Episodic Migraine Comorbidities: Avoiding Pitfalls and Taking Therapeutic Opportunities

Impact of Spinal Manipulative Therapy on Brain Function and Pain Alleviation in Lumbar Disc Herniation: A Resting-State fMRI Study

OBJECTIVE

To elucidate how spinal manipulative therapy (SMT) exerts its analgesic effects through regulating brain function in lumbar disc herniation (LDH) patients by utilizing resting-state functional magnetic resonance imaging (rs-fMRI).

METHODS

From September 2021 to September 2023, we enrolled LDH patients (LDH group, n=31) and age- and sex-matched healthy controls (HCs, n=28). LDH group underwent rs-fMRI at 2 distinct time points (TPs): prior to the initiation of SMT (TP1) and subsequent to the completion of the SMT sessions (TP2). SMT was administered once every other day for 30 min per session, totally 14 treatment sessions over a span of 4 weeks. HCs did not receive SMT treatment and underwent only one fMRI scan. Additionally, participants in LDH group completed clinical questionnaires on pain using the Visual Analog Scale (VAS) and the Japanese Orthopedic Association (JOA) score, whereas HCs did not undergo clinical scale assessments. The effects on the brain were jointly characterized using the amplitude of low-frequency fluctuations (ALFF) and regional homogeneity (ReHo). Correlation analyses were conducted between specific brain regions and clinical scales.

RESULTS

Following SMT treatment, pain symptoms in LDH patients were notably alleviated and accompanied by evident activation of effects in the brain. In comparison to TP1, TP2 exhibited the most significant increase in ALFF values for Temporal_Sup_R and the most notable decrease in ALFF values for Paracentral_Lobule_L (voxelwise P<0.005; clusters >30; FDR correction). Additionally, the most substantial enhancement in ReHo values was observed for the Cuneus_R, while the most prominent reduction was noted for the Olfactory_R (voxelwise P<0.005; clusters >30; FDR correction). Moreover, a comparative analysis revealed that, in contrast to HCs, LDH patients at TP1 exhibited the most significant increase in ALFF values for Temporal_Pole_Sup_L and the most notable decrease in ALFF values for Frontal_Mid_L (voxelwise P<0.005; clusters >30; FDR correction). Furthermore, the most significant enhancement in ReHo values was observed for Postcentral_L, while the most prominent reduction was identified for ParaHippocampal_L (voxelwise P<0.005; clusters >30; FDR correction). Notably, correlation analysis with clinical scales revealed a robust positive correlation between the Cuneus_R score and the rate of change in the VAS score (r=0.9333, P<0.0001).

CONCLUSIONS

Long-term chronic lower back pain in patients with LDH manifests significant activation of the "AUN-DMN-S1-SAN" neural circuitry. The visual network, represented by the Cuneus_R, is highly likely to be a key brain network in which the analgesic efficacy of SMT becomes effective in treating LDH patients. (Trial registration No. NCT06277739).

Pain Management for Older Adults Across the Cognitive Trajectory

Purpose of review

This review investigated current research on the relationship between chronic pain and cognitive performance, subjective cognitive decline, and dementia. In addition, we reviewed current research on pain management in older adults across the cognitive trajectory.

Recent findings

Chronic pain remains a common problem in older adults. A new, international classification system highlights the complexity of chronic pain syndromes. Research supports relationships between chronic pain and changes in cognitive performance in generally healthy adults. Evidence also supports associations between pain and subjective cognitive decline, which is considered a possible precursor to dementia. The impact of dementia on pain expression is also reviewed. To manage pain in older adults, we present a multimodal pain management hierarchy that includes pharmacological and non-pharmacological treatments. To avoid the risks and side effects of analgesics, non-pharmacological treatment is recommended as the first line therapy for chronic pain. Medical cannabis and music therapy are two non-pharmacological treatments that have been the focus of substantial recent research; evidence supports their effectiveness in reducing pain and both strategies warrant further investigation.

Summary

Chronic pain is associated with different levels of cognitive decline across the cognitive trajectory. Medical cannabis and music therapy are the two emerging non-pharmacological treatment methods. Clinical studies with rigorous research design are needed to further investigate the effects of these two strategies on pain relief in older adults.

