Platelets and migraine

Construction and validation of a nomogram for predicting remission of migraine patients with patent foramen ovale after closure

OBJECTIVE

This study aimed to construct and validate a nomogram model that predicts the remission of migraine attacks by screening factors that affect the prognosis of migraine patients with patent foramen ovale (PFO) after closure.

METHOD

Retrospective analysis was conducted in migraine patients with PFO who underwent PFO closure in the Department of Cardiology of Jiangsu Province Hospital from September 2020 to April 2023. Based on the Migraine Disability Assessment (MIDAS) scores from the 1-year follow-up after PFO closure, all patients who met the inclusion criteria were categorized into a remission group and a non-remission group. The primary efficacy endpoint was remission of migraine headache. After collecting clinical data, transcranial doppler sonography (TCD) results and MIDAS scores, LASSO (least absolute shrinkage and selection operator) regression and multivariable logistic regression analysis were used to filter variables predictive to migraine remission and construct the nomogram model. The Nomogram's accuracy and consistency were respectively assessed through Receiver Operating Characteristic (ROC) curves and calibration curves. Additionally, an analysis of decision curves (DCA) was conducted to evaluate the clinical utility of this newly developed model.

RESULT

A total of 241 consecutive patients were included in the study. The remission group included 21 males and 93 females, with a median age of 39 (30.25,50) years. The non-remission group included 26 males and 101 females, with a median age of 35 (25.5,47.5) years. All Patients were randomly divided into a training cohort and a validation cohort. Multivariable logistic regression analysis showed that 5 independent predictors, including MIDAS before closure (p = 0.0002), mitigating factors (p = 0.0057), number of attacks/month (p = 0.0058), TCD (p = 0.0093) and Platelet Crit (PCT) (p = 0.0351), played a significant role in the prediction of remission of migraine patients with PFO after closure. Based on these independent predictors, the predictive nomogram model of migraine remission in PFO patients was constructed. The application of the nomogram in the training cohort exhibited good discrimination (area under the ROC curve was 0.7763[95% CI 0.7108-0.8418]), which was confirmed in the validation cohort (AUC was 0.704[95% CI 0.5533-0.8547]). The calibration curve showed that the nomogram model demonstrated good calibration performance. Additionally, the decision curve analysis indicated the clinical utility of the nomogram model.

CONCLUSION

The construction of the nomogram model had a considerable predictive accuracy for migraine remission in patients after PFO closure, which may provide constructive guidance for clinical decision making.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

SIGNIFICANCE STATEMENT

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

Association between oxidative balance score and self-reported severe headache or migraine based on NHANES 1999 to 2004 data: A cross-sectional study

Purpose

The pathophysiological mechanisms underlying migraine remain elusive, with oxidative stress hypothesized as a potential etiological factor. The Oxidative Balance Score (OBS) is a comprehensive tool for assessing the impact of diet and lifestyle on oxidative stress, thereby gauging an individual's overall antioxidant capacity. In this cross-sectional study, we explored the correlation between OBS and migraine prevalence among a cohort of US adults.

Methods

We analyzed data from 6195 participants aged 20 years and above, drawn from the National Health and Nutrition Examination Survey (NHANES) conducted between 1999 and 2004. We employed multiple logistic regression, coupled with sensitivity analyses, to investigate the relationship between OBS and migraine. Subsequent subgroup analyses and interaction tests were performed to assess the consistency of this association across the population.

Results

Multiple logistic regression revealed an inverse relationship between OBS and the likelihood of experiencing migraines. Specifically, individuals in the highest OBS quartile exhibited a significantly reduced migraine risk compared to those in the lowest quartile (OR = 0.98, 95% Confidence Interval (CI): 0.97-0.99, P = 0.0001). Furthermore, restricted cubic spline curves indicated a non-linear association between dietary OBS and migraine incidence (non-linear P = 0.0258).

Discussion

Our findings suggest that adherence to an antioxidant-rich diet may be an effective strategy for mitigating migraine, potentially by influencing oxidative balance.

Study design and rationale of COMPETE: Comparison of the effect of medication therapy in alleviating migraine with patent foramen ovale

BACKGROUND

Previous studies have examined the impact of antithrombotic agents on Patent Foramen Ovale (PFO) in relation to migraine. However, differences in effectiveness of different antithrombotic agents and traditional migraine medications are not known.

METHODS/DESIGN

This study is an investigator-initiated, randomized, multicenter, single-masked (outcomes assessor), and active-controlled parallel-group trial (ClinicalTrials.gov Identifier: NCT05546320), with the objective of evaluating the prevention efficacy of antithrombotic agents compared to first-line migraine medication in PFO patients. The trial involves 1,000 migraine patients with a right-to-left shunt at the atrial level, randomized in a 1:1:1:1 fashion to receive either aspirin 300 mg QD, clopidogrel 75 mg QD, rivaroxaban 20 mg QD, or the active-control metoprolol 25 mg BID. The primary efficacy end point is the response rate, defined as a 50% or greater reduction in the average migraine attack days per month or in the average number of migraine attacks per month at 12-week visit compared to baseline.

CONCLUSIONS

The COMPETE trial aims to provide valuable insights into the comparative effectiveness of antithrombotic agents and standard migraine therapies in patients with PFO. This study holds the promise of advancing treatment approaches for individuals having migraines associated with PFO, thus addressing an important gap in current migraine management strategies.

