing migraine in this elderly population.

CONCLUSIONS

The incidence of migraine increased concomitantly with increased WHtR. However, central obesity has a protective effect against migraine occurrence in individuals ≥60 years. Thus, our findings underscore the importance of WHtR in migraine prevention and management strategies and highlight its potential as a critical biomarker for mitigating migraine incidence.

Phasic perfusion dynamics among migraine subtypes: a multimodel arterial spin labeling investigation

BACKGROUND

Migraine-related perfusion changes are documented but inconsistent across studies due to limited sample size and insufficient phenotyping. The phasic and spatial dynamics across migraine subtypes remains poorly characterized. This study aimed to determine spatiotemporal dynamics of gray matter (GM) perfusion in migraine.

METHODS

We prospectively recruited episodic (EM) and chronic migraine (CM) patients, diagnosed with the International Headache Society criteria and healthy controls (HCs) between 2021 and 2023 from the headache center in a tertiary medical center, and adjacent communities. Magnetic resonance (3-tesla) arterial spin labeling (ASL) was conducted for whole brain cerebral blood flow (CBF) in all participants. The voxel-wise and whole brain gray matter (GM) CBF were compared between subgroups. Spatial pattern analysis of CBF and its correlations with headache frequency were investigated regarding different migraine phases and subtypes. Sex- and age-adjusted voxel-wise and whole brain GM comparisons were performed between HCs and different EM and CM phases. Spatial pattern analysis was conducted by CBF clusters with phasic differences and spin permutation test. Correlations between headache frequency and CBF were investigated regarding different EM and CM phases.

RESULTS

Totally 344 subjects (172 EM, 120 CM, and 52 HCs) were enrolled. Higher CBF in different anatomical locations was identified in ictal EM and CM. The combined panels of the specific locations with altered CBF in ictal EM on receiver operating characteristic curve analysis demonstrated areas under curve of 0.780 (vs. HCs) and 0.811 (vs. preictal EM). The spatial distribution of ictal-interictal CBF alteration of EM and CM were not correlated with each other (p = 0.665; r = - 0.018). Positive correlations between headache frequency and CBF were noted in ictal EM and CM regarding whole GM and specific anatomical locations.

CONCLUSIONS

Patients with migraine exhibited unique spatiotemporal CBF dynamics across different phases and distinct between subtypes. The findings provide neurobiological insights into how selected anatomical structures engage in a migraine attack and adapt to plastic change of repeated attacks along with chronicity.

Causal effects of sedentary behaviours on the risk of migraine: A univariable and multivariable Mendelian randomization study

BACKGROUND

Migraine is a common and burdensome neurological disorder. The causal relationship between sedentary behaviours (SBs) and migraine remains instinct. We aimed to evaluate the roles of SBs including watching TV, using computer and driving in the risk of migraine.

METHODS

We conducted a univariable and multivariable Mendelian randomization (MR) study based on summary datasets of large genome-wide association studies. The inverse variance weighted method was utilized as the primary analytical tool. Cochran's Q, MR-Egger intercept test, MR pleiotropy residual sum and outlier and leave-one-out were conducted as sensitivity analysis. Additionally, we performed a meta-analysis to combine the causal estimates.

RESULTS

In the discovery analysis, we identified causal associations between time spent watching TV and an increased risk of migraine (p = 0.015) and migraine without aura (MO) (p = 0.002). Such causalities with increasing risk of migraine (p = 0.005), and MO (p = 0.006) were further verified using summary datasets from another study in the replication analysis. There was no significant causal association found between time spent using computer, driving and migraine or its two subtypes. The meta-analysis and multivariable MR analysis also strongly supported the causal relationships between time spent watching TV and an increased risk of migraine (p = 0.0003 and p = 0.034), as well as MO (p < 0.0001 and p = 0.0004), respectively. These findings were robust under all sensitivity analysis.

CONCLUSIONS

Our study suggested that time spent watching TV may be causally associated with an increased risk of migraine, particularly MO. Large-scale and well-designed cohort studies may be warranted for further validation.