The effect of probiotic supplementation on the clinical and para-clinical findings of multiple sclerosis: a randomized clinical trial

Multiple Sclerosis (MS) is a chronic demyelination disease of the central nervous system (CNS). The gut-brain axis involves communication between the nervous, endocrine, and immune systems. Probiotics can positively impact immune and inflammatory responses by regulating gut microbiota. A total of 40 MS patients (average age of 34.38 ± 6.65) were examined to determine the effect of the Saccharomyces boulardii supplement for four months compared to a placebo. The results showed that the Saccharomyces boulardii significantly decreased the inflammatory marker high-sensitivity C-reactive protein (hs-CRP) compared to the placebo (P < 0.001). The serum antioxidant capacity (TAC) also increased significantly in the probiotic group compared to the placebo (p = 0.004). Both the probiotic and placebo groups showed a reduction in the oxidative stress indicator malondialdehyde (MDA), but there was no significant difference between the two groups. Pain intensity (measured by Visual Analogue Scale) and fatigue severity (measured by Fatigue Severity Scale) significantly decreased in the probiotic group compared to the placebo (p = 0.004 and p = 0.01, respectively). The probiotic group experienced significant improvement in some quality of life scales (measured by 36-Item Short Form Survey) and somatic and social dysfunction subscale of General Health Questionnaire scores compared to the placebo group (p = 0.01). The study suggests that the Saccharomyces boulardii probiotic supplement may benefit inflammatory markers, oxidative stress indicators, pain, fatigue, and quality of life in MS patients.

Towards precision medicine in migraine: Recent therapeutic advances and potential biomarkers to understand heterogeneity and treatment response

After 35 years since the introduction of the International Classification of Headache Disorders (ICHD), we are living in the era of the second great revolution in migraine therapies. First, discoveries of triptans provided a breakthrough in acute migraine treatment utilizing bench-to-bedside research results on the role of serotonin in migraine. Next, the discovery of the role of neuropeptides, more specifically calcitonin gene-related peptide (CGRP) in migraine attack led to the development of anti-CGRP therapies that are effective both in acute and preventive treatment, and are also able to reduce migraine-related burden. Here, we reviewed the most recent clinical studies and real-world data on available migraine-specific medications, including triptans, ditants, gepants and anti-CGRP monoclonal antibodies. Novel drug targets, such as PACAP and amylins were also discussed. To address the main challenges of migraine therapy, the high heterogeneity of people with migraine, the prevalent presence of various comorbid disorders, and the insufficient medical care of migraine patients were covered. Promising novel approaches from the fields of omics, blood and saliva biomarker, imaging and provocation studies might bring solutions for these challenges with the potential to identify further drug targets, distinguish more homogeneous patient subgroups, contribute to more optimal drug selection strategies, and detect biomarkers in association with headache features or predicting treatment efficacy. In the future, the combined analysis of data of different biomarker modalities with machine learning algorithms may serve precision medicine in migraine treatment.

Migraine and the Gender Divide

Migraine is a global neurologic disease that is highly prevalent, especially in women. Studies have observed a predisposition for the development of migraine in women, although the mechanisms involved have yet to be fully elucidated. This review aimed to summarize the recent evidence regarding the epidemiology, pathophysiology, and treatment of migraine and highlight key sex differences. We also identify gaps in care for both women and men living with migraine and discuss the presence of migraine-related stigma and how this may impact the efficacy of clinical care.

Applying a biopsychosocial model to migraine: rationale and clinical implications

Migraine is a complex condition in which genetic predisposition interacts with other biological and environmental factors determining its course. A hyperresponsive brain cortex, peripheral and central alterations in pain processing, and comorbidities play a role from an individual biological standpoint. Besides, dysfunctional psychological mechanisms, social and lifestyle factors may intervene and impact on the clinical phenotype of the disease, promote its transformation from episodic into chronic migraine and may increase migraine-related disability.Thus, given the multifactorial origin of the condition, the application of a biopsychosocial approach in the management of migraine could favor therapeutic success. While in chronic pain conditions the biopsychosocial approach is already a mainstay of treatment, in migraine the biomedical approach is still dominant. It is instead advisable to carefully consider the individual with migraine as a whole, in order to plan a tailored treatment. In this review, we first reported an analytical and critical discussion of the biological, psychological, and social factors involved in migraine. Then, we addressed the management implications of the application of a biopsychosocial model discussing how the integration between non-pharmacological management and conventional biomedical treatment may provide advantages to migraine care.