Association Between Copper Intake and Migraine: a National Cross-sectional Study

Migraine is a common clinical neurological disorder that adversely affects humans and society. The relationship between copper intake and migraine has been less studied and controversial. The purpose of this study was to determine the relationship between copper intake and migraine and to guide dietary interventions. The data for this study were obtained from the National Health and Nutrition Examination Survey (NHANES) database from 1999 to 2004, involving a total of 12,724 participants. The relationship between copper intake and migraine was examined using weighted multivariate logistic regression models, and smooth-fit curves were plotted to explore the relationship. After non-linear relationships were found, recursive algorithms and two-stage linear regression models were used to calculate inflection points. Stratified analyses were also performed to explore population differences. In the model corrected for all covariates, the OR (95% CI) of copper intake with migraine was 1.19 (0.97, 1.46), which was not statistically significant. However, the results of the linear trend test suggested that their relationship might be non-linear. Smooth-fit curves confirmed the non-linear relationship between copper intake and migraine, and an inflection point (0.98 mg/day) was identified. There was no statistical significance before the inflection point, but after the inflection point, copper intake was positively associated with migraine attacks. Stratified analyses showed that this non-linear relationship persisted in females, people under 45 years old, and people with BMI less than 30. In this large cross-sectional study, we found a non-linear correlation between copper intake and migraine.

No association between blood-based markers of immune system and migraine status: a population-based cohort study

BACKGROUND

Although some evidence implicates the immune system in migraine attacks, its role during attack-free periods remains largely unexplored. Therefore, we assessed the association between the immune system and migraine status.

METHODS

From the population-based Rotterdam Study, we included 6593 participants who underwent blood sampling and migraine assessments. In the blood samples, we measured white blood-cell-based immune markers. As a marker for the innate immune system, granulocyte and platelet counts were determined, whereas lymphocyte counts were used as a marker for the adaptive immune system. Migraine was assessed using a validated questionnaire based on ICHD-2 criteria. We investigated associations between blood-cell counts and migraine using logistic regression models adjusting for age, sex and other variables.

RESULTS

Mean age of participants was 65.6 ± 11.2 years and 56.7% were female. The lifetime prevalence of migraine was 15.1% (995/6593). We found no statistically significant associations between granulocyte (odds ratio [OR] per standard deviation increase 1.01 95% Confidence Interval [CI]: 0.93-1.09), platelet (OR 1.01 CI: 0.94-1.09) or lymphocyte counts (OR 1.01 CI: 0.93-1.08) and migraine status.

CONCLUSIONS

Our results do not support an association between white blood-cell-based immunity markers and migraine status.

Migraine and cardiovascular disease: what cardiologists should know

Migraine is a chronic neurovascular disease with a complex, not fully understood pathophysiology with multiple causes. People with migraine suffer from recurrent moderate to severe headache attacks varying from 4 to 72 h. The prevalence of migraine is two to three times higher in women compared with men. Importantly, it is the most disabling disease in women <50 years of age due to a high number of years lived with disability, resulting in a very high global socioeconomic burden. Robust evidence exists on the association between migraine with aura and increased incidence of cardiovascular disease (CVD), in particular ischaemic stroke. People with migraine with aura have an increased risk of atrial fibrillation, myocardial infarction, and cardiovascular death compared with those without migraine. Ongoing studies investigate the relation between migraine and angina with non-obstructive coronary arteries and migraine patients with patent foramen ovale. Medication for the treatment of migraine can be preventative medication, such as beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, antiepileptics, antidepressants, some of the long-acting calcitonin gene-related peptide receptor antagonists, or monoclonal antibodies against calcitonin gene-related peptide or its receptor, or acute medication, such as triptans and calcitonin gene-related peptide receptor antagonists. However, these medications might raise concerns when migraine patients also have CVD due to possible (coronary) side effects. Specifically, knowledge gaps remain for the contraindication to newer treatments for migraine. All cardiologists will encounter patients with CVD and migraine. This state-of-the-art review will outline the basic pathophysiology of migraine and the associations between migraine and CVD, discuss current therapies, and propose future directions for research.

Migraine and risk of rheumatoid arthritis: A systematic review and meta-analysis of observational studies

Background

Exposure to Migraine may be one of the risk factors for the onset of rheumatoid arthritis (RA), while the relationship between the two is debatable. In this study, the connection between migraine and the risk of RA was investigated using a systematic review and meta-analysis of the pertinent literature.

Methods

Up to July 2022, the PubMed, EMBASE, Web of Science (WOS), and scopus databases were employed to search for observational studies on the risk of RA in migraineurs. The effect sizes were pooled using a random-effects model or a fixed-effects model.

Results

Out of 2345 records, 5 studies (3 case and control studies and 2 cohort studies) were identified and included in the meta-analysis. According to a pooled analysis, migraine sufferers had a higher chance of developing RA (pooled adjusted effect estimate: 1.94, 95% confidence interval: 1.74-2.17; p < 0.01).

Conclusions

Migraine can be legitimately regarded as a risk factor for RA since this study demonstrated a relationship between migraine and RA. This conclusion should be treated with caution due to low power and precision. Rigorous design and larger sample sizes of studies are needed to verify the findings.

Prevalence and clinical characteristics of white matter hyperintensities in Migraine: A meta-analysis

BACKGROUND

Current evidences show an increased risk of white matter hyperintensities (WMHs) in migraineurs compared to age-matched controls. However, WMHs prevalence and the associations between WMHs and clinical characteristics in migraineurs have not been systematically evaluated using a meta-analytical approach. This study explored the pooled prevalence of WMHs and the associations of WMHs with the clinical characteristics in patients with migraine.

