New international classification of migraine with aura (ICHD-2) applied to 362 migraine patients

Migraine with aura

This chapter describes the different types of aura including rare aura subtypes such as retinal aura. In addition, aura manifestations not classified in the International Classification of Headache Disorders and auras in headache disorders others than migraine are also described. The differential diagnosis of migraine aura comprises several neurological disorders which should be known to specialists. Migraine aura also has impact on the choice of migraine treatment; recommendations for the treatment of the migraine aura itself are also presented in this chapter.

Prevalence and impact of visual aura in migraine and probable migraine: a population study

Visual aura (VA) presents in 98% of cases of migraine with aura. However, data on its prevalence and impact in individuals with migraine and probable migraine (PM) are limited. Data from the nation-wide, population-based Circannual Change in Headache and Sleep Study were collected. Participants with VA rating scale scores ≥ 3 were classified as having VA. Of 3,030 participants, 170 (5.6%) and 337 (11.1%) had migraine and PM, respectively; VA prevalence did not differ between these cohorts (29.4% [50/170] vs. 24.3% [82/337], p = 0.219). Participants with migraine with VA had a higher headache frequency per month (4.0 [2.0-10.0] vs. 2.0 [1.0-4.8], p = 0.014) and more severe cutaneous allodynia (12-item Allodynia Symptom Checklist score; 3.0 [1.0-8.0] vs. 2.0 [0.0-4.8], p = 0.046) than those without VA. Participants with PM with VA had a higher headache frequency per month (2.0 [2.0-8.0] vs. 2.0 [0.6-4.0], p = 0.001), greater disability (Migraine Disability Assessment score; 10.0 [5.0-26.3] vs. 5.0 [2.0-12.0], p < 0.001), and more severe cutaneous allodynia (12-item Allodynia Symptom Checklist score, 2.5 [0.0-6.0] vs. 0.0 [0.0-3.0], p < 0.001) than those without VA. VA prevalence was similar between migraine and PM. Some symptoms were more severe in the presence of VA.

Hormonal contraceptives and risk of ischemic stroke in women with migraine: a consensus statement from the European Headache Federation (EHF) and the European Society of Contraception and Reproductive Health (ESC)

Several data indicate that migraine, especially migraine with aura, is associated with an increased risk of ischemic stroke and other vascular events. Of concern is whether the risk of ischemic stroke in migraineurs is magnified by the use of hormonal contraceptives. As migraine prevalence is high in women of reproductive age, it is common to face the issue of migraine and hormonal contraceptive use in clinical practice. In this document, we systematically reviewed data about the association between migraine, ischemic stroke and hormonal contraceptive use. Thereafter a consensus procedure among international experts was done to develop statements to support clinical decision making, in terms of cardiovascular safety, for prescription of hormonal contraceptives to women with migraine. Overall, quality of current evidence regarding the risk of ischemic stroke in migraineurs associated with the use of hormonal contraceptives is low. Available data suggest that combined hormonal contraceptive may further increase the risk of ischemic stroke in those who have migraine, specifically migraine with aura. Thus, our current statements privilege safety and provide several suggestions to try to avoid possible risks. As the quality of available data is poor further research is needed on this topic to increase safe use of hormonal contraceptives in women with migraine.

Risk Factors and Clinical Manifestations of Juxtacortical Small Lesions: A Neuroimaging Study

Background and objective

White matter hyperintensities can be easily identified by brain imaging. Juxtacortical small lesion (JCSL) is a special type of white matter lesion, defined as no greater than 5 mm in diameter and adjacent to the cerebral cortex in location. We notice lately that JCSLs alone may be associated to various neurological symptoms. Here, we design the present study to determine the risk factors for JCSLs and their clinical manifestations in patients in our neurology clinic.

Methods

206 participants suffered from neurological disorders and completed magnetic resonance imaging (MRI) examinations were divided into two groups: patients with JCSLs and patients without lesions on MRI. Meanwhile, 129 age- and sex-matched healthy volunteers were also recruited. Laboratory examinations and the phenotypes and distributions of the symptoms of the three groups were compared.

Results

The serum levels of apoB and homocysteine (HCY) were independently related to the appearance of JCSLs and HCY level was also associated with the number of JCSLs. Patients with JCSLs might present with headache, insomnia, and/or anxiety/depression, which were related with the anatomical locations of the lesions.

Conclusion

These data suggest that JCSLs are symptomatic and might in result fromarteriole atherosclerosis, which should raise our attention.