SIGNIFICANCE STATEMENT

This study represents the first attempt to investigate whether a causal relationship exists between SBs and migraine. Utilizing MR analysis helps mitigate reverse causation bias and confounding factors commonly encountered in observational cohorts, thereby enhancing the robustness of derived causal associations. Our MR analysis revealed that time spent watching TV may serve as a potential risk factor for migraine, particularly MO.

One-Year and Five-Year Outcomes in Medication Overuse Headache: A Real-World Study

BACKGROUND

Medication overuse headache (MOH) is one of the global health-related problems that imposes significant morbidity. Effective management requires the abrupt cessation of the overused medications, transition therapy in the initial days, and initiation of preventive treatment. The objective of this study is to provide one-year and five-year follow-ups of study participants diagnosed with chronic migraine and MOH. The study will examine the efficacy of withdrawal therapy, the use of conventional preventive medication, and the use of anti-calcitonin gene-related peptide (anti-CGRP) monoclonal antibodies.

METHODOLOGY

We conducted a single-center, prospective, and descriptive study at a tertiary center in Brazil. The population was included by convenience sampling of consecutive subjects diagnosed with chronic migraine and MOH. Demographics and clinical data at baseline and one-year and five-year follow-ups were collected in the clinical records.

RESULTS

Among 142 subjects, 116 were females and 26 were males, with a mean age of 42.1±14.3. They were followed for five years. The diagnosis was performed at the mean age of 24.9±14.7 years after the headache onset, and the time with headache ≥15 days per month was 6.3±7.6 years. On baseline, the average number of headache days per month (HDM) was 25.2±5.9. There was a reduction in HDM. At one-year and five-year follow-ups, a ≥75% reduction in HDM was observed, respectively, in 51.4% and 70.4% of the sample.

CONCLUSIONS

The five-year follow-up of chronic migraine and MOH treated with the discontinuation of excessive medication, the use of preventative pharmacological agents, and the optional inclusion of anti-CGRP pathway monoclonal antibody led to a significant decrease in the initial occurrence of HDM.

Telomere length exhibits inverse association with migraine among Americans aged 20-50 years, without implications beyond age 50: a cross-sectional study

Migraine, common in individuals under 50 years, is linked to oxidative stress. The association between telomere length shortening and migraine, along with potential age-related influences, has not been comprehensively studied. This cross-sectional study included data from 6169 participants in the National Health and Nutrition Survey (NHANES) from 1999 to 2002, encompassing information on peripheral blood leukocyte telomere length, severe headache or migraine, and potential confounders. Stratifying by age (20-50 years, > 50 years), we employed multivariable logistic regression, restricted cubic splines and interaction test to investigate age-influenced telomere length in relation to migraine. In participants aged 20-50 years, the odds ratio (OR) for migraine in the shortest telomere length group T1 (0.39-0.89) was 1.35 (95% confidence interval [95% CI] 1.01, 1.79) compared to the longest group T3 (1.10-9.42), whereas in those aged > 50 years, the OR of T1 was 0.93 (95% CI 0.60, 1.43). Additionally, telomere length and age interacted in the development of migraine (p for interaction: 0.010). In individuals aged 20-50, an L-shaped relationship was found between telomere length and migraine, with an inflection point at 1.02T/S ratio. The OR was 9.34 (95% CI 1.56, 55.99) for telomere lengths < 1.02T/S ratio. These findings suggest age influences the association between telomere length and migraine in U.S. adults.

1H-MRS reveals abnormal energy metabolism and excitatory-inhibitory imbalance in a chronic migraine-like state induced by nitroglycerin in mice

BACKGROUND

Chronic migraine is closely related to the dysregulation of neurochemical substances in the brain, with metabolic imbalance being one of the proposed causes of chronic migraine. This study aims to evaluate the metabolic changes between energy metabolism and excitatory and inhibitory neurotransmitters in key brain regions of mice with chronic migraine-like state and to uncover the dysfunctional pathways of migraine.

METHODS

A chronic migraine-like state mouse model was established by repeated administration of nitroglycerin (NTG). We used von Frey filaments to assess the mechanical thresholds of the hind paw and periorbital in wild-type and familial hemiplegic migraine type 2 mice. After the experiments, tissue was collected from five brain regions: the somatosensory cortex (SSP), hippocampus, thalamus (TH), hypothalamus, and the spinal trigeminal nucleus caudalis (TNC). Proton magnetic resonance spectroscopy (1H-MRS) was employed to study the changes in brain metabolites associated with migraine, aiming to explore the mechanisms underlying metabolic imbalance in chronic migraine-like state.

