Migraine and retinal microvascular abnormalities: the Atherosclerosis Risk in Communities Study

Retinal neural tissue and vascular calibres in migraine: the Northern Finland Birth Cohort Eye Study

PURPOSE

To evaluate the possible effects of migraine on retinal nerve fibre layer (RNFL), ganglion cell-inner plexiform layer (GC-IPL), macular thickness and retinal arteriolar and venular diameters (CRAE, CRVE) in a population-based birth cohort.

METHODS

375 migraineurs and 1489 healthy controls were included in this cross-sectional cohort study. RNFL, GC-IPL and macular thickness parameters were measured by spectral domain optical coherence tomography (OCT), and vascular parameters were measured from fundus photographs. Migraine was determined by a questionnaire and specific features were selected as covariates (gender, smoking status, systolic blood pressure, refraction and diabetes).

RESULTS

There were no statistically significant differences between healthy controls and migraineurs in average RNFL (p = 0.123), macular (p = 0.488) or GC-IPL (p = 0.437) thickness. Migraine did not have a significant effect on any of the macular or GC-IPL subfields. For RNFL subfields, only temporal inferior was borderline significantly increased in migraineurs (p = 0.039) in adjusted results. No statistically significant differences were found between study groups on retinal vascular calibres CRAE (p = 0.879), CRVE (p = 0.145) or AVR (p = 0.259). GC-IPL thickness was found to be positively correlated with CRAE and CRVE in both study groups as GC-IPL thickness increased together with the increase in CRAE and CRVE (p-trend < 0.001 in both), and a similar trend was detected with central macular subfield thickness and systolic (p-trend < 0.001) and diastolic (p-trend = 0.010) blood pressure, but only in the control group.

CONCLUSION

There were no remarkable differences between migraineurs and healthy controls in retinal vascular or structural parameters in our study.

Retinal and peripapillary vascular density in episodic and chronic migraine cases without aura

BACKGROUND

Migraine is a neurovascular disease that can cause ocular and systemic ischemic damage. Despite from aura, a limited number of studies have considered the effect of the chronic migraine in cases without aura. Our aim was to evaluate the differences in the retinal and optic disk microvasculature among episodic and chronic migraine cases without aura using optical coherence tomography angiography (OCTA) imaging.

METHODS

45 cases with migraine, and 25 control subjects were included in this prospective, cross-sectional study. OCTA was performed at 3 × 3 mm and 6 × 6 mm of the macula and at 4.5 × 4.5 mm of the optic disk. Retinal nerve fiber layer (RNFL) thickness, ganglion cell complex thickness, and vessel densities of the optic nerve and macula were compared among the three groups: a control group, an episodic migraine without aura (EMWOA) group, and a chronic migraine without aura (CMWOA) group.

RESULTS

In EMWOA group, circumpapillary vascular density (cpVD) was not decreased significantly in any quadrants (all, p>0.05). Compared to the control group, CMWOA group had significantly lower RNFL thickness in superior-temporal quadrants (p = 0.002 and 0.006, respectively), while cpVD differed only in the temporal quadrant and temporal inferior sector (p = 0.002 and p = 0.009, respectively).

CONCLUSIONS

Temporal peripapillary perfusion is valuable in the follow-up of chronic migraine cases. Longitudinal studies are needed to determine the place of OCTA in the follow-up of migraine.

Microvascular involvement in migraine: an optical coherence tomography angiography study

OBJECTIVE

The aim of this study was to evaluate the microvasculature of the macula and the optic nerve in patients affected by migraine with aura (MA) and without aura (MO) by optical coherence tomography angiography (OCTA), comparing the findings with healthy controls (HC).

METHODS

We collected data from ocular and orthotic examinations, including eye motility, intraocular pressure measurement, best-corrected visual acuity (BCVA) measurement, objective refraction measurement, fundus examination, macular and optic disk OCTA examination. All subjects were imaged with solix fullrange OCT. The following OCTA parameters were recorded: macular vessel density (VD), inside disc VD, peripapillary VD, disc whole image VD, fovea choriocapillaris VD, fovea VD, parafovea VD, peripapillary thickness, fovea thickness, parafovea thickness, macular full retinal thickness, and foveal avascular zone (FAZ) parameters. Clinical and demographical data about migraine patients were collected by a neurologist.

RESULTS

We included 56 eyes from 28 patients with a diagnosis of MO, 32 eyes from 16 patients with a diagnosis of MA, and 32 eyes from 16 HC subjects. The FAZ area was 0.230 ± 0.099 mm² in the MO group, 0.248 ± 0.091 mm² in the MA group and 0.184 ± 0.061 mm² in the control group. The FAZ area was significantly larger in the MA group than in the HC group (p = 0.007). The foveal choriocapillaris VD was significantly lower in MA patients (63.6 ± 2.49%) when compared with MO patients (65.27 ± 3.29%) (p = 0.02).

CONCLUSION

An impairment of retinal microcirculation can be detected in patients with MA, as demonstrated by the enlargement of FAZ. Moreover, the study of choroid circulation may reveal microvascular damage in patients with migraine with aura. OCTA is a useful non-invasive screening tool for the detection of microcirculatory disturbance in patients with migraine.

Contribution of microvascular dysfunction to chronic pain

There is growing evidence that microvascular dysfunction is a pathology accompanying various injuries and conditions that produce chronic pain and may represent a significant contributing factor. Dysfunction that occurs within each component of the microvasculature, including arterioles, capillaries and venules impacts the health of surrounding tissue and produces pathology that can both initiate pain and influence pain sensitivity. This mini review will discuss evidence for a critical role of microvascular dysfunction or injury in pathologies that contribute to chronic pain conditions such as complex regional pain syndrome (CRPS) and fibromyalgia.

Migraine and its relation to other risk factors in patients with acute ischemic stroke and acute coronary syndrome

Background

Migraine has been recently studied as a risk factor for ischemic stroke (IS) and a possible link to a broader range of ischemic vascular disorders including angina and myocardial infarction is suggested.

Objectives

to study migraine and its relation to other risk factors in patients with acute IS and acute coronary syndrome (ACS).

Patients and methods

We studied 200 patients, 114 patients had acute IS and 86 patients with ACS, in addition to 850 control participants. All patients were subjected to detailed clinical and laboratory evaluation; including evaluation of traditional risk factors. All stroke patients were subjected to CT scan. Diagnosis of acute coronary syndrome was established clinically by ECG and cardiac specific enzymes. Migraine was diagnosed according to the international headache society and assessment of migraine severity was measured by the Migraine Disability Assessment (MIDAS) questionnaire.

Results

In patients with ischemic stroke, Risk Ratios (RR) of migraine was 3.3 for all migrainous patients, higher for migraine with aura (MA). In the cardiovascular group, it was 2.75 and again higher in MA. A positive correlation between migraine severity and both stroke severity and cardiac affection severity was found though non-significant in the cardiovascular group. There was no significant difference in hospital outcome in migrainous patients in both groups.