METHODS

A systematic review and meta-analysis of observational studies reporting the occurrence and clinical characteristics of patients with WMHs attributed to migraine was performed. We searched the PubMed, Web of Science, and Embase databases. Random-effects models were used to calculate the pooled prevalence rate, odds ratio (OR), or mean difference (MD) with corresponding 95% confidence intervals (CIs).

RESULTS

Thirty eligible studies were identified including 3,502 migraineurs aged 37.2 (mean) years. The pooled WMHs prevalence was 44 %, 45 %, and 38 % in migraine, migraine with aura, and migraine without aura groups, respectively. In migraineurs with WMHs, the frontal lobe and subcortical white matter were the most susceptible area. Compared with non-migraine controls, patients with migraine had increased odds for WMHs (OR 4.32, 95 % CI = 2.56-7.28, I² = 67 %). According to reported univariable results from included studies, pooled analysis showed that clinical characteristics including age, presence of aura, disease duration, hypertension, diabetes mellitus and right-to-left shunt were associated with the presence of WMHs. Migraine pain and aura characteristics were not related to WMHs.

CONCLUSIONS

These data suggest that WMHs are common in migraine, especially in those who are older or have aura, hypertension, diabetes mellitus, or right-to-left shunt. A better understanding of the WMHs attributed to migraine is needed in future studies.

Clinical characteristics and management of headache in patients with myeloproliferative neoplasms

Background

Headache is frequently reported as a neurological manifestation of myeloproliferative neoplasms (MPNs), including polycythemia vera and essential thrombocythaemia. This study sought to clarify the clinical characteristics and response to treatment of headaches in patients with MPNs.

Methods

We prospectively studied 137 patients with MPNs. The following information was gathered to assess the features of headache at baseline and at follow-up (>6 months): (1) average duration of headache attacks, (2) number of headache days per month, (3) numerical rating scale (NRS), (4) Headache Impact Test-6 (HIT-6), and (5) Migraine Disability Assessment (MIDAS). We compared those parameters for headaches between the baseline and follow-up interviews according to the management.

Results

Thirty-seven (27.0%) patients had headache. The prevalence of headaches gradually decreased with increasing age (Age ≤ 49 years: 61.0%, 50-59 years: 38.5%, 60-69 years: 17.2%, 70-79 years: 5.1%, and ≥80 years: 0.0%, P < 0.001). Multiple logistic regression analysis showed that younger age, but not platelet counts or the JAK2 V617F mutation, was independently associated with headaches (Odds Ratios 2.004, 95% confidence intervals 1.293-3.108, P = 0.002). Scintillating scotomas were present in 22 (59.5%) of 37 patients with headaches, while four patients developed sudden headaches that lasted for only 0-10 min. Follow-up interviews were available for 31 (83.8%) of 37 patients with headaches. Twenty-one (67.7%) patients were treated with low-dose aspirin (100 mg once daily) [low-dose aspirin alone: n = 9; combined cytoreductive therapy: n = 12] for headache management. All parameters for headache [average duration of headache attacks, number of headache days per month, NRS score, HIT-6 score, and MIDAS score (all P < 0.001)] were significantly improved at follow-up in patients taking low-dose aspirin. However, there were no significant differences in these parameters of headaches in patients who did not receive low-dose aspirin.

Conclusion

Headaches is common in patients with MPNs, particularly in younger patients. MPN-related headaches may be managed by using low-dose aspirin and controlling MPNs.

Association of Body Mass Index, Blood Pressure, and Interictal Serum Levels of Cytokines in Migraine with and without Aura

The aim of the study was to clarify correlations between body mass index (BMI), blood pressure (BP), and serum levels of cytokines in female migraine patients. A total of 14 migraineurs with aura, and 12 without aura during their interictal period were compared with 25 controls. Interleukin-8 (IL-8), soluble intercellular adhesion molecule-1 (sICAM-1), soluble vascular cell adhesion molecule-1 (sVCAM-1), matrix metalloproteinase-9 (MMP-9), interferon gamma (IFN-γ), monocyte chemoattractant protein-1 (MCP-1), transforming growth factor alpha (TGF-α), and plasminogen activator inhibitor-1 (PAI-1) were measured. Migraineurs have elevated levels of IL-8, but decreased serum levels of PAI-1 and sICAM-1 during the interictal period, regardless of aura. BMI correlates with BP, and also with IFN-γ and MMP-9 only in patients with aura. There are three correlations in migraine patients with aura that are absent in patients without aura: between IL-8 and PAI-1; MMP-9 and IL-8; and IL-8 and sICAM-1. Migraineurs without aura, on the other hand, have correlations that patients with aura do not have (between PAI-1 and MCP-1, sICAM-1; between MMP-9 and sICAM-1, MCP-1; between TGF-α and PAI-1, MMP-9, sICAM-1; between sICAM-1 and MMP-9, PAI-1, MCP-1; as well as between sVCAM-1 and MCP-1). PAI-1, TGF, and MMP-9 could be used as biomarkers to distinguish migraineurs from healthy individuals.