RESULTS

In NTG-induced chronic migraine-like state model, we observed a significant reduction in energy metabolism during central sensitization, an increase in excitatory neurotransmitters such as glutamate, and a tendency for inhibitory neurotransmitters like GABA to decrease. The TNC and thalamus were the most affected regions. Furthermore, the consistency of N-acetylaspartate levels highlighted the importance of the TNC-TH-SSP pathway in the ascending nociceptive transmission of migraine.

CONCLUSION

Abnormal energy metabolism and neurotransmitter imbalance in the brain region of NTG-induced chronic migraine-like state model are crucial mechanisms contributing to the chronicity of migraine.

A randomized, double-blind, placebo-controlled parallel trial to test the effect of inulin supplementation on migraine headache characteristics, quality of life and mental health symptoms in women with migraine

Migraine is a complex neurovascular disorder characterized by recurrent headache attacks that are often accompanied by symptoms such as vomiting, nausea, and sensitivity to sound or light. Preventing migraine attacks is highly important. Recent research has indicated that alterations in gut microbiota may influence the underlying mechanisms of migraines. This study aimed to investigate the effects of inulin supplementation on migraine headache characteristics, quality of life (QOL), and mental health symptoms in women with migraines. In a randomized double-blind placebo-controlled trial, 80 women with migraines aged 20 to 50 years were randomly assigned to receive 10 g day-1 of inulin or a placebo supplement for 12 weeks. Severity, frequency, and duration of migraine attacks, as well as depression, anxiety, stress, QOL, and headache impact test (HIT-6) scores, were examined at the start of the study and after 12 weeks of intervention. In this study, the primary outcome focused on the frequency of headache attacks, while secondary outcomes encompassed the duration and severity of headache attacks, QOL, and mental health. There was a significant reduction in severity (-1.95 vs. -0.84, P = 0.004), duration (-6.95 vs. -2.05, P = 0.023), frequency (-2.09 vs. -0.37, P < 0.001), and HIT-6 score (-10.30 vs. -6.52, P < 0.023) in the inulin group compared with the control. Inulin supplementation improved mental health symptoms, including depression (-4.47 vs. -1.45, P < 0.001), anxiety (-4.37 vs. -0.70, P < 0.001), and stress (-4.40 vs. -1.50, P < 0.001). However, no significant difference was observed between the two groups regarding changes in QOL score. This study provides evidence supporting the beneficial effects of inulin supplement on migraine symptoms and mental health status in women with migraines. Further studies are necessary to confirm these findings. Trial registration: Iranian Registry of Clinical Trials (https://www.irct.ir) (ID: IRCT20121216011763N58).

Effectiveness of combining greater occipital nerve block and pulsed radiofrequency treatment in patients with chronic migraine: a double-blind, randomized controlled trial

BACKGROUND

Pulsed radiofrequency (PRF) treatment targeting the greater occipital nerve (GON) has shown efficacy in treating various conditions. This double-blind, randomized controlled study aimed to evaluate the effects of combining PRF therapy with GON block (GONB) therapy in patients with chronic migraine.

METHODS

The study consisted of two groups: GONB and GONB + PRF, each comprising 16 patients with chronic migraine. Using 0.5-Hz sensorial stimulation, a 5-cm-long radiofrequency needle was inserted under ultrasound guidance in both groups. Subsequently, all patients received a GONB by administering 2 mL of 0.25% bupivacaine. In the GONB + PRF group, patients underwent 4 min of PRF at 42℃, whereas the GONB group did not receive any PRF treatment. Follow-up examinations were performed at 1, 2, 3 and 6 months after the procedure to evaluate the frequency and severity of migraine attacks, number of headache days, and analgesic consumption.

RESULTS

In the GONB + PRF group, the visual analog scale (VAS) score, number of migraine attacks, number of headache days, and analgesic consumption were significantly lower compared to the GONB group (P < 0.05). Significant decreases (60%) in mean VAS scores, number of migraine attacks, number of headache days, and consumption of analgesic medications were observed in the GONB + PRF group at the 1-, 2-, 3-, and 6-month follow-ups compared with the pre-treatment period (P < 0.05).