Conclusions

Patients with migraine have higher risk than non-migrainous patients for both cerebrovascular and coronary vascular diseases. Risk is stronger in MA in both conditions. Considering migraine in risk stratification of cerebrovascular and cardiovascular diseases is recommended.

Evaluation of retinal vessel and perfusion density in migraine patients by optical coherence tomography angiography

BACKGROUND

Migraine is a neurovascular disease and has been reported as a risk factor for ocular vascular complications. Our study aimed to compare the retinal vessel density and perfusion density between migraine patients and healthy subjects by optical coherence tomography angiography (OCTA).

METHODS

In this prospective study, 23 patients with migraine with aura (MWA) and 31 patients with migraine without aura (MWOA), and 32 age- and gender-matched healthy controls (HC) were enrolled. The vessel density (VD) and perfusion density (PD) were evaluated in a 6 × 6 mm scan of the macula and optic nerve head (ONH) with the Cirrus HD-OCT 5000 device. The measurement area is divided into three areas: center (c), inner ring (ir), outer ring (or) (with diameters of 1, 3, and 6 mm respectively), and nine subfields, according to the Early Treatment Retinopathy Study grid.

RESULTS

The macular cVD, cPD, and temporal orVD in MWA and MWOA groups were significantly reduced than those of HC. On optic nerve head OCTA, patients with MWA had decreased cVD, average irVD, inferior irVD, and temporal orVD compared with HCs while MWOA had reduced cVD than HC group. In addition, PD was not significantly different among MWA, MWOA, and HC groups in any measure in the optic nerve head. The Migraine Disability Assessment Score (MIDAS) and attack frequency were significantly inversely correlated with cVD, cPD, irVD, and irPD of macula and ONH.

CONCLUSIONS

Vessel and perfusion density of macula were reduced in both MWA and MWOA. Vessel density, but not perfusion density of ONH was decreased in MWA. The migraine severity and attack frequency were significantly inversely correlated with vessel and perfusion density of macula and ONH.

Bioinformatics approach to identify the influences of SARS-COV2 infections on atherosclerosis

Coronavirus disease (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has been a global pandemic since early 2020. Understanding the relationship between various systemic disease and COVID-19 through disease ontology (DO) analysis, an approach based on disease similarity studies, has found that COVID-19 is most strongly associated with atherosclerosis. The study provides new insights for the common pathogenesis of COVID-19 and atherosclerosis by looking for common transcriptional features. Two datasets (GSE152418 and GSE100927) were downloaded from GEO database to search for common differentially expressed genes (DEGs) and shared pathways. A total of 34 DEGs were identified. Among them, ten hub genes with high degrees of connectivity were picked out, namely C1QA, C1QB, C1QC, CD163, SIGLEC1, APOE, MS4A4A, VSIG4, CCR1 and STAB1. This study suggests the critical role played by Complement and coagulation cascades in COVID-19 and atherosclerosis. Our findings underscore the importance of C1q in the pathogenesis of COVID-19 and atherosclerosis. Activation of the complement system can lead to endothelial dysfunction. The DEGs identified in this study provide new biomarkers and potential therapeutic targets for the prevention of atherosclerosis.

Investigation of the correlation between diabetic retinopathy and prevalent and incident migraine in a national cohort study

Migraine is a disease characterized by cerebral vasodilation. While diabetes has previously been associated with a lower risk of migraine, it is not known if diabetic retinopathy (DR), a retinal peripheral vascular occlusive disease, is a potential biomarker of protection against migraine. Therefore, we aimed to examine diabetic retinopathy as a marker of prevalent and 5-year incident migraine. In a national cohort, we compared patients with diabetes attending DR screening from The Danish National Registry of Diabetic Retinopathy (cases, n = 205,970) to an age- and gender-matched group of patients without diabetes (controls, n = 1,003,170). In the cross-sectional study, a multivariable model demonstrated a lower prevalence of migraine among cases compared with controls (OR 0.83, 95% CI 0.81–0.85), with a lower risk in cases with DR than in those without (OR 0.69, 95% CI 0.65–0.72). In the prospective study, a lower risk of incident migraine was found in a multivariable model in cases (HR 0.76, 95% CI 0.70–0.82), but this did not depend upon the presence of DR. To conclude, in a national study of more than 1.2 million people, patients screened for DR had a lower risk of present migraine, but DR was not a protective marker of incident migraine.

The eye in migraine: a review of retinal imaging findings in migraine

Migraine is a common headache disorder with neurovascular involvement. Because eyecare practitioners are likely to encounter people with migraine in their everyday practice, it is important to understand how migraine might impact on ocular health. In this narrative review, we provide an update on the latest ophthalmic imaging evidence for retinal involvement in migraine, derived from studies of retinal structure and retinal vascular perfusion using spectral domain and swept source optical coherence tomography (OCT) and OCT angiography. Combined structural OCT evidence from a recent meta-analysis indicates subtle and non-specific thinning of the peripapillary retinal nerve fibre layer (RNFL) in people with migraine, whereas there is little consistent evidence for structural abnormalities of the macular region. Recent advances in OCT angiography technology have also provided an opportunity to visualise microstructural damage and vascular dysregulation in the eyes of people with migraine. However, given that OCT and OCT angiography studies have been exclusively cross-sectional, it is not possible to demonstrate the causal effect of migraine events. Furthermore, the lack of common methodology (different ophthalmic imaging devices and analysis algorithms), and very limited datasets (small samples, heterogenous migraine groups), lead to an inability to make strong conclusions regarding the nature of altered retinal structure and vascular perfusion in migraine. Nevertheless, we discuss the clinical implications of such observations for eyecare practitioners and provide practical advice for the monitoring and management of patients with a history of migraine.

Evaluation of retinal and optic nerve vasculature by optic coherence tomography angiography in Migraine with Aura

PURPOSE

This study aimed to evaluate the retina by optic coherence tomography angiography (OCTA) in patients with migraine with aura (MA) in comparison with healthy controls.

MATERIALS AND METHODS

A total of 60 patients with MA and 56 control subjects who applied to the Ophthalmology Clinic of Dicle University between January 2020 and February 2020 were included in this study. In all patients, the vascular density (VD) of the radial peripapillary capillaries (RPCs) and optic nerve head (ONH), the VD of deep and superficial macular vascular networks, and foveal avascular zone (FAZ) were measured.

RESULTS

Patients with MA showed reduced VD measurements of the nasal and inferotemporal ONH, inferonasal RPCs, and deep macular plexus. No statistically significant difference was observed in the superficial macular VD values between the study groups. The majority of patients with MA showed hypertrophy in the deep FAZ.

CONCLUSION

There was a decrease in VD measurements in the deep macular capillary plexus, ONH, and peripapillary capillaries and hypertrophy in the deep FAZ in patients with MA. According to these results, patients with MA may have an increased risk of developing ocular and systemic vascular complications. Therefore, OCTA can be used to evaluate systemic and ocular hypoperfusion in patients with MA.