Psychosocial Variables and Healthcare Resources in Patients with Fibromyalgia, Migraine and Comorbid Fibromyalgia and Migraine: A Cross-Sectional Study

Fibromyalgia and migraine frequently coexist. We aimed to compare the burden caused by fibromyalgia (FM), migraine (M) and comorbid fibromyalgia and migraine (FM + M) by assessing psychosocial variables and the use of healthcare resources. A survey was posted to the websites of different patients’ associations. It included sociodemographic data, the Patient Health Questionnaire-9, the Insomnia Severity Index, the EuroQOL-5D-5L and a questionnaire evaluating the use of healthcare resources during the past six months. In total, 139 FM patients, 169 M patients and 148 FM + M patients participated in the survey. Mean depression and insomnia scores were clinically relevant in every group and significantly higher in FM + M (16.3 ± 5.4 for depression, 18.5 ± 5.6 for insomnia) than in FM (14.3 ± 5.7 for depression, 16.8 ± 5.5 for insomnia) or M (11.7 ± 5.4 for depression, 13.1 ± 5.9 for depression), where p < 0.001 in both cases. Suicidal ideation was frequent in every group, but significantly more frequent in FM + M (63% vs. 45% in FM and 35% in M; p < 0.001). EQ-5D-5L (0.656 ± 0.1 in FM + M, 0.674 ± 0.1 in FM, 0.827 ± 0.1 in M, p < 0.001) and EQ-5D-5L VAS scores (38.2 ± 21.9 in FM + M, 45.6 ± 21.8 in FM, 63.5 ± 23.7 in M, p < 0.00) were lower than the reported mean population values and the lowest in FM + M. FM and FM + M used more healthcare resources than M. It is concluded that the psychosocial burden was high in the three samples. FM and FM + M had a more relevant impact on patients’ wellbeing and required more medical attention than M. The burden caused by FM + M was higher than in both individual diseases.

NCOR2 is a novel candidate gene for migraine-epilepsy phenotype

HYPOTHESIS

To identify genetic factors predisposing to migraine-epilepsy phenotype utilizing a multi-generational family with known linkage to chr12q24.2-q24.3.

METHODS

We used single nucleotide polymorphism (SNP) genotyping and next-generation sequencing technologies to perform linkage, haplotype, and variant analyses in an extended Finnish migraine-epilepsy family (n = 120). In addition, we used a large genome-wide association study (GWAS) dataset of migraine and two biobank studies, UK Biobank and FinnGen, to test whether variants within the susceptibility region associate with migraine or epilepsy related phenotypes in a population setting.

RESULTS

The family showed the highest evidence of linkage (LOD 3.42) between rs7966411 and epilepsy. The haplotype shared among 12 out of 13 epilepsy patients in the family covers almost the entire NCOR2 and co-localizes with one of the risk loci of the recent GWAS on migraine. The haplotype harbors nine low-frequency variants with potential regulatory functions. Three of them, in addition to two common variants, show nominal associations with neurological disorders in either UK Biobank or FinnGen.

CONCLUSION

We provide several independent lines of evidence supporting association between migraine-epilepsy phenotype and NCOR2. Our study suggests that NCOR2 may have a role in both migraine and epilepsy and thus would provide evidence for shared pathophysiology underlying these two diseases.

The association between obesity and migraine and possible mechanisms of action: an integrative literature review

IntroductionObesity is a multifactorial disease and is defined by the excessive accumulation of adipose tissue that can cause harm to human health. The presence of obesity is an important risk factor for migraine chronification. However, not much is known about the link between the two diseases. MethodsIn this study, an integrative literature review was conducted to better understand the mechanisms of interaction between migraine and obesity. Therefore, a search of PubMed and the Virtual Health Library (VHL) was performed with the following keywords: enxaqueca e obesidade; enxaqueca e obesidade e inflamação; enxaqueca e obesidade e neuropeptídeos; migraine and obesity; migraine and obesity and inflammation; migraine and obesity and neuropeptides. ResultsThe search identified 22 articles. After reading and analyzing the articles, three thematic categories emerged: 1) Obesity as an Aggravating Factor for Migraine 2) Mechanisms Studied between Obesity and Migraine 3) The Effect of Weight Loss on Migraine Symptoms. ConclusionsThe chronic low-grade inflammation associated with obesity can cause a predisposition to migraine chronification. The abnormal secretion of adipokines, dysregulation of the sympathetic nervous system, and hypothalamic dysfunction have been suggested to be the main shared mechanisms between both diseases.