CONCLUSIONS

The combination of GONB and PRF presents a promising new treatment option for patients with chronic migraine. This approach has demonstrated efficacy in minimizing analgesic use, decreasing the frequency of migraine attacks, reducing the number of headache days and decreasing the severity of migraine attacks.

TRIAL REGISTRATION

NCT05464212.

Hypoperfusion of periaqueductal gray as an imaging biomarker in chronic migraine beyond diagnosis: A 3D pseudocontinuous arterial spin labeling MR imaging

BACKGROUND

The periaqueductal gray (PAG) is at the center of a powerful descending antinociceptive neuronal network, and is a key node in the descending pain regulatory system of pain. However, less is known about the altered perfusion of PAG in chronic migraine (CM).

AIM

To measure the perfusion of PAG matter, an important structure in pain modulation, in CM with magnetic resonance (MR) perfusion without contrast administration.

METHODS

Three-dimensional pseudocontinuous arterial spin labeling (3D-PCASL) and brain structure imaging were performed in 13 patients with CM and 15 normal subjects. The inverse deformation field generated by brain structure image segmentation was applied to the midbrain PAG template to generate individualized PAG. Then the perfusion value of the PAG area of the midbrain was extracted based on the individual PAG mask.

RESULTS

Cerebral blood flow (CBF) value of PAG in CM patients (47.98 ± 8.38 mL/100 mg min) was significantly lower than that of the control group (59.87 ± 14.24 mL/100 mg min). Receiver operating characteristic (ROC) curve analysis showed that the area under the curve was 0.77 (95% confidence interval [CI], 0.60, 0.94), and the cutoff value for the diagnosis of CM was 54.83 mL/100 mg min with a sensitivity 84.60% and a specificity 60%.

CONCLUSION

Imaging evidence of the impaired pain conduction pathway in CM may be related with the decreased perfusion in the PAG, which could be considered as an imaging biomarker for the diagnosis and therapy evaluation.

Effectiveness and safety of pharmacological prophylaxis for chronic migraine: a systematic review and network meta-analysis

BACKGROUND

Chronic migraine (CM) significantly impacts both the physical and mental health of patients. Current studies on the safety and effectiveness of different pharmacological prophylaxis interventions for CM are limited. To address this gap, we conducted a network meta-analysis (NMA) to compare and rank the efficacy and safety of various drugs in preventing CM.

METHODS

Two independent researchers systematically searched four databases from their inception to August 1, 2023, to identify eligible randomized controlled trials (RCTs). Subsequently, they performed data extraction and assessed the risk of bias. A NMA was then performed. Continuous outcomes and binary outcomes were displayed as weighted mean difference (WMD) and risk ratio (RR), respectively, and corresponding 95% confidence intervals (CI) were reported. The surface under the cumulative ranking curve (SUCRA) was used to rank each intervention separately.

RESULTS

24 RCTs involving 8789 patients were included. Compared to placebo, Botulinum toxin A demonstrated the most significant effect in reducing the monthly migraine days for CM patients (MD = 3.88, 95% CI 0.48, 7.28); in terms of improving the response rate by a 50% reduction in monthly migraine days, Topiramate (RR = 50.06, 95% CI 3.18, 787.30) was the most effective; there was no statistically significant difference between all preventive drugs and placebo in improving the migraine disability assessment (MIDAS) score; in terms of the incidence of adverse events, Eptinezumab (RR = 1.09, 95% CI 0.8, 1.54) exhibited the highest safety profile.

CONCLUSION

Among all the drugs for the preventive drugs for CM, Botulinum toxin A has the best efficacy and safety profile, closely followed by calcitonin gene-related peptide (CGRP) monoclonal antibodies (mAbs).

Comparative effectiveness and tolerability of calcitonin gene-related peptide (CGRP) monoclonal antibodies and onabotulinumtoxinA in chronic migraine: A multicenter, real-world study in Taiwan

OBJECTIVE

To compare the real-world effectiveness and tolerability of calcitonin gene-related peptide (CGRP) monoclonal antibodies (mAbs) and onabotulinumtoxinA in chronic migraine (CM) patients.