Migraine as a Risk Factor for Peripheral Artery Occlusive Disease: A Population-Based Cohort Study

We aim to evaluate the development of peripheral occlusive artery disease (PAOD) in patients with migraine by using the National Health Insurance Research Database in Taiwan. A retrospective cohort study was conducted and individuals with diagnostic codes of migraine were enrolled in the study group after excluding those diagnosed with PAOD before the index date. Each subject with migraine was propensity-score matched to another non-migraine patient and the latter served as the control group. A total of 37,288 patients were finally enrolled in the groups. The primary outcome was set as the development of PAOD between the two groups while multiple possible risk factors, including demographic data and comorbidities, were analyzed via the Cox proportional hazards regression. There were 885 and 530 PAOD events in the study and control groups, and the study group had a significantly higher adjusted hazard ratio (1.65, 95% confidential interval: 1.48–1.84, p < 0.001), and the cumulative incidence also revealed a correlation between migraine and PAOD. Other potential risk factors related to the existence of PAOD include age, hypertension, chronic kidney disease, diabetes mellitus, coronary artery disease, stroke, and asthma. For individuals without certain systemic diseases including hypertension, chronic liver disease, chronic kidney disease, coronary artery disease, stroke, asthma, or heart failure, the hazard ratio of subsequent PAOD was significantly higher in the migraine patients than that in the non-migraine individuals (all p < 0.001). In conclusion, the presence of migraine is a significant risk factor for the development of subsequent PAOD.

Evaluation of retinal vessel density and choriocapillaris flow in migraine patients with and without aura

PURPOSE

Migraine is thought to be a neurovascular disorder and increases the likelyhood to develop ischemic complications. Studies have shown that vascular disorders such as ischemic optic neuropathy, retinal artery and vein obstructions are more common in patients with migraine. This study aimed to evaluate the differences between retinal and optic disc microvasculature between migraine patients with and without aura and healthy controls using optical coherence tomography angiography (OCTA) imaging.

METHODS

Thirty-three patients with migraine and 28 healthy subjects were included in this prospective cross sectional study. Optical coherence tomography angiography imaging was performed for the macula and optic disc. Vessel densities (VD) and choriocapillaris flow values were compared between three groups: control group, migraine with aura (MWA), and migraine without aura (MWOA).

RESULTS

There was no difference between the three groups for the VDs of the foveal, perifoveal, parafoveal, and the whole area. The choriocapillaris flow of patients with MWA was significantly less than that of the MWOA and control groups. The VDs of the optic disc revealed no significant difference between the three groups.

CONCLUSION

A lack of choriocapillaris autoregulatory mechanisms may be a possible cause of the decrease in choriocapillaris flow in patients with MWA.

Prevalence and Clinical Factors of Migraine in Patients With Spontaneous Coronary Artery Dissection

Background Spontaneous coronary artery dissection (SCAD) is a cause of acute coronary syndrome predominantly in women without usual cardiovascular risk factors. Many have a history of migraine headaches, but this association is poorly understood. This study aimed to determine migraine prevalence among SCAD patients and assess differences in clinical factors based on migraine history. Methods and Results A cohort study was conducted using the Mayo Clinic SCAD "Virtual" Multi-Center Registry composed of patients with SCAD as confirmed on coronary angiography. Participant-provided data and records were reviewed for migraine history, risk factors, SCAD details, therapies, and outcomes. Among 585 patients (96% women), 236 had migraine history; the lifetime and 1-year prevalence of migraine were 40% and 26%, respectively. Migraine was more common in SCAD women than comparable literature-reported female populations (42% versus 24%, P<0.0001; 42% versus 33%, P<0.0001). Among all SCAD patients, those with migraine history were more likely to be female (99.6% versus 94%; P=0.0002); have SCAD at a younger age (45.2±9.0 years versus 47.6±9.9 years; P=0.0027); have depression (27% versus 17%; P=0.025); have recurrent post-SCAD chest pain at 1 month (50% versus 39%; P=0.035); and, among those assessed, have aneurysms, pseudoaneurysms, or dissections (28% versus 18%; P=0.018). There was no difference in recurrent SCAD at 5 years for those with versus without migraine (15% versus 19%; P=0.39). Conclusions Many SCAD patients have a history of migraine. SCAD patients with migraine are younger at the time of SCAD; have more aneurysms, pseudoaneurysms, and dissections among those imaged; and more often report a history of depression and post-SCAD chest pain. Clinical Trial Registration URL: https://www.clinicaltrials.gov . Unique identifiers: NCT01429727, NCT01427179.

Evaluation of the lamina cribrosa thickness and depth in patients with migraine

PURPOSE

The aim of the study was to evaluate the lamina cribrosa (LC) thickness, LC depth, and retinal nerve fiber layer (RNFL) thickness, in migraine patients with and without aura, by using optical coherence tomography (OCT).

METHODS

This single-center, case-control study included 27 migraine with aura (Group I), 35 migraine patients without aura (Group II), and 35 healthy controls (Group III). In only the right eyes of participants, RNFL thickness in all quadrants was analyzed via OCT, whereas LC thickness and depth were measured by enhanced depth imaging OCT.

RESULTS

The mean age and sex distributions did not differ significantly across the groups (p = 0.460 and p = 0.941). The RNFL thickness was significantly lower in Group I (average and superotemporal, superonasal, and inferotemporal quadrants) and Group II (average and superotemporal and superonasal quadrants) when compared with Group III. Disease duration was significantly correlated with RNFL thickness on average and in all quadrants except in the superonasal quadrant in Groups I and II. Patients in Groups I and II had significantly thinner LC thicknesses and deeper LC depth than healthy participants in Group III.

CONCLUSIONS

The LC and RNFL thicknesses were thinner and the LC depth was deeper in migraine patients with or without aura than in healthy individuals, and disease duration correlated significantly with RNFL thickness. Both results suggest that migraine patients are at risk of developing glaucoma.

Frequency of dyslipidemia in migraineurs in comparison to control group

BACKGROUND

Migraine is a common disease with neurovascular nature, which is commonly prevalent in the general population. Due to the significant prevalence of migraine and its long-term complications, it is necessary to pay attention to its exacerbating factors. Therefore, the aim of this study was to evaluate the frequency distribution of dyslipidemia in patients with migraine compared with control group.

MATERIALS AND METHODS

This is a case-control study, in which 50 patients with migraine (with aura and without aura) were confirmed by the criteria of International Headache Society. Migraineurs and control group (n = 50) were selected from among patients who referred to the Neurology Clinic of Imam Hossein Hospital. The levels of total cholesterol, triglyceride, low-density lipoprotein (LDL), and high-density lipoprotein (HDL) cholesterol were measured in both the groups. SPSS software (version 21) was used to analyze the data.

RESULTS

The findings showed that among migraineurs, 21 patients (42%) revealed high levels of cholesterol and 22 revealed high levels of LDL (44%); whereas among subjects without migraine, 12 subjects (24%) exhibited high levels of cholesterol and 12 (24%) high levels of LDL, where a significant correlation between the two groups was achieved.