Cerebral Hemodynamics, Right-to-Left Shunt and White Matter Hyperintensities in Patients with Migraine with Aura, Young Stroke Patients and Controls

Background: Migraine with aura (MA) patients present an increased risk of cerebrovascular events. However, whether these patients present an increased white matter hyperintensities (WMHs) load compared to the general population is still under debate. Our study aimed to evaluate the relationship between cerebral hemodynamics, right-to-left shunt (RLS) and WMHs in MA patients, young patients with cryptogenic stroke or motor transient ischemic attack (TIA) and controls. Methods: We enrolled 30 MA patients, 20 young (<60 years) patients with cryptogenic stroke/motor TIA, and 10 controls. All the subjects underwent a transcranial Doppler bubble test to detect RLS and cerebral hemodynamics assessed by the breath holding index (BHI) for the middle (MCA) and posterior (PCA) cerebral arteries. Vascular risk factors were collected. The WMHs load on FLAIR MRI sequences was quantitatively assessed. Results: The stroke/TIA patients presented a higher prevalence of RLS (100%) compared with the other groups (p < 0.001). The MA patients presented a higher BHI compared with the other groups in the PCA (p = 0.010) and higher RLS prevalence (60%) than controls (30%) (p < 0.001). The WMHs load did not differ across groups. BHI and RLS were not correlated to the WMHs load in the groups. Conclusions: A preserved or more reactive cerebral hemodynamics and the presence of a RLS are likely not involved in the genesis of WMHs in MA patients. A higher BHI may counteract the risk related to their higher prevalence of RLS. These results need to be confirmed by further studies to be able to effectively identify the protective role of cerebral hemodynamics in the increased RLS frequency in MA patients.

Migraine in Patients Undergoing PFO Closure

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Patients experiencing MHA-PFO on aspirin are characterized by a marked thrombin generation capacity sustained by an elevated number of platelets and MVs expressing a functionally active tissue factor.

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MHA-PFO patients are also characterized by an altered oxidative stress status, ie, increased platelet ROS production and blood GSSG/GSH ratio.

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This prothrombotic condition fully reverts upon PFO closure and is associated with 100% migraine remission.

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MHA-PFO plasma and GSSG, added to blood of healthy subjects, mirrored the in vivo platelet activation and this effect is blunted by N-acetylcysteine, thus supporting the etiopathogenetic role of oxidative stress in this clinical setting.

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Aspirin had little effect on the platelet prothrombotic phenotype that was better controlled by P2Y₁₂ antagonist.

The association between migraine and patent foramen ovale (PFO) has been documented. We aimed to investigate platelet activation, prothrombotic phenotype, and oxidative stress status of migraineurs with PFO on 100 mg/day aspirin, before and 6 months after PFO closure. Data show that, before PFO closure, expression of the classical platelet activation markers is comparable in patients and aspirin-treated healthy subjects. Conversely, MHA-PFO patients display an increased prothrombotic phenotype (higher tissue factor^pos platelets and microvesicles and thrombin-generation potential), sustained by an altered oxidative stress status. This phenotype, which is more controlled by P2Y₁₂-blockade than by aspirin, reverted after PFO closure together with a complete migraine remission. (pLatelEts And MigRaine iN patEnt foRamen Ovale [LEARNER]; NCT03521193)

An Insight into Recent Advances on Platelet Function in Health and Disease

Platelets play a variety of roles in vascular biology and are best recognized as primary hemostasis and thrombosis mediators. Platelets have a large number of receptors and secretory molecules that are required for platelet functionality. Upon activation, platelets release multiple substances that have the ability to influence both physiological and pathophysiological processes including inflammation, tissue regeneration and repair, cancer progression, and spreading. The involvement of platelets in the progression and seriousness of a variety of disorders other than thrombosis is still being discovered, especially in the areas of inflammation and the immunological response. This review represents an integrated summary of recent advances on the function of platelets in pathophysiology that connects hemostasis, inflammation, and immunological response in health and disease and suggests that antiplatelet treatment might be used for more than only thrombosis.

[Comorbidity in migraine]

Migraine is a common and often disabling disease with a prominent genetic basis. There are many comorbidities associated with migraine which have been identified as risk factors for progression to chronic migraine. Each of these has its own genetic load and shares some common characteristics with migraine. The identification of migraine comorbidities may help clarify common underlying genetic and biological mechanisms of diseases. The treatment of migraine should involve a multifaceted approach, aimed at identifying and reducing possible risk and comorbidity factors. This may prevent the evolution toward a chronic form and then toward pharmacological resistance.

Therapeutic Plateletpheresis in Patients With Thrombocytosis: Gender, Hemoglobin Before Apheresis Significantly Affect Collection Efficiency

Background: Thrombocytosis is a common symptom in myeloproliferative neoplasms (MPN), and excessive proliferation may deteriorate into thrombosis, bleeding, myelofibrosis, and may ultimately convert to acute leukemia. This study aimed to investigate the collection efficiency of plateletpheresis (CEPP) and factors influencing its efficacy in patients with thrombocytosis.

Materials and Methods: From September 2010 to December 2016, 81 patients from two institutions in China with myeloproliferative neoplasms and thrombocytosis accompanied by severe symptoms were treated with plateletpheresis by Fresenius COM. TEC machine.

Results: After apheresis, the median CEPP was 20.71% (IQR: 9.99–36.69%) and median PLT reduction rate was 25.87% (IQR: 21.78–36.23%). Further analysis showed that no significant difference was observed between PLT count with 800–1,000 × 10⁹/L and > 1,000 × 10⁹/L. The PLT counts significantly decreased (P < 0.001) after plateletpheresis, the red blood cell (RBC), white blood cell (WBC), hemoglobin (HGB), and hematocrit (HCT) levels showed no significant differences before- or after- plateletpheresis. Multivariate analysis showed that female sex (P = 0.009) and HGB (P = 0.010) before apheresis were associated with CEPP. Female (P = 0.022), HCT (P = 0.001) and blood volume (P = 0.015) were associated with the PLT reduction rate. Furthermore, symptoms were relieved after apheresis in patients whose PLT count was 800–1,000 × 10⁹/L accompanied with symptoms.