METHODS

This multicenter study involved retrospective analysis of prospectively collected data of CM patients treated with CGRP mAbs or onabotulinumtoxinA, including difficult-to-treat (DTT) patients (i.e., ≥3 preventive failures). Treatment outcomes were determined at 6 months based on prospective headache diaries and Migraine Disability Assessment (MIDAS).

RESULTS

The study included 316 (55 M/261F, mean age 44.4 ± 13.5 years) and 333 (61 M/272F, mean age 47.9 ± 13.4 years) CM patients treated with CGRP mAbs or onabotulinbumtoxinA, respectively. At 6 months, CGRP mAb treatment was associated with a greater decrease in monthly migraine days (MMDs) (-13.0 vs. -8.7 days/month, p < 0.001) and a higher ≥50% responder rate (RR) (74.7% vs. 50.7%, p < 0.001) compared with onabotulinumtoxinA injections. The findings were consistent in DTT patients (-13.0 vs. -9.1 MMDs, p < 0.001; ≥50% RR: 73.9% vs. 50.3%, p < 0.001) or those with medication-overuse headache (MOH) (-13.3 vs. -9.0 MMDs, p < 0.001; ≥50% RR: 79.0% vs. 51.6%, p < 0.001). Besides, patients receiving CGRP mAbs had greater improvement (-42.2 vs. -11.8, p < 0.001) and a higher ≥50% RR (62.0% vs. 40.0%, p = 0.001) in MIDAS scores and a lower rate of adverse events (AEs) (6.0% vs. 21.0%, p < 0.001). However, none of the patients discontinued treatment due to AEs.

CONCLUSIONS

In this multicenter, real-world study, CGRP mAbs were more effective than onabotulinumtoxinA in CM patients, even in DTT or MOH patients. All of these injectables were well tolerated. Further prospective studies are needed to verify these findings.

Insights from 25 years of onabotulinumtoxinA in migraine - mechanisms and management

OnabotulinumtoxinA (BTX-A) was first linked to beneficial effects in migraine 25 years ago and was approved by the FDA for preventive treatment of chronic migraine in 2010. The treatment has since had a major impact on the well-being of people with chronic migraine. The clinical development programme for BTX-A and research since its approval have provided insights into the neuromodulatory sensory effect of BTX-A, how it can control chronic migraine despite its peripheral action, and the underlying biology of migraine as a disease. In this Review, we consider the impact that BTX-A has had on the management of chronic migraine and on the research field. We discuss the insights provided by clinical research, encompassing the clinical trials and subsequent real-world evidence, and the mechanistic insights provided by preclinical and translational research. We also provide an overview of future directions of research in the field BTX-A in migraine and the clinical translation of this research.

Brain-wide mapping of c-Fos expression in nitroglycerin-induced models of migraine

BACKGROUND

Migraine is a neurological disorder characterized by complex, widespread, and sudden attacks with an unclear pathogenesis, particularly in chronic migraine (CM). Specific brain regions, including the insula, amygdala, thalamus, and cingulate, medial prefrontal, and anterior cingulate cortex, are commonly activated by pain stimuli in patients with CM and animal models. This study employs fluorescence microscopy optical sectioning tomography (fMOST) technology and AAV-PHP.eB whole-brain expression to map activation patterns of brain regions in CM mice, thus enhancing the understanding of CM pathogenesis and suggesting potential treatment targets.

METHODS

By repeatedly administering nitroglycerin (NTG) to induce migraine-like pain in mice, a chronic migraine model (CMM) was established. Olcegepant (OLC) was then used as treatment and its effects on mechanical pain hypersensitivity and brain region activation were observed. All mice underwent mechanical withdrawal threshold, light-aversive, and elevated plus maze tests. Viral injections were administered to the mice one month prior to modelling, and brain samples were collected 2 h after the final NTG/vehicle control injection for whole-brain imaging using fMOST.