CONCLUSION

The present results showed that migraine is associated with higher level of cholesterol and LDL when compared with the control group, where a significant relationship was found.

Effects of different endurance exercise modalities on migraine days and cerebrovascular health in episodic migraineurs: A randomized controlled trial

Aerobic exercise training is a promising complementary treatment option in migraine and can reduce migraine days and improve retinal microvascular function. Our aim was to elucidate whether different aerobic exercise programs at high vs moderate intensities distinctly affect migraine days as primary outcome and retinal vessel parameters as a secondary. In this randomized controlled trial, migraine days were recorded by a validated migraine diary in 45 migraineurs of which 36 (female: 28; age: 36 (SD:10)/BMI: 23.1 (5.3) completed the training period (dropout: 20%). Participants were assigned (Strata: age, gender, fitness and migraine symptomatology) to either high intensity interval training (HIT), moderate continuous training (MCT), or a control group (CON). Intervention groups trained twice a week over a 12-week intervention period. Static retinal vessel analysis, central retinal arteriolar (CRAE) and venular (CRVE) diameters, as well as the arteriolar-to-venular diameter ratio (AVR) were obtained for cerebrovascular health assessment. Incremental treadmill testing yielded maximal and submaximal fitness parameters. Overall, moderate migraine day reductions were observed (ηP2 = .12): HIT revealed 89% likely beneficial effects (SMD = 1.05) compared to MCT (SMD = 0.50) and CON (SMD = 0.59). Very large intervention effects on AVR improvement (ηP2 = 0.27), slightly favoring HIT (SMD=-0.43) over CON (SMD=0), were observed. HIT seems more effective for migraine day reduction and improvement of cerebrovascular health compared to MCT. Intermittent exercise programs of higher intensities may need to be considered as an additional treatment option in migraine patients.

Superior Effects of High-Intensity Interval Training vs. Moderate Continuous Training on Arterial Stiffness in Episodic Migraine: A Randomized Controlled Trial

Background: Migraine is associated with increased cardiovascular risk and vascular dysfunction. Since aerobic exercise can reduce cardiovascular risk, the present randomized controlled trail aimed at investigating the effects of high-intensity interval training (HIT) vs. moderate continuous exercise training (MCT) on arterial stiffness in migraine patients.

Methods: Forty-eight episodic migraineurs were initially enrolled in the study. 37 patients [female: 30; age: 37 (SD: 10); BMI: 23.1 (5.2); Migraine days per month: 3.7 (2.5)] completed the intervention. Central blood pressure, pulse wave reflection, and aortic pulse wave velocity (PWV) were obtained by an oscillometric monitor. Incremental treadmill exercise testing yielded maximal and submaximal fitness parameters. Participants were randomly assigned to either HIT, MCT, or a control group (CON). The intervention groups trained twice a week over a 12-week intervention period.

Results: After adjustment for between-group baseline differences, a moderate meaningful overall reduction of the augmentation index at 75 min⁻¹ heart rate (AIx@75) was observed [partial eta squared (ηp2) = 0.16; p = 0.06]. With 91% likely beneficial effects, HIT was more effective in reducing AIx@75 than MCT [HIT: pre 22.0 (9.7), post 14.9 (13.0), standardized mean difference (SMD) = 0.62; MCT: pre 16.6 (8.5), post 21.3 (10.4), SMD −0.49]. HIT induced a relevant reduction in central systolic blood pressure [cSBP: pre 118 (23) mmHg, post 110 (16) mmHg, SMD = 0.42] with a 59% possibly beneficial effect compared to CON, while MCT showed larger effects in lowering central diastolic blood pressure [pre 78 (7) mmHg, post 74 (7) mmHg, SMD = 0.61], presenting 60% possibly beneficial effects compared to CON. Central aortic PWV showed no changes in any of the three groups. Migraine days were reduced more successfully by HIT than MCT (HIT: SMD = 1.05; MCT: SMD = 0.43).

Conclusion: HIT but not MCT reduces AIx@75 as a measure of pulse wave reflection and indirect marker of systemic arterial stiffness. Both exercise modalities beneficially affect central blood pressure. HIT proved to be an effective complementary treatment option to reduce vascular dysfunction and blood pressure in migraineurs.

Foveal and Peripapillary Vascular Decrement in Migraine With Aura Demonstrated by Optical Coherence Tomography Angiography

Purpose

Migraine, particularly with aura, has been associated with ocular and systemic ischemic complications, but there are limited data on the ocular vasculature in migraine. We used optical coherence tomography angiography (OCTA) to assess perfusion of the macula and optic nerve in migraine patients, with (MA) and without (MO) aura, compared to healthy controls (HC).

Methods

We recruited 15 MA (mean age 42 years), 12 MO (mean age 46 years), and 22 HC (mean age 39 years) participants from neurology and neuro-ophthalmology clinics. Participants underwent optical coherence tomography and 3 × 3 mm OCTA of the macula and optic nerve. Foveal avascular zone area was automatically measured using AngioVue software, and vessel density was calculated as blood vessel length divided by scan area (mm-1) after skeletonization of OCTA images.

Results

On macular OCTA, MA participants had an enlarged foveal avascular zone area when compared with HC (0.300 ± 0.019 vs. 0.220 ± 0.066 mm2, P = 0.006). In addition, superficial foveal vessel density was decreased in MA participants when compared with MO participants (7.8 ± 0.31 vs. 9.3 ± 0.44, P = 0.04) and HC (7.8 ± 0.31 vs. 9.4 ± 0.21 mm-1, P = 0.002). On optic nerve OCTA, the MA participants had reduced superior peripapillary vessel density when compared with the MO participants (12.0 ± 0.45 vs. 14.0 ± 0.38 mm-1, P = 0.031) and HC (12.0 ± 0.45 vs. 14.1 ± 0.53 mm-1, P = 0.035). There were no significant differences between the MO and HC groups.

Conclusions

Migraine with, but not without, aura was associated with foveal and peripapillary vascular decrements, which may possibly mediate increased risk of ocular and systemic vascular complications in these patients. OCTA could potentially be useful as a biomarker for migraine with aura.

The retinal microcirculation in migraine: The Rotterdam Study

Background To explore the role of microvascular pathology in migraine, we investigated the association between migraine and retinal microvascular damage. Methods We included 3270 participants (age ≥ 45 years, 63% women) from the population-based Rotterdam Study (2006-2009). Participants with migraine were identified using a validated questionnaire based on ICHD-II criteria (n = 562). Retinopathy signs were graded on fundus photographs. Retinal arteriolar and venular caliber were measured by semi-automatic assessment of fundus photographs. Associations of migraine with retinopathy and retinal microvascular calibers were examined using logistic and linear regression models, respectively, adjusting for age, sex, and cardiovascular risk factors. Results Migraine was not associated with the presence of retinopathy (odds ratio (OR): 1.09, 95% confidence interval (CI) 0.62; 1.92). In the fully adjusted model, adjusting for the companion vessel, persons with migraine did not differ in retinal arteriolar or venular caliber compared to persons without migraine (mean difference in standardized arteriolar caliber -0.05 (95%CI -0.13; 0.03); in standardized venular caliber -0.00 (95%CI -0.09; 0.08)). Migraine subtypes, including migraine with aura, were also not associated with retinal microvascular damage. Conclusions Our findings suggest that migraine is not associated with retinopathy or difference in retinal microvascular caliber. Further studies are needed to confirm these results.