Mild closed head traumatic brain injury-induced changes in monoamine neurotransmitters in the trigeminal subnuclei of a rat model: mechanisms underlying orofacial allodynias and headache

Our recent findings have demonstrated that rodent models of closed head traumatic brain injury exhibit comprehensive evidence of progressive and enduring orofacial allodynias, a hypersensitive pain response induced by non-painful stimulation. These allodynias, tested using thermal hyperalgesia, correlated with changes in several known pain signaling receptors and molecules along the trigeminal pain pathway, especially in the trigeminal nucleus caudalis. This study focused to extend our previous work to investigate the changes in monoamine neurotransmitter immunoreactivity changes in spinal trigeminal nucleus oralis, pars interpolaris and nucleus tractus solitaries following mild to moderate closed head traumatic brain injury, which are related to tactile allodynia, touch-pressure sensitivity, and visceral pain. Our results exhibited significant alterations in the excitatory monoamine, serotonin, in spinal trigeminal nucleus oralis and pars interpolaris which usually modulate tactile and mechanical sensitivity in addition to the thermal sensitivity. Moreover, we also detected a robust alteration in the expression of serotonin, and inhibitory molecule norepinephrine in the nucleus tractus solitaries, which might indicate the possibility of an alteration in visceral pain, and existence of other morbidities related to solitary nucleus dysfunction in this rodent model of mild to moderate closed head traumatic brain injury. Collectively, widespread changes in monoamine neurotransmitter may be related to orofacial allodynhias and headache after traumatic brain injury.

Diagnosing migraine

Migraine is a common headache disorder, particularly in women. It usually starts during the teens and twenties, a time when many women are seeking contraception advice. Migraine without aura is the most prevalent type of migraine, affecting up to 70% of people with migraine, while the remainder experience attacks with and/or without aura. Aura is a phase of focal neurological symptoms, typically visual. An increasing body of evidence identifies aura as a marker of increased risk of ischaemic stroke and its presence is a contraindication to the use of combined hormonal contraception (CHC). However, aura is often confused with more generalised premonitory visual symptoms of migraine that may precede attacks of migraine with and without aura, which are not associated with stroke risk. Diagnostic confidence is needed so that CHC is not withheld unnecessarily.

Epigenetics and migraine; complex mitochondrial interactions contributing to disease susceptibility

Migraine is a common neurological disorder classified by the World Health Organisation (WHO) as one of the top twenty most debilitating diseases in the developed world. Current therapies are only effective for a proportion of sufferers and new therapeutic targets are desperately needed to alleviate this burden. Recently the role of epigenetics in the development of many complex diseases including migraine has become an emerging topic. By understanding the importance of acetylation, methylation and other epigenetic modifications, it then follows that this modification process is a potential target to manipulate epigenetic status with the goal of treating disease. Bisulphite sequencing and methylated DNA immunoprecipitation have been used to demonstrate the presence of methylated cytosines in the human D-loop of mitochondrial DNA (mtDNA), proving that the mitochondrial genome is methylated. For the first time, it has been shown that there is a difference in mtDNA epigenetic status between healthy controls and those with disease, especially for neurodegenerative and age related conditions. Given co-morbidities with migraine and the suggestive link between mitochondrial dysfunction and the lowered threshold for triggering a migraine attack, mitochondrial methylation may be a new avenue to pursue. Creative thinking and new approaches are needed to solve complex problems and a systems biology approach, where multiple layers of information are integrated is becoming more important in complex disease modelling.

Clinical characteristics of basilar-type migraine in the neurological clinic of a university hospital

OBJECTIVES

The aim of this study was to investigate the prevalence and clinical characteristics of basilar-type migraine in the neurology outpatient clinic of a university hospital in China.

METHODS

This cross-sectional study was conducted in the neurology outpatient of a tertiary care hospital in Chongqing between January 2010 and December 2011. All consecutive patients citing headache as their chief complaint were asked to complete a face-to-face interview by a qualified headache specialist using a detailed questionnaire for headache. The diagnosis of basilar-type migraine was made according to International Classification of Headache Disorders Second Edition.

RESULTS

Of the 1,526 headache patients, 23 (1.5%) were diagnosed with basilar-type migraine (19 women, four men). Basilar-type migraine occurred in 6.6% (23/348) of patients with migraine with nonhemiplegic aura. Mean age at onset was 20.3 ± 11.7 years (range 6-49 years). Among these patients, 65% (15/23) reported bilateral pain, 35% (8/23) unilateral pain. The basilar-type aura comprised diplopia 52%, vertigo 43%, tinnitus 43%, bilateral visual symptoms 39%, hypacusia 26%, ataxia 26%, dysarthria 22%, bilateral paresthesias 13%, and decreased level of consciousness 13%. Intense emotional stimuli (74%) and sleep disorders (65%) were the most common trigger factors, followed by change in weather, sunshine, cold wind, acute stress, alcohol, and fatigue.