RESULTS

In the NTG-induced CMM, mechanical pain threshold decreased, photophobia, and anxiety-like behavior were observed, and OLC was found to improve these manifestations. fMOST whole-brain imaging results suggest that the isocortex-cerebral cortex plate region, including somatomotor areas (MO), somatosensory areas (SS), and main olfactory bulb (MOB), appears to be the most sensitive area of activation in CM (P < 0.05). Other brain regions such as the inferior colliculus (IC) and intermediate reticular nucleus (IRN) were also exhibited significant activation (P < 0.05). The improvement in migraine-like symptoms observed with OLC treatment may be related to its effects on these brain regions, particularly SS, MO, ansiform lobule (AN), IC, spinal nucleus of the trigeminal, caudal part (Sp5c), IRN, and parvicellular reticular nucleus (PARN) (P < 0.05).

CONCLUSIONS

fMOST whole-brain imaging reveals c-Fos + cells in numerous brain regions. OLC improves migraine-like symptoms by modulating brain activity in some brain regions. This study demonstrates the activation of the specific brain areas in NTG-induced CMM and suggests some regions as a potential treatment mechanism according to OLC.

Association between the Composite Dietary Antioxidant Index and severe headache or migraine: results from the National Health and Nutrition Examination Survey

Background

Severe headache or migraine is a neurological disease that seriously affects the quality of human life. Oxidative stress is considered a main factor in the pathogenesis of severe headache or migraine. The Composite Dietary Antioxidant Index (CDAI) is a score calculated using six dietary antioxidant components (including vitamins A, C, E, selenium, zinc, and carotenoid), which represents a person's level of dietary antioxidant ingredients. Based on the theory of oxidative stress, we speculated that CDAIs may be relevant to the risk of severe headache or migraine, as the relationship between the CDAI and severe headache or migraine is unclear. Hence, the purpose of this study was to explore the relationship between the CDAI and severe headache or migraine in participants.

Methods

We performed a cross-sectional study using data from the National Health and Nutrition Examination Survey (NHANES) that were collected from 2001 to 2004. A total of 4,943 participants were included, of whom 1,232 experienced severe headaches or migraines. Participants' CDAIs were calculated based on their intake of six dietary antioxidants. We used logistic regression models, limited cubic spline analysis, and subgroup analysis to assess the association of CDAI with severe headache or migraine.

Results

The multivariate logistic regression model (correcting for all potential covariates) revealed that the odds ratio (95% Confidence Interval [CI]) for the association between CDAI and severe headache or migraine was 0.97 (95% CI = 0.95-1.00, p = 0.048). Compared with individuals with low CDAIs in Quartile (Q)1, the adjusted Odds Ratio between the CDAI and severe headache or migraine in Q2, Q3, and Q4 were 0.84 (95% CI = 0.69-1.01, p = 0.07), 0.77 (95% CI = 0.63-0.96, p = 0.017), and 0.73 (95% CI = 0.56-0.95, p = 0.02), respectively. Restricted cubic spline regression analysis showed an L-shaped relationship between the CDAI and severe headache or migraine.

Conclusion

Our findings indicate that higher CDAI was associated with a lower risk of severe headache or migraine.

Long-Term Outcome After Discontinuation of CGRP-Targeting Therapy for Migraine

PURPOSE OF REVIEW

Calcitonin gene-related peptide (CGRP)-targeting agents are potential candidates for disease-modifying migraine drugs. However, most studies on CGRP-targeting agents have assessed efficacy outcomes rather than long-term effects after discontinuation. This review aimed to synthesize and scrutinize the latest clinical data on the outcomes after the discontinuation of CGRP-targeting therapy in patients with episodic and chronic migraine, with a particular focus on chronic migraine.

RECENT FINDINGS

Real-world studies involving patients with migraine have reported consistent findings of worsened headache frequency and quality of life after the discontinuation of CGRP monoclonal antibodies (CGRP mAbs). Although many patients maintain improvements for up to 4 months after discontinuation compared to baseline (before starting CGRP mAbs), no studies have evaluated the effects of stopping treatment for > 5 months, which is the five-half-life of CGRP mAbs. Several studies have suggested that patients treated with CGRP receptor mAbs experience more rapid deterioration than those treated with CGRP ligand mAbs after discontinuing CGRP mAbs. The results of real-world studies suggest that for many patients with migraine, the benefits of CGRP mAbs diminish months after discontinuation. Therefore, anti-CGRP therapies may not be considered disease-modifying. However, the comprehensive assessment of the disease-modifying potential of these drugs requires studies with extended treatment and cessation durations.