The Paradoxical Significance of Headache in Hypertension

BACKGROUND

The cardiovascular prognostic value of various types of headache, particularly migraine, in the general population remains controversial. The aim of the present study was to assess their prognostic value for all-cause, cardiovascular and stroke mortalities in hypertensive patients.

METHODS

A total of 1,914 hypertensive individuals were first categorized according to the absence or presence of headache and thereafter according to the 3 subtypes of headache: migraine, daily headache, and other headache.

RESULTS

Multiple regression analysis demonstrated that all headache types were predicted by gender (women), diastolic blood pressure, absence of diabetes, secondary hypertension, and a trend for severe retinopathy. After 30 years of follow-up, 1,076 deaths were observed, 580 of whom were from cardiovascular cause and 97 from acute stroke. In a multivariable Cox model adjusted for major confounders, patients having headache had a decreased risk for all-cause mortality (hazard ratio (HR) 0.82; 95% confidence interval (CI) 0.73-0.93) and cardiovascular mortality (HR 0.80; 95% CI 0.68-0.95), but not for stroke mortality (HR 1.00; 95% CI 0.70-1.43). When considering only patients with headache, "daily headache" had a nonsignificant better prognostic value for all-cause and cardiovascular mortality than "other headache" (HR 0.83; 95% CI 0.68-1.01; HR 0.89; 95% CI 0.69-1.16, respectively) and "migraine" (HR 0.85; 95% CI 0.65-1.11; HR 0.78; 95% CI 0.55-1.10, respectively).

CONCLUSION

Presence of nonspecific headache in hypertensive patients has a paradoxical significance in that it is associated with a high-risk profile but does not result in a worse prognosis over the long term.

Migraine and risk of cardiovascular disease in women: prospective cohort study

OBJECTIVE

 To evaluate the association between migraine and incident cardiovascular disease and cardiovascular mortality in women.

DESIGN

 Prospective cohort study among Nurses' Health Study II participants, with follow-up from 1989 and through June 2011.

SETTING

 Cohort of female nurses in United States.

PARTICIPANTS

 115 541 women aged 25-42 years at baseline and free of angina and cardiovascular disease. Cumulative follow-up rates were more than 90%.

MAIN OUTCOME MEASURES

 The primary outcome of the study was major cardiovascular disease, a combined endpoint of myocardial infarction, stroke, or fatal cardiovascular disease. Secondary outcome measures included individual endpoints of myocardial infarction, stroke, angina/coronary revascularization procedures, and cardiovascular mortality.

RESULTS

 17 531 (15.2%) women reported a physician's diagnosis of migraine. Over 20 years of follow-up, 1329 major cardiovascular disease events occurred and 223 women died from cardiovascular disease. After adjustment for potential confounding factors, migraine was associated with an increased risk for major cardiovascular disease (hazard ratio 1.50, 95% confidence interval 1.33 to 1.69), myocardial infarction (1.39, 1.18 to 1.64), stroke (1.62, 1.37 to 1.92), and angina/coronary revascularization procedures (1.73, 1.29 to 2.32), compared with women without migraine. Furthermore, migraine was associated with a significantly increased risk for cardiovascular disease mortality (hazard ratio 1.37, 1.02 to 1.83). Associations were similar across subgroups of women, including by age (<50/≥50), smoking status (current/past/never), hypertension (yes/no), postmenopausal hormone therapy (current/not current), and oral contraceptive use (current/not current).

CONCLUSIONS

 Results of this large, prospective cohort study in women with more than 20 years of follow-up indicate a consistent link between migraine and cardiovascular disease events, including cardiovascular mortality. Women with migraine should be evaluated for their vascular risk. Future targeted research is warranted to identify preventive strategies to reduce the risk of future cardiovascular disease among patients with migraine.

Age-specific association of migraine with cryptogenic TIA and stroke: Population-based study

OBJECTIVE

To determine whether there is an association between previous migraine and cryptogenic TIA or ischemic stroke at older ages.

METHODS

We determined the age-specific associations of history of migraine and Trial of Org 10172 in Acute Stroke Treatment (TOAST) subtype of TIA and ischemic stroke in a population-based cohort study (Oxford Vascular Study; 2002-2012).

RESULTS

Among 1,810 eligible patients with TIA or ischemic stroke, 668 (36.9%) had cryptogenic events, of whom 187 (28.0%) had previous migraine. Migraine was more commonly associated with cryptogenic events than with those of known etiology (odds ratio [OR] 1.73, 95% confidence interval [CI] 1.38-2.16, p < 0.0001; cardioembolic 2.00, 1.50-2.66, p < 0.0001; large artery 1.75, 1.20-2.53, p = 0.003; small vessel 1.32, 0.95-1.83, p = 0.096). The association of migraine with cryptogenic events was independent of age, sex, and all measured vascular risk factors (RFs) (adjusted OR 1.68, 1.33-2.13, p < 0.0001) and was strongest at older ages (<55 years, OR 1.11, 0.55-2.23; 55-64 years, 1.48, 0.83-2.63; ≥65 years, 1.81, 1.39-2.36) and in patients without vascular RFs (0 RFs OR 2.62, 1.33-5.15; 1 RF 2.01, 1.35-3.01; 2 RFs 1.80, 1.21-2.68; 3 RFs 1.21, 0.71-2.07; 4 RFs 0.92, 0.28-2.99). Results were consistent for migraine with or without aura and for analyses excluding TIA or stratified by sex or vascular territory of event.

CONCLUSIONS

In this population-based study of stroke etiology stratified by age, migraine was most strongly associated with cryptogenic TIA and ischemic stroke, particularly at older ages, suggesting a causal role or a shared etiology.

Systemic and cerebral endothelial dysfunction in chronic migraine. A case-control study with an active comparator

BACKGROUND AND OBJECTIVE

Unlike migraine and migraine with aura, little information exists regarding chronic migraine (CM) as a risk factor for cardiovascular disease. In this study we aim to determine whether an association between CM and endothelial dysfunction exists.

METHODS

Individuals 18 years and older diagnosed with episodic migraine (EM) and CM according to ICHD criteria were studied. After an overnight fast and abstinence from vasoactive drugs, ultrasound studies were performed and blood samples taken from patients and matched controls according to internationally agreed on protocols.