Migraine and stress-an exploratory cross-country study of external stress factors

OBJECTIVE

The data collected by the Global Burden of Disease 2016 project indicate that migraine ranks second in high-income countries with very competitive and flexible labour markets, and first in low- and middle-income countries suffering from civic unrest and conflict. This raises the question whether external stress factors may be correlated with migraine years lived with disability per 100,000 inhabitants (YLD). The objective of this exploratory study is to test the hypothesis that external stress factors are correlated with the prevalence and severity of migraine at the country level. The analysis uses two country groups: developed and developing countries. For the first group, the proxy variables for stress are labour productivity and unemployment rate. For the second group, the proxy variables measure conflict-related deaths and share of migrant/refugee population.

RESULTS

The results show a positive relationship between the stress variables on the one hand and migraine YLD on the other hand for both country groups. Almost all results are statistically significant at p < 0.01. These exploratory findings suggest that societal stress factors may be potential candidates for modifiable factors for the prevalence and/or severity of migraine at the country level.

Lasmiditan in patients with common migraine comorbidities: a post hoc efficacy and safety analysis of two phase 3 randomized clinical trials

OBJECTIVE

Determine whether common migraine comorbidities affect the efficacy and safety of lasmiditan, a 5-HT_1F receptor agonist approved in the United States for the acute treatment of migraine.

METHODS

In SPARTAN and SAMURAI (double-blind Phase 3 clinical trials), patients with migraine were randomized to oral lasmiditan 50 mg (SPARTAN only), 100mg, 200 mg, or placebo. Lasmiditan increased the proportion of pain-free and most bothersome symptom (MBS)-free patients at 2 h after dose compared with placebo. Most common treatment-emergent adverse events (TEAEs) were dizziness, paraesthesia, somnolence, fatigue, nausea, muscular weakness, and hypoesthesia. Based upon literature review of common migraine comorbidities, Anxiety, Allergy, Bronchial, Cardiac, Depression, Fatigue, Gastrointestinal, Hormonal, Musculoskeletal/Pain, Neurological, Obesity, Sleep, and Vascular Comorbidity Groups were created. Using pooled results, efficacy and TEAEs were assessed to compare patients with or without a given common migraine comorbidity. To compare treatment groups, p-values were calculated for treatment-by-subgroup interaction, based on logistic regression with treatment-by-comorbidity condition status (Yes/No) as the interaction term; study, treatment group, and comorbidity condition status (Yes/No) were covariates. Differential treatment effect based upon comorbidity status was also examined. Trial registration at clinicaltrials.gov: SAMURAI (NCT02439320) and SPARTAN (NCT02605174).

RESULTS

Across all the Comorbidity Groups, with the potential exception of fatigue, treatment-by-subgroup interaction analyses did not provide evidence of a lasmiditan-driven lasmiditan versus placebo differential treatment effect dependent on Yes versus No comorbidity subgroup for either efficacy or TEAE assessments.

CONCLUSIONS

The efficacy and safety of lasmiditan for treatment of individual migraine attacks appear to be independent of comorbid conditions.

Multidimensional assessment of the effects of erenumab in chronic migraine patients with previous unsuccessful preventive treatments: a comprehensive real-world experience

BACKGROUND

erenumab was safe and effective in clinical trials for the prevention of migraine. However, real-life data are still lacking. Here we report the clinical experience from an Italian real-world setting using erenumab in patients with chronic migraine experiencing previous unsuccessful preventive treatments.