Conclusions: It is reasonable to perform plateletpheresis when the PLT count is over 800 × 10⁹/L and patients are complicated by clinical symptoms such as dizziness, headache, somnolence, and stupor. Plateletpheresis is effective in removing PLTs especially in females with high HGB.

Headache and immunological/autoimmune disorders: a comprehensive review of available epidemiological evidence with insights on potential underlying mechanisms

Several lines of evidence support a role of the immune system in headache pathogenesis, with particular regard to migraine. Firstly, alterations in cytokine profile and in lymphocyte subsets have been reported in headache patients. Secondly, several genetic and environmental pathogenic factors seem to be frequently shared by headache and immunological/autoimmune diseases. Accordingly, immunological alterations in primary headaches, in particular in migraine, have been suggested to predispose some patients to the development of immunological and autoimmune diseases. On the other hand, pathogenic mechanisms underlying autoimmune disorders, in some cases, seem to favour the onset of headache. Therefore, an association between headache and immunological/autoimmune disorders has been thoroughly investigated in the last years. The knowledge of this possible association may have relevant implications in the clinical practice when deciding diagnostic and therapeutic approaches. The present review summarizes findings to date regarding the plausible relationship between headache and immunological/autoimmune disorders, starting from a description of immunological alteration of primary headaches, and moving onward to the evidence supporting a potential link between headache and each specific autoimmune/immunological disease.

5-hydroxytryptamine in migraine: The puzzling role of ionotropic 5-HT3 receptor in the context of established therapeutic effect of metabotropic 5-HT1 subtypes

5-hydroxytryptamine (5-HT; serotonin) is traditionally considered as a key mediator implicated in migraine. Multiple 5-HT receptor subtypes contribute to a variety of region-specific functional effects. The raphé nuclei control nociceptive inputs by releasing 5-HT in the brainstem, whereas dural mast cells provide the humoral source of 5-HT in the meninges. Triptans (5-HT_1B/D agonists) and ditans (5-HT_1F agonists) are the best established 5-HT anti-migraine agents. However, activation of meningeal afferents via ionotropic 5-HT₃ receptors results in long-lasting excitatory drive suggesting a pro-nociceptive role for these receptors in migraine. Nevertheless, clinical data do not clearly support the applicability of currently available 5-HT₃ antagonists to migraine treatment. The reasons for this might be the presence of 5-HT₃ receptors on inhibitory interneurons dampening the excitatory drive, a lack of 5-HT₃ A-E subunit-selective antagonists and gender/age-dependent effects. This review is focusing on the controversial role of 5-HT₃ receptors in migraine pathology and related pharmacological perspectives of 5-HT ligands.

Involvement of P2Y12 receptors in an NTG-induced model of migraine in male mice

BACKGROUND AND PURPOSE

P2Y₁₂ receptors (P2Y₁₂ Rs) are known to regulate different forms of pain and inflammation. In this study we investigated the participation of P2Y₁₂ Rs in an animal model of migraine.

EXPERIMENTAL APPROACH

We tested the effect of the centrally administered selective P2Y₁₂ R antagonist PSB-0739, and P2Y₁₂ R gene deficiency in acute nitroglycerin (NTG)-treated mice. Additionally, platelet depletion was used to investigate the role of platelet P2Y₁₂ Rs during migraine-like pain.

KEY RESULTS

NTG induced sensory hypersensitivity of C57BL/6 wild-type (P2ry12^+/+ ) mice, accompanied by an increase in c-fos and CGRP expression in the upper cervical spinal cord (C1-C2) and trigeminal nucleus caudalis (TNC). Similar changes were also observed in P2Y₁₂ R gene-deficient (P2ry12^-/- ) mice. Prophylactic intrathecal application of PSB-0739 reversed thermal hyperalgesia and head grooming time in wild-type mice but had no effect in P2ry12^-/- mice; furthermore, it was also effective when applied as a post-treatment. PSB-0739 administration suppressed the expression of c-fos in C1-C2 and TNC, and decrease C1-C2 levels of dopamine and serotonin in wild-type mice. NTG treatment itself did not change adenosine diphosphate (ADP)-induced platelet activation measured by CD62P upregulation in wild-type mice. Platelet depletion by anti-mouse CD41 antibody and clopidogrel attenuated NTG-induced thermal hypersensitivity and head grooming time in mice.

CONCLUSION AND IMPLICATIONS

Taken together, our findings show that acute inhibition of P2Y₁₂ Rs alleviates migraine-like pain in mice, by modulating the expression of c-fos, and platelet P2Y₁₂ Rs might contribute to this effect. Hence, it is suggested that the blockade of P2Y₁₂ Rs may have therapeutic potential against migraine.