RESULTS

A total of 113 individuals were enrolled (35 CM, 37 EM, 41 controls). CM patients had a lower percentage of flow-mediated vasodilation (FMD; difference of means = 5.03%; p = 1.0E-6) and breath-holding index (BHI; difference of means 0.754; p = 2.0E-6), as well as increased carotid intima media thickness (cIMT; difference of means = 0.128 mm; p = 7.0E-5) than controls. The EM patients and controls comparison found similar, but less pronounced, differences: decreased BHI (p = 0.031), and increased cIMT (p = 0.028). Fibrinogen (r = 0.277; p = 0.006), C-reactive protein (r = 0.288; p = 0.003), and erythrocyte rate sedimentation (r = 0.298; p = 0.002) also correlated with cIMT, and inversely with BHImV and FMD.

CONCLUSIONS

Migraine is associated with systemic and cerebral endothelial dysfunction demonstrated by ultrasound studies and biological markers. The degree of these changes was strongly associated with the severity of migraine. Our data indicate that migraine may be a cerebral disorder with systemic endothelial damage.

Migraine and the risk for stroke and cardiovascular disease

Numerous data have pointed to an association between migraine and cardiovascular diseases. The majority of the available data have indicated that migraine with aura can be considered a risk factor for ischemic stroke, whereas migraine without aura cannot be reliably considered as such. High frequency of attacks and a recent onset of migraine have been related to an increased ischemic stroke risk. In addition, in young subjects with ischemic stroke migraine with aura represents an independent risk factor of overall recurrent vascular events and of recurrent ischemic stroke. Also the risk of transient ischemic attack seems to be increased in migraineurs, although this issue has not been extensively investigated. Several studies have also addressed the possible association between migraine and hemorrhagic stroke. Although the results of these individual studies were conflicting, their meta-analysis showed that migraine is associated with a 1.5-fold increase in the risk of hemorrhagic stroke (including intracerebral and subarachnoid hemorrhage). Some studies have identified migraine also as a possible risk factor for cardiac vascular events while others have yielded negative results. A meta-analysis did not show an increased risk of myocardial infarction in subjects with any migraine vs no migraine but subsequently, data has pointed to an association between any migraine with cardiac ischemic disease. Migraine has also been associated by some studies with vascular mortality and with vascular diseases in regions other than the brain and the heart. Several studies have also indicated that compared with nonmigraineurs, migraineurs have a higher burden of asymptomatic white matter brain lesions and, according to some studies, also infarct-like lesions at brain magnetic resonance. The mechanisms underlying the relationship between migraine and cardiovascular disease are still unclear. The possible explanation may rely on a peculiar vascular vulnerability of migraineurs that may contribute to the pathogenesis of migraine and, in the presence of some other unknown factors may also contribute, over time, to the development of cardiovascular disease. At the moment, there are no reliable features that may indicate which subjects, across the overall migraine population, will develop vascular events and so far, no drugs are recommended for the vascular prevention in migraineurs unless other clear indications are present. In general, the acute treatment and the secondary prevention measures of a patient with stroke who has a history of migraine do not differ from that of other stroke patients. There is currently no direct evidence to support that a migraine prophylactic treatment will reduce future stroke risk in secondary prevention.

Flow in the left anterior descending coronary artery in patients with migraine headache

Migraine is a common neurovascular disorder characterized by attacks of severe headache, autonomic and neurologic symptoms. Migraine can affect many systems in the body, yet its effects on cardiovascular system are unclear. We hypothesized that migraine and coronary microvascular angina may be manifestations of a common systemic microvascular dysfunction and clinically associated. Forty patients with migraine and 35 healthy volunteers were included into the study. Using transthoracic Doppler echocardiography, coronary flow was visualized in the middle or distal part of the left anterior descending artery. Coronary diastolic peak flow velocities were measured with pulse wave Doppler at baseline and after dipyridamole infusion (0.56 mg/kg/4 min). Coronary flow reserve of <2 was considered normal. In addition, thorough 2-dimensional and Doppler echocardiographic examinations were also performed. Fifty-two women and 23 men were included. Coronary flow reserve was significantly lesser in the migraine group than in the control group (1.99 ± 0.3 vs 2.90 ± 0.5, p <0.05). In addition, mitral annular velocities were lower and the ratio of early mitral inflow velocity to early mitral annular velocity (E/E' lateral and E/E' septal) was higher in migraineurs than in the control group (p <0.05 for all), indicating diastolic function abnormalities in the migraine group. In conclusion, these findings suggest that there is an association between coronary microvascular dysfunction and migraine independently of the metabolic state of the patients. A common pathophysiologic pathway of impaired endothelial vasodilatation, vasomotor dysfunction, and increased systemic inflammatory factors may play a role in these 2 clinical conditions and could be the underlying cause of subclinical systolic and diastolic left ventricular dysfunction in migraineurs.

Primary headache and silent myocardial ischemia in patients with coronary artery disease

OBJECTIVE

The mechanisms by which migraine is linked to ischemic vascular disease remain uncertain and are likely to be complex. The aim of this study was to investigate the correlation between silent myocardial ischemia (SMI) and a history of documented primary headache in a large population of patients with exercise-induced myocardial ischemia.

METHODS

The study involved 1,427 consecutive patients (918 symptomatic and 509 asymptomatic patients) with exercise-induced myocardial ischemia and documented coronary artery disease (CAD).

RESULTS

Patients with anginal symptoms during exercise-induced myocardial ischemia had a significantly higher prevalence of primary headache than those without (41 vs. 30%, p < 0.001). Patients with angina pectoris in daily life also had greater prevalence of primary headache than those without anginal symptoms (37 vs. 20%; p < 0.0001). Symptomatic patients during percutaneous transluminal coronary angiography or myocardial infarction had a greater prevalence of primary headache than asymptomatic patients (p < 0.001 and p = 0.005, respectively).

CONCLUSIONS

Our data suggest that a history of headache in CAD population is correlated to a high probability of anginal symptoms and a decreased probability of SMI. The anamnestic absence of headache requires a close monitoring for patients with risk factors for CAD, because this population seems to have a lower susceptibility to pain and the risk of developing SMI might be increased.

[Migraine and vascular risk]

Migraine with aura is well known to be associated with an increased risk of ischemic stroke. This risk dramatically increases in smokers and uses of oral contraceptives. Brain MRI studies suggest that migraine is associated with silent brain infarcts. Migraine is also established as a risk factor for significantly more cerebral white matter lesions. Recent data suggest that migraine is also associated with coronary artery disease. Data concerning an increase risk of mortality in migraine are controversial. The pathophysiology of the increased risk of ischemic events is unclear. Migrainous infarcts seem to be very rare. Migraine is associated with an increased risk of cervical artery dissection. Classical vascular risk factors are more common in migraineurs. Triptans are not associated with an increased risk of ischemic events. Another explanation is a probable endothelial dysfunction and a lower level of endothelial progenitor cells in migraine. A prothrombotic state in migraine is also another possible explanation due to genetic polymorphisms. Appropriate management for primary vascular prevention in migraineurs is not different from that proposed for the general population. Oral contraceptives should be avoided in migraineurs with aura, especially if they smoke.

New insights into the cardiovascular risk of migraine and the role of white matter hyperintensities: is gold all that glitters?