CONCLUSION

Basilar-type migraine is an episodic disorder and occurred in 1.5% of patients with headache. More than one-half of patients have their first attack in the second and third decade of life. Trigger factors were common, and patients should be educated to avoid trigger factors.

Serotonin and CGRP in migraine

Migraine is defined as recurrent attack of headache that are commonly unilateral and accompanied by gastrointestinal and visual disorders. Migraine is more prevalent in females than males with a ratio of 3:1. It is primarily a complex neurovascular disorder involving local vasodilation of intracranial, extracerebral blood vessels and simultaneous stimulation of surrounding trigeminal sensory nervous pain pathway that results in headache. The activation of 'trigeminovascular system' causes release of various vasodilators, especially calcitonin gene-related peptide (CGRP) that induces pain response. At the same time, decreased levels of neurotransmitter, serotonin have been observed in migraineurs. Serotonin receptors have been found on the trigeminal nerve and cranial vessels and their agonists especially triptans prove effective in migraine treatment. It has been found that triptans act on trigeminovascular system and bring the elevated serum levels of key molecules like calcitonin gene related peptide (CGRP) to normal. Currently CGRP receptor antagonists, olcegepant and telcagepant are under consideration for antimigraine therapeutics. It has been observed that varying levels of ovarian hormones especially estrogen influence serotonin neurotransmission system and CGRP levels making women more predisposed to migraine attacks. This review provides comprehensive information about the role of serotonin and CGRP in migraine, specifically the menstrual migraine.

Characterization of consistent triggers of migraine with aura

Objective

The aim of the present study was to characterize perceived consistent triggers of migraine with aura (MA).

Method

Questionnaires specifically designed to characterize various trigger factors were sent to 181 participants identified in an earlier study. All participants had formerly identified at least one factor that often or always triggered an MA attack. They only answered questions regarding this or these factor(s).

Results

The response rate to the questionnaire was 70% (126/179). A number of subtype triggers were mentioned by a high proportion of patients: too much work (under the stress category 54/64), reflected sunlight (under the light category 35/44), too little sleep (under the sleep category 19/24), red wine (under the alcohol category 20/22), passive smoking (under the smoke category 11/11), menstruation (under the menstruation or break from the pill category 12/14) and perfume (under the fumes/heavy scents category 12/15). Hormones, light and stress were reported to cause at least 50 % of MA attacks in 62%, 47% and 42% of participants, respectively. No participants reported alcohol to be the trigger of 50% or more of their attacks. In the groups of participants with “light”, “fumes/heavy scents”, “smoke” or “physical effort” as triggers, nearly all patients reported that an exposure time to the trigger of less than 3 hours (90-100% of patients) was necessary to trigger an attack and a latency to onset of attack of less than 3 hours (90-100% of patients).

Conclusion

Our study has provided new knowledge about factors that in particular patients consistently trigger MA. In daily routine practice this information should be helpful in identifying factors to avoid. Patients with trigger factors that always or usually trigger attacks of MA will be highly useful for imaging and other experimental studies.

Trigger factors in migraine with aura

The aim of the present study was to identify trigger factors in migraine with aura (MA). A total of 629 MA patients representative of the Danish population were sent a questionnaire listing 16 trigger factors thought to be relevant as well as space for free text. Distinction was made between attacks with or without aura within each patient. The questionnaire was returned by 522 patients of whom 347 had current MA attacks. In total 80% with current attacks (278/347) indicated that at least one factor triggered their migraine, and 67% (187/278) in this group indicated that they were aware of at least one factor often or always giving rise to an attack of MA. Forty-one per cent (113/278) had co-occurring attacks of migraine without aura (MO). Stress (following stress), bright light, intense emotional influences, stress (during stress) and sleeping too much or too little were the trigger factors mentioned by most. Attack frequency had little impact on the number of trigger factors. Women reported more trigger factors than men. Patients having attacks of both MA and MO reported more trigger factors for MO attacks than for MA attacks. In conclusion, 80% of patients with MA reported trigger factors and two-thirds of these reported at least one trigger factor often or always triggering an attack of MA. Patients should be educated to avoid these factors.

Migraine with aura: new understanding from clinical epidemiologic studies

PURPOSE OF REVIEW

To discuss the consequences of recent clinical data on migraine with aura for clinical practice and future research in the light of new diagnostic criteria for migraine with aura.