Relationship between migraine headache and hematological parameters

Although migraine is a neurological disorder known for its long, physiopathology remains unclear. The aim of this study was to investigate the levels of hematological parameters and neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), lymphocyte/monocyte ratio (LMR) and neutrophil/monocyte ratio (NMR) used as inflammatory markers in patients diagnosed with migraine. This retrospective study was performed with 250 patients and 215 healthy volunteers who were followed up in the neurology outpatient clinic with the diagnosis of migraine. Hematological parameters, C-reactive protein (CRP), NLR, PLR, LMR, NMR ratios were compared in the patient and control groups. Patients with migraine were grouped according to loss of function, the severity of pain and aura. 20.8% of patients in the mean age of 36.37 ± 8.683 had migraine with aura. We found that NMR values in migraine with aura (MWA) were significantly higher than in the control group. CRP, PLR and NMR values in migraine without aura (MWOA) were significantly higher than in the control group. Mean platelet volume (MPV) and platelet values were higher in patients with MWA and MWOA compared to the control group but did not show a statistically significant difference. We believe that these results support systemic inflammation in patients with migraine and the presence of a continuous inflammatory process even in periods without attacks. More comprehensive studies are needed to clarify the underlying pathophysiology that may guide the follow-up and treatment of the disease.

Evaluation of Neutrophil-to-Lymphocyte Ratio, Platelet-to-Lymphocyte Ratio, and C-Reactive Protein in Tension-Type Headache Patients

Objectives  A tension headache is the most common type of headache, and its causes are multifactorial. A relationship has been shown between migraine headaches and neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and C-reactive protein (CRP). In this study, we investigated the NLR, PLR, and serum CRP levels in frequent episodic tension-type headache (FETTH) and chronic tension-type headache (CTTH) patients.

Materials and Methods  This retrospective study included 64 patients with FETTH, 80 patients with CTTH, and 60 healthy controls who were followed up in the neurology clinic. Hematological parameters were compared between the patient and control groups.

Results  In CTTH patients, platelets, NLR, PLR, and CRP values were statistically higher than in FETTH patients and patients in the control group. In FETTH patients, the PLR value was higher than in patients in the control group, but there was no statistically significant difference in NLR and CRP values between FETTH patients and patients in the control group. Also, there was no correlation between these values and age and gender.

Conclusion  Increase platelet count might have an effect on tension-type headache pathophysiology. Systemic inflammation parameters were shown to be significantly higher in CTTH patients. More comprehensive studies are needed to evaluate the effect of systemic inflammation on the chronicity of tension headaches.

Bidirectional association between migraine and rheumatoid arthritis: two longitudinal follow-up studies with a national sample cohort

OBJECTIVE

To investigate the bidirectional association between migraine and rheumatoid arthritis (RA).

DESIGN

Two longitudinal follow-up studies.

SETTING

Data collected from a national cohort between 2002 and 2013 by the Korean National Health Insurance Service-Health Screening Cohort.

PARTICIPANTS

In cohort 1, matching resulted in the inclusion of 31 589 migraine patients and 126 356 control I participants. In cohort 2, matching resulted in the inclusion of 9287 RA patients and 37 148 control II participants.

PRIMARY AND SECONDARY OUTCOME MEASURES

The HRs for RA in patients with migraine (cohort 1) and migraine in patients with RA (cohort 2) were analysed using stratified Cox proportional hazard models after adjusting for autoimmune disease, Charlson Comorbidity Index scores without rheumatoid diseases, obesity (body mass index), smoking and history of alcohol intake. Subgroup analyses stratified by age, sex, income and region of residence were also performed.

RESULTS

The incidence of RA in the migraine group (2.0% (640/31 589)) was higher than that in the control I group (1.4% (1709/126 356), p<0.001). The adjusted HR for RA in the migraine without aura group was 1.48 (95% CIs=1.34 to 1.63, p<0.001).The incidence of migraine in the RA group (6.4% (590/9287)) was higher than that in the control II group (4.6% (1721/37 148), p<0.001). The adjusted HR for migraine without aura in the RA group was 1.35 (95% CI=1.23 to 1.49, p<0.001).

CONCLUSION

Migraine increases the risk of RA, and RA is also associated with an increased risk of migraine.

Pathophysiological Bases of Comorbidity in Migraine

Despite that it is commonly accepted that migraine is a disorder of the nervous system with a prominent genetic basis, it is comorbid with a plethora of medical conditions. Several studies have found bidirectional comorbidity between migraine and different disorders including neurological, psychiatric, cardio- and cerebrovascular, gastrointestinal, metaboloendocrine, and immunological conditions. Each of these has its own genetic load and shares some common characteristics with migraine. The bidirectional mechanisms that are likely to underlie this extensive comorbidity between migraine and other diseases are manifold. Comorbid pathologies can induce and promote thalamocortical network dysexcitability, multi-organ transient or persistent pro-inflammatory state, and disproportionate energetic needs in a variable combination, which in turn may be causative mechanisms of the activation of an ample defensive system with includes the trigeminovascular system in conjunction with the neuroendocrine hypothalamic system. This strategy is designed to maintain brain homeostasis by regulating homeostatic needs, such as normal subcortico-cortical excitability, energy balance, osmoregulation, and emotional response. In this light, the treatment of migraine should always involves a multidisciplinary approach, aimed at identifying and, if necessary, eliminating possible risk and comorbidity factors.

Neurology of Preeclampsia and Related Disorders: an Update in Neuro-obstetrics

PURPOSE OF REVIEW

Preeclampsia and related hypertensive disorders of pregnancy affect up to 10% of pregnancies. Neurological complications are common and neurologists often become involved in the care of obstetric patients with preeclampsia. Here, we review the definition(s), epidemiology, clinical features, and pathophysiology of preeclampsia, focusing on maternal neurological complications and headache as a common presenting symptom of preeclampsia.