The role of migraine as an independent risk factor for cardiovascular events has been debated for several years, while it is more established for ischemic stroke. Recently, new studies have examined the likelihood of migraine to determine cardiovascular events, supporting the hypothesis of a predominant role in patients with migraine with aura, the risk including both sexes. In the literature, multiple pathophysiological mechanisms are described to explain this association, and are here discussed. Furthermore, the emerging evidence that a higher headache frequency and long-term migraine may worsen the cardio-metabolic profile in migraineurs (e.g. with a higher Framingham risk score and risk of developing atherosclerosis, insulin resistance and metabolic syndrome) makes it increasingly necessary to reduce the number and severity of attacks, not only to alleviate the painful symptoms, but also to improve the prognosis in these patients.

Nonmydriatic ocular fundus photography among headache patients in an emergency department

OBJECTIVES

Determine the frequency of and the predictive factors for abnormal ocular fundus findings among emergency department (ED) headache patients.

METHODS

Cross-sectional study of prospectively enrolled adult patients presenting to our ED with a chief complaint of headache. Ocular fundus photographs were obtained using a nonmydriatic fundus camera that does not require pupillary dilation. Demographic and neuroimaging information was collected. Photographs were reviewed independently by 2 neuroophthalmologists for findings relevant to acute care. The results were analyzed using univariate statistics and logistic regression modeling.

RESULTS

We included 497 patients (median age: 40 years, 73% women), among whom 42 (8.5%, 95% confidence interval: 6%-11%) had ocular fundus abnormalities. Of these 42 patients, 12 had disc edema, 9 had optic nerve pallor, 6 had grade III/IV hypertensive retinopathy, and 15 had isolated retinal hemorrhages. Body mass index ≥ 35 kg/m(2) (odds ratio [OR]: 2.3, p = 0.02), younger age (OR: 0.7 per 10-year increase, p = 0.02), and higher mean arterial blood pressure (OR: 1.3 per 10-mm Hg increase, p = 0.003) were predictive of abnormal retinal photography. Patients with an abnormal fundus had a higher percentage of hospital admission (21% vs 10%, p = 0.04). Among the 34 patients with abnormal ocular fundi who had brain imaging, 14 (41%) had normal imaging.

CONCLUSIONS

Ocular fundus abnormalities were found in 8.5% of patients with headache presenting to our ED. Predictors of abnormal funduscopic findings included higher body mass index, younger age, and higher blood pressure. Our study confirms the importance of funduscopic examination in patients with headache, particularly in the ED, and reaffirms the utility of nonmydriatic fundus photography in this setting.

Direct visualization and characterization of erythrocyte flow in human retinal capillaries

Imaging the retinal vasculature offers a surrogate view of systemic vascular health, allowing noninvasive and longitudinal assessment of vascular pathology. The earliest anomalies in vascular disease arise in the microvasculature, however current imaging methods lack the spatiotemporal resolution to track blood flow at the capillary level. We report here on novel imaging technology that allows direct, noninvasive optical imaging of erythrocyte flow in human retinal capillaries. This was made possible using adaptive optics for high spatial resolution (1.5 μm), sCMOS camera technology for high temporal resolution (460 fps), and tunable wavebands from a broadband laser for maximal erythrocyte contrast. Particle image velocimetry on our data sequences was used to quantify flow. We observed marked spatiotemporal variability in velocity, which ranged from 0.3 to 3.3 mm/s, and changed by up to a factor of 4 in a given capillary during the 130 ms imaging period. Both mean and standard deviation across the imaged capillary network varied markedly with time, yet their ratio remained a relatively constant parameter (0.50 ± 0.056). Our observations concur with previous work using less direct methods, validating this as an investigative tool for the study of microvascular disease in humans.

Migraine, cerebrovascular disease and the metabolic syndrome

Evidence is emerging that migraine is not solely a headache disorder. Observations that ischemic stroke could occur in the setting of a migraine attack, and that migraine headaches could be precipitated by cerebral ischemia, initially highlighted a possibly association between migraine and cerebrovascular disease. More recently, large population-based studies that have demonstrated that migraineurs are at increased risk of stroke outside the setting of a migraine attack have prompted the concept that migraine and cerebrovascular disease are comorbid conditions. Explanations for this association are numerous and widely debated, particularly as the comorbid association does not appear to be confined to the cerebral circulation as cardiovascular and peripheral vascular disease also appear to be comorbid with migraine. A growing body of evidence has also suggested that migraineurs are more likely to be obese, hypertensive, hyperlipidemic and have impaired insulin sensitivity, all features of the metabolic syndrome. The comorbid association between migraine and cerebrovascular disease may consequently be explained by migraineurs having the metabolic syndrome and consequently being at increased risk of cerebrovascular disease. This review will summarise the salient evidence suggesting a comorbid association between migraine, cerebrovascular disease and the metabolic syndrome.

Migraine and vascular diseases: a review of the evidence and potential implications for management

INTRODUCTION

The higher-than-expected incidence of vascular diseases reported in migraineurs suggests that migraine may, in some cases, be a dangerous condition rather than just a distressing but harmless disorder. We provide a systematic review of data linking migraine to vascular diseases.

MIGRAINE AND VASCULAR DISEASES

Available data indicate an increased risk of ischemic stroke in subjects suffering from migraine with aura. In addition, evidence suggests an association between migraine with aura and cardiac disease, intracerebral hemorrhage, retinal vasculopathy and mortality that needs to be further corroborated; consequently, for those conditions, migraine with aura can be only considered among the less-well-documented risk factors. As the absolute risk of ischemic stroke in the overall migraineur population is low, subjects suffering from migraine with aura should be made aware of the possible link but not unduly alarmed. It is a common notion that the vascular risk of migraineurs may be further increased by the presence of easily treatable vascular risk factors such as arterial hypertension, cigarette smoking and oral contraceptive use.

CONCLUSIONS

Forthcoming guidelines should appropriately recommend supporting migraineurs not only with measures aimed at decreasing headache frequency, thus improving quality of life, but also with general measures and preventive strategies aimed to reduce the overall vascular risk. In fact, headache specialists should take care not only of relieving pain but also of assessing and treating concurrent vascular risk factors, while gynecologists, in particular, should routinely consider the presence and type of migraine before prescribing oral contraceptives.

Associations between cerebral and systemic endothelial function in migraine patients: a post-hoc study

Background

There is a growing interest in the role of the endothelium in migraine. Recently, our group showed differences in endothelial function between the anterior and posterior cerebral circulation in healthy subjects, reduced vasodilatatory capacity of the posterior cerebral circulation and unimpaired systemic endothelial function in migraine patients without comorbidities. However, the relationship between cerebral and systemic endothelial function and the anterior and posterior cerebral endothelial function in migraine patients is still not clear.