RECENT FINDINGS

Migraine with aura is now distinguished from hemiplegic migraine and from basilar migraine. Migraine with typical aura has an aura consisting of visual, sensory, or speech symptoms. The aura symptoms typically develop gradually over 5 or more minutes, last between 5 and 60 minutes and, when more than one symptom is present, they occur in succession. Half-sidedness is typical of visual and sensory symptoms, whereas speech symptoms are typically aphasic, primarily of the Broca type. A visual aura rating scale with a high sensitivity and specificity has been developed to standardize the diagnosis of visual aura. The new classification, the new criteria, and the new knowledge about clinical features of migraine with aura are important both for routine clinical diagnosis and for future research studies.

SUMMARY

Recent studies of the clinical features of migraine with aura allow a more precise diagnosis and classification than previously possible. A clear distinction between migraine with typical aura, hemiplegic migraine, and basilar migraine is important for genetic and other research studies.

Implications of Clinical Subtypes of Migraine With Aura

OBJECTIVE

To compare the clinical characteristics of familial hemiplegic migraine (FHM), sporadic hemiplegic migraine (SHM), and nonhemiplegic migraine with aura (NHMA) and further, to compare subtypes of NHMA.

BACKGROUND

To discover distinct underlying genetic and pathophysiological mechanisms it is crucial to drive clinical subdivision of migraine with aura as far as possible. The documentation of subtypes of migraine with aura depends on the clinical characteristics as the genetic mechanisms are unknown except for the dominantly inherited FHM.

METHODS

Patients with FHM, SHM, or familial NHMA were recruited from specialist practice and diagnosed according to the International Classification of Headache Disorders (ICHD) in a validated interview by a physician. Patients with hemiplegic migraine had a physical and neurological examination. Patients with population-based NHMA from a previous Danish study were used for comparison.

RESULTS

We recruited 147 patients with FHM, 105 with SHM, and 362 with familial NHMA. FHM and SHM had similar aura and headache characteristics. Patients with FHM and SHM were more likely to experience two or more aura symptoms (100% vs. 31%, P < .0001), they more often had prolonged aura symptoms, they almost always had a headache associated with the aura (93% vs. 58%, P < .0001), and they more frequently had basilar-type symptoms (69% vs. 10%, P < .0001) than patients with population-based NHMA. Patients with familial NHMA were more likely to experience two or more aura symptoms than patients with population-based NHMA (61% vs. 32%, P < .0001). Within the subtypes of NHMA, patients with typical aura with migraine headache had an earlier age at onset (20 +/- 10 vs. 23 +/- 13 years, P= .044) and a higher co-occurrence of migraine without aura (43% vs. 22%, P= .002) than patients with typical aura with nonmigraine headache.

CONCLUSIONS

The present study proves that distinct subtypes of migraine with aura exist. It further underlines the phenotypic differences between the different subtypes of migraine with aura which likely are caused by different etiological mechanisms. In future studies FHM, SHM, and NHMA therefore should be analyzed as separate entities and patients with NHMA may be stratified by ICHD-2 subtype of NHMA.

The Visual Aura Rating Scale (VARS) for migraine aura diagnosis

To supplement the traditional ICHD-2 diagnosis for migraine with aura (MA) we developed a diagnostic scale for migraine aura that quantifies the importance of the cardinal characteristics of MA. Since more than 99% of MA patients have visual aura, we developed for simplicity a Visual Aura Rating Scale (VARS). In total 427 patients with MA (ICHD-2) or nonaura visual disturbances were diagnosed in a validated semistructured interview by a trained physician. The patients were separated into a derivation sample and a validation sample. By regression analysis we identified the visual aura characteristics associated with MA in the derivation sample. Based on the identified characteristics we developed VARS and derived a predictive VARS score which was tested in the validation sample. The VARS score is the weighted sum of the presence of five visual symptom characteristics: duration 5-60 min (3 points), develops gradually > or = 5 min (2 points), scotoma (2 points), zig-zag lines (2 points), and unilateral (1 point). The maximum score is 10 points. A VARS score of 5 or more diagnosed MA with a sensitivity of 96% (95% CI 92-99%) and a specificity of 98%(95% CI 95-100%) in the derivation sample, and a sensitivity of 91% (95% CI 86-95%) and a specificity of 96% (95% CI 91-100%) in the validation sample. VARS adds evidence based weights to a number of clearly specified characteristics; it is easy to learn, apply and teach and may therefore be a valuable addition to traditional ICHD-2 diagnosis.