RECENT FINDINGS

Neurological symptoms are early and disease-defining features of preeclampsia. Neurological complications of preeclampsia may include headaches, visual symptoms, cerebral edema, seizures, or acute cerebrovascular disorders such as intracerebral hemorrhage or reversible cerebral vasoconstriction syndrome. A history of migraine is an independent risk factor for vascular diseases during pregnancy, including preeclampsia and maternal stroke. The pathophysiology of both preeclampsia and migraine is complex, and the mechanisms linking the two are not fully understood. Overlapping clinical and pathophysiological features of migraine and preeclampsia include inflammation, vascular endothelial dysfunction, and changes in vasoreactivity. Neurological complications are recognized as a major contributor to maternal morbidity and mortality. Pregnant and postpartum women commonly present with headache, and red flags in the clinical history and examination should prompt urgent neuroimaging and laboratory evaluation. A focused headache history should be elicited from patients as part of routine obstetrical care to identify patients at an increased risk of preeclampsia and related hypertensive disorders of pregnancy. Collaborative models of care and scientific investigation in the emerging field of neuro-obstetrics have the common goal of reducing the risk of maternal neurological morbidity and mortality from preeclampsia.

Deep Phenotyping of Headache in Hospitalized COVID-19 Patients via Principal Component Analysis

Objectives: Headache is a common symptom in systemic infections, and one of the symptoms of the novel coronavirus disease 2019 (COVID-19). The objective of this study was to characterize the phenotype of COVID-19 headache via machine learning. Methods: We performed a cross-sectional study nested in a retrospective cohort. Hospitalized patients with COVID-19 confirmed diagnosis who described headache were included in the study. Generalized Linear Models and Principal Component Analysis were employed to detect associations between intensity and self-reported disability caused by headache, quality and topography of headache, migraine features, COVID-19 symptoms, and results from laboratory tests. Results: One hundred and six patients were included in the study, with a mean age of 56.6 ± 11.2, including 68 (64.2%) females. Higher intensity and/or disability caused by headache were associated with female sex, fever, abnormal platelet count and leukocytosis, as well as migraine symptoms such as aggravation by physical activity, pulsating pain, and simultaneous photophobia and phonophobia. Pain in the frontal area (83.0% of the sample), pulsating quality, higher intensity of pain, and presence of nausea were related to lymphopenia. Pressing pain and lack of aggravation by routine physical activity were linked to low C-reactive protein and procalcitonin levels. Conclusion: Intensity and disability caused by headache attributed to COVID-19 are associated with the disease state and symptoms. Two distinct headache phenotypes were observed in relation with COVID-19 status. One phenotype seems to associate migraine symptoms with hematologic and inflammatory biomarkers of severe COVID-19; while another phenotype would link tension-type headache symptoms to milder COVID-19.

Progress in Traditional Chinese Medicine for the Treatment of Migraine

Migraine is a recurrent disease with complex pathogenesis and is difficult to cure. At present, commercially available western migraine drugs are prone to generate side effects while treating the disease. Traditional Chinese medicine (TCM) avoids side effects via treatment with the principles of “treating both symptoms and root causes”, “overall adjustment”, and “treatment based on syndrome differentiation”. Three strategies of drug treatment were developed based on the syndromes, i.e., removing stasis, calming liver Yang, and reinforcing deficiency. Prescriptions of removing stasis mostly contain Chuanxiong rhizome (Chuan Xiong) to remove blood stasis by promoting blood circulation and improve properties of hemorheology, and Da Chuan Xiong Formula (DCXF) is a traditional prescription widely used in clinical practice. Prescriptions of calming liver Yang usually take Ramulus Uncariae cum Uncis (Gou Teng) as the main herb, which can calm the liver Yang via improving vasomotor function, and Tian Ma Gou Teng Decoction (TMGTD) is the representative drug. For reinforcing deficiency, Chinese doctors frequently utilize Angelica Sinensis (Dang Gui) and Astragali Radix (Huang Qi) to nourish blood and Qi in order to improve the weak state of human body; Dang Gui Bu Xue Decoction (DGBXD) is the commonly used prescription. These strategies not only treat the symptoms of diseases but also their root causes, and with the features of multiple targets, in multiple ways. Therefore, TCM prescriptions have obvious advantages in the treatment of chronic diseases such as migraine. In this review, we provided an overview of the pathogenesis of migraine and the function of representative TCM preparations in therapy of migraine as well as the mechanism of action according to effective researches, in order to provide reference and clue for further researches.

Predictive value of laboratory parameters in childhood migraine

Migraine is a neurovascular disease characterized by inflammation of the cerebral and extra cerebral vessels and appears in the form of attacks. Although the pathophysiology of migraine is not fully known, the data obtained because of long-term studies reliably support the presence of a potential relationship between migraine pathogenesis and platelet biology. The aim of this study was to investigate the effect of migraine on MPV and other blood parameters as well as the relationship between the hematologic parameters and characteristics of the headache and whether they possess diagnostic value as inflammation and platelet biology play a fundamental role in the disorder. The study group consisted of 56 patients who were followed up and treated with a diagnosis of migraine and 45 healthy patients. The median creatinine, CRP and TSH values of the children in the migraine group were found to be statistically significantly higher than the healthy control group. Serum iron levels of the migraine group were found to be statistically significantly lower than the control group. No statistically significant difference was found between the two groups in terms of MPV. However, when we examined only the patient group, we found MPV to be statistically significantly higher in girls. Increased MPV and decreased serum iron levels may be related to migraine. More comprehensive studies including a larger population are required to evaluate the specific parameters that may guide the follow-up and treatment of the disorder with simple tests to be used in routine practice and to elucidate the underlying pathophysiology.