Methods

We compared cerebral and systemic endothelial function through post-hoc linear regression analysis of cerebrovascular reactivity (CVR) to L-arginine between the middle cerebral artery (MCA) and flow-mediated vasodilatation (FMD) of the right brachial artery and the posterior cerebral artery (PCA) and FMD in migraine patients without comorbidities and in healthy subjects. The anterior and posterior cerebral endothelial function was also compared using post-hoc linear regression analysis between CVR to L-arginine in the MCA and the PCA.

Results

No significant correlation was found between CVR to L-arginine in the MCA and FMD and in the PCA and FMD in migraine patients with aura (p = 0.880 vs. p = 0.682), without aura (p = 0.153 vs. p = 0.179) and in healthy subjects (p = 0.869 vs. p = 0.662). On the other hand, we found a significant correlation between CVR to L-arginine in the MCA and PCA in migraine patients with aura (p = 0.004), without aura (p = 0.001) and in healthy subjects (p = 0.002). Detailed analysis of the linear regression between all migraine patients and healthy subjects did not show any difference in the regression coefficient (slope) (p = 0.382). However, a significant difference in curve elevation (intercept) was found (p = 0.002).

Conclusions

Our study suggests that the endothelial function in the cerebral and systemic circulation might be different in migraine patients without comorbidities, while that of the anterior and posterior cerebral circulation might be coupled. These results could improve understanding of endothelial function in migraine patients without comorbidities.

Functional somatic syndromes, anxiety disorders and the upper airway: a matter of paradigms

The relationship between the functional somatic syndromes, anxiety disorders and the upper airway (particularly, sleep disordered breathing) remains ambiguous. This ambiguity, despite a growing body of research supporting a relationship, may result from the absence of a paradigm to explain how upper airway dysfunction can promote disorders commonly associated with one's mental health. This review models the functional somatic syndromes and anxiety disorders as consequences of chronically increased hypothalamic-pituitary-adrenal axis activity. It then examines the literature supporting a relationship between these disorders and upper airway dysfunction during wakefulness and sleep. Finally, building upon an existing paradigm of neural sensitization, sleep disordered breathing is linked to functional somatic syndromes and anxiety disorders through chronic activation of the hypothalamic-pituitary-adrenal axis.

Migraine aura pathophysiology: the role of blood vessels and microembolisation

Migraine attacks with auras are sometimes associated with underlying hereditary or acquired cerebrovascular disorders. A unifying pathophysiological explanation linking migraine to these conditions has been difficult to identify. On the basis of genetic and epidemiological evidence, we suggest that changes in blood vessels, hypoperfusion disorders, and microembolisation can cause neurovascular dysfunction and evoke cortical spreading depression, an event that is widely thought to underlie aura symptoms. In fact, recent experimental data have indicated that focal, mild, and transient ischaemia can trigger cortical spreading depression without an enduring tissue signature. Although migraine with aura has many causes (eg, neuronal network excitability), it seems that migraine and stroke might both be triggered by hypoperfusion and could therefore exist on a continuum of vascular complications in a subset of patients who have these hereditary or acquired comorbid vascular conditions.

Migraine and cardiovascular disease: a population-based study

OBJECTIVES

Although the relationship between migraine and cardiovascular disease (CVD) has been studied, several questions remain unanswered. Herein we contrast the rate of diagnosed CVD as well as of risk factors for CVD in individuals with migraine with and without aura (MA and MO) and in controls.

METHODS

In this case-control study, migraineurs (n = 6,102) and controls (n = 5,243) were representative of the adult US population. Headache diagnosis was formally assigned using a validated mailed questionnaire which also obtained details on treatment, comorbidities, and other variables. CVD events were obtained based on self-reported medical diagnosis. Risk factors for CVD and modified Framingham scores were computed.

RESULTS

In unadjusted analyses, migraine overall and MA were associated with myocardial infarction, stroke, and claudication, and MO was associated with myocardial infarction and claudication. Migraineurs were more likely than controls to have a medical diagnosis of diabetes (12.6% vs 9.4%, odds ratio [OR] 1.4, 95% confidence interval [CI] 1.2-1.6), hypertension (33.1% vs 27.5%, OR 1.4, 95% CI 1.3-1.6), and high cholesterol (32.7% vs 25.6%, OR 1.4, 95% CI 1.3-1.5). Risk was highest in MA, but remained elevated in MO. Framingham scores were significantly higher in MO and MA than in controls. After adjustments (gender, age, disability, treatment, CVD risk factors), migraine remained significantly associated with myocardial infarction (OR 2.2, 95% CI 1.7-2.8), stroke (OR 1.5, 95% CI 1.2-2.1), and claudication (OR 2.69, 95% CI 1.98-3.23).

CONCLUSION

Both migraine with and without aura are associated with cardiovascular disease (CVD) and with risk factors for CVD. However, since our sample size is large, the clinical relevance of the differences is yet to be established.

Migraine as a systemic vasculopathy

Epidemiological studies suggests that migraine is associated with disorders of the cerebral, coronary, retinal, dermal and peripheral vasculature. There is evidence that migraine is associated with endothelial dysfunction, both as a cause and a consequence. Endothelial dysfunction, a vascular risk factor, is characterized by endothelial activation and impaired vascular reactivity. Plasma and genetic biomarkers for these conditions have been identified. The clinical significance lies in the potential for the rapid identification of migraineurs at increased risk of ischaemic stroke and vascular disease through ascertainment of endothelial dysfunction biomarkers. It is uncertain whether stroke, myocardial infarction and other vasculopathies can be prevented by migraine prophylaxis, endothelial repair, platelet inhibition or a combination of these strategies.

Ankle-brachial index, a screening for peripheral obstructive arterial disease, and migraine - a controlled study

BACKGROUND

Epidemiological studies support the association between migraine, especially migraine with aura, and vascular disorders. The ankle-brachial index (ABI) is largely used as a surrogate of peripheral obstructive arterial disorders (POAD). Accordingly, in this study we contrasted the ABI in individuals with migraine and in controls.

METHODS

We investigated 50 migraineurs and 38 controls and obtained the ABI (ratio between the systolic arterial pressure obtained in the legs and in the arms) using digital sphygmomanometry. As per validation studies, we used the cut-off of 0.9 as the normal limit for the ABI. We adjusted for gender, use of contraceptive hormones, tabagism, and other cardiovascular risk factors.

RESULTS

We found abnormal values of ABI, suggestive of mild or moderate POAD, in 31 individuals (35.2%). Mean value was 0.96 (standard deviation = 0.10). None of our patients had ABI < 0.4, which would suggest severe POAD. Mean ABI for migraineurs was 0.94 (0.11), and for controls it was 0.99 (0.09). Difference was significant (t = 2.21 and P = .022). After adjustments, ABI remained significantly associated with migraine status (P = .024). Adjustments were reasonably effective (chi(2) of Hosmer-Lemeshow = 1.06, P = .590).

CONCLUSION

Our findings suggest that decreased values of ABI are more common in migraineurs than in controls. Although causality was not assessed by us, the relationship is of importance per se. Doctors should measure the ABI in individuals with migraine as an easy way to screen for cardiovascular risk.