METHODS

Seventy patients with chronic migraine and failure to ≥4 migraine preventive medication classes initially received monthly erenumab 70 mg s.c. Patients without a clinically meaningful improvement, considered as a > 30% reduction in headache days per month, after ≥3 months of therapy switched to monthly erenumab 140 mg. At the first administration and after 3 and 6 months, patients underwent extensive interviews to assess clinical parameters of disease severity and migraine-related disability and impact, and validated questionnaires to explore depression/anxiety, sleep, and quality of life (QoL). Finally, the Pain Catastrophizing Scale, Allodynia Symptom Checklist-12 and MIGraine attacks-Subjective COGnitive impairments scale (MIG-SCOG) were administered.

RESULTS

70% of patients were "responders" after the third administration of erenumab 70 mg, whereas 30% switched to erenumab 140 mg; 29% (6 pts) responded after the sixth administration. The headache-day frequency was reduced from 21.1 ± 0.7 to 11.4 ± 0.9 days after the third administration (p < 0.001) and to 8.9 ± 0.7 days after the sixth administration (p < 0.001). 53% and 70% of patients, respectively, showed a reduction of ≥50% of headache days/month after the third and the sixth administrations. Also improved were headache pain severity, migraine-related disability, and impact on daily living, QoL, pain catastrophizing and allodynia (all p < 0.001), quality of sleep, symptoms of depression or anxiety (p < 0.05) but not MIG-SCOG. There were no new adverse event signals.

CONCLUSION

These real-world data support monthly erenumab 70 or 140 mg s.c. as a safe and effective preventive treatment to reduce headache frequency and severity in chronic migraine patients experiencing previous unsuccessful preventive treatments.

Exercise and Chronic Pain

In this chapter, we describe the impact and etiology of chronic pain, the associated changes in the nervous system, and the mechanisms by which exercise may be able to affect and reverse these changes. Evidence for efficacy of exercise in different conditions associated with chronic pain is presented, with focus on chronic low back pain, fibromyalgia, osteoarthritis, rheumatoid arthritis, and migraines. While the efficacy of exercise and level of evidence supporting it vary in different diseases, exercise has direct and indirect benefits for most patients suffering from chronic pain. Effective exercise regimens include education and cognitive restructuring to promote behavioral activation and reconceptualization of what pain means, with the goal of gradually reversing the vicious cycle of pain, inertia, sedentary behavior, and worsening disability. Long-term, consistent, individualized exercise-based treatment approaches are most likely to result in improvements in pain and function.

Response Predictors in Chronic Migraine: Medication Overuse and Depressive Symptoms Negatively Impact Onabotulinumtoxin-A Treatment

Background: Despite numerous studies that have investigated clinical, radiological, and biochemical response predictors, the clinical profile of those patients who might benefit from OnabotulinumtoxinA is still missing. The aim of the present study was to identify potential OnabotulinumtoxinA response predictors among several clinical characteristics and confirm OnabotulinumtoxinA efficacy and safety in chronic migraine (CM) prevention.

Methods: The study was conducted at the Headache Center—Neurology Clinic—Spedali Civili Hospital of Brescia. Eighty-four consecutive CM patients were enrolled, with a mean age of 48 years (SD 9.7) and a mean disease duration of 10.1 years (SD 6.6). The mean reported headache-days frequency was 22.5 (SD 5.9) per month, while the mean number of severe headache-days was 15.2 (SD 8.9) with a mean monthly medication intake of 33.2 (SD 5.6). The clinical characteristics analyzed as potential response predictors were: gender, disease duration, migraine characteristics (location, side constancy, unilateral autonomic and neurovegetative symptoms), previous prophylactic treatments, add-on therapies, withdrawal therapies, psychiatric (anxiety and depression symptoms) comorbidities and medication overuse.

Results: A significant reduction from baseline to 3, 6, 9, and 12 month treatment cycles in total headache days, high intensity headache days and triptans consumption per month was found. Depressive symptoms and medication overuse negatively predicted OnabotulinumtoxinA outcome.

Conclusions: Our results confirm the efficacy and safety of OnabotulinumtoxinA in CM. Depressive comorbidity and medication overuse, among all clinical variables, were the only significant response predictors. Such findings provide interesting insights regarding patients selection for OnabotulinumtoxinA treatment as, with the introduction of anti calcitonin gene-related (CGRP) monoclonal antibodies, clinicians will have to thoroughly judge and tailor among the many available therapeutic options now available. Future research might be needed to confirm our findings, in particular for its therapeutic implications.