Increased Hemoglobin and Plateletcrit Levels Indicating Hemoconcentration in Pediatric Patients with Migraine

INTRODUCTION

Fluid intake was reported to reduce migraine attacks. This may be due to its effect on hemoconcentration. Hemoconcentration may manifest itself by increasing in the hemoglobin and platelet-related values. This study aimed to reveal hemoconcentration by evaluating complete blood cell counts in attack-free periods of pediatric patients with migraine.

MATERIALS AND METHODS

Consecutive children with migraine (n = 70) and tension-type headache (TTH) (n = 65) were compared with the control groups. Control 1 (n = 70) and control 2 (n = 60) groups consisted of age- and gender-matched patients, respectively. Control 2 group patients had gastrointestinal symptoms leading to fluid loss, which may have caused hemoconcentration. To evaluate hemoglobin and platelets together, the M1-value was created by multiplying hemoglobin level by plateletcrit.

RESULTS

The M1-value was higher in the migraine group than in control 1 and TTH groups (P = 0.017 and 0.034) and the hemoglobin and hematocrit levels were also higher in the migraine group than in control 2 group (P = 0.013 and 0.012). Female patients with migraine had higher hemoglobin levels as compared to the female patients in control group 1 (P = 0.041). Male patients with migraine had higher M1-values than the male patients in control group 1 (P = 0.034). In the subgroup of migraine with aura (n = 10), folic acid was significantly lower than the other patients with migraine (P = 0.02).

CONCLUSION

This study suggests that migraine may be accompanied with hemoconcentration in children.

Is Migraine an MPV-Related Disease? An Observational Study of Polish Neurological Patients

Many studies have found correlations between abnormal MPV and clinical reactivity in a variety of diseases. In the present paper, we sought MPV-related neurological diseases that are less frequently reported in the literature. The electronic medical records of 852 neurological patients with mean platelet volume (MPV) measurements (F = 45%, age = 55.7 ± 18.7, 8–104) were searched after the patients had received a diagnosis of a neurological disease (new and old episodes) according to the nine classes of the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10). A set of consecutive statistical methods (i.e., cluster analysis, segmented regression, linear correlation, propensity score matching, and mixed effects Poisson regression) were used to establish a link between MPV and neurological disease. A statistically significant (p < 0.05) relationship with MPV was found only in pain syndrome patients, with seven out of eight clinically diagnosed migraine episodes. With all other ICD-10 classes of neurological diseases, the effect of MPV was found to be nonsignificant (p > 0.05). MPV may implicate a clinical relationship with pain syndrome and migraine episodes. More complex statistics could help analyse data and find new correlations.

A Possible Role of Amyloidogenic Blood Clotting in the Evolving Haemodynamics of Female Migraine-With-Aura: Results From a Pilot Study

Introduction: Migraine is a debilitating primary headache disorder with a poorly understood aetiology. An extensive body of literature supports the theory of migraine as a systemic vascular inflammatory disorder characterised by endothelial dysfunction. It is also well-known that chronic inflammation results in an excessive burden of oxidative stress and therefore cellular dysfunction. In this study the effects of excessive oxidative stress through the phases of female migraine-with-aura (FMA) were evaluated by examining the health of the systems of haemostasis.

Methods: Blood was obtained from 11 FMA patients at baseline and during the headache phase of migraine, as well as from 8 healthy age-matched female controls. Samples were analysed using thromboelastography (TEG) to evaluate viscoelastic profiles, light microscopy for erythrocyte morphology, Scanning Electron Microscopy (SEM) for erythrocyte and fibrin clot structure, confocal microscopy for β-amyloid detection in fibrin clots.

Results: Viscoelastic profiles from platelet poor plasma showed decreased clot reaction times in FMA at baseline (95% CI [5.56, 8.41]) vs. control (95% CI [7.22, 11.68]); as well as decreased time to maximum thrombus generation for the same comparison (95% CI [6.78, 10.20] vs. [8.90, 12.96]). Morphological analysis of erythrocytes indicated widespread macrocytosis, poikilocytosis and eryptosis in the migraineurs. Analysis of fibrin networks indicated that this hypercoagulability may be a result of aberrant fibrin polymerisation kinetics caused by the adoption of a β-amyloid conformation of fibrin(ogen).

Conclusion: The results reaffirm the hypercoagulable state in migraine, and would suggest that this state is most likely a result of a systemic inflammatory state which induces oxidative damage to both erythrocytes and fibrin(ogen) in female episodic migraine-with-aura. Furthermore, if the amylodogenic changes to fibrin(ogen) were observed in a larger cohort, this would support theories of micro-embolisation in migraine-with-aura.

P2Y12 receptor mediates microglial activation via RhoA/ROCK pathway in the trigeminal nucleus caudalis in a mouse model of chronic migraine

BACKGROUND

Microglial activation contributes to the development of chronic migraine (CM). The P2Y12 receptor (P2Y12R), a metabolic purinoceptor that is expressed on microglia in the central nervous system (CNS), has been indicated to play a critical role in the pathogenesis of chronic pain. However, whether it contributes to the mechanism of CM remains unknown. Thus, the present study investigated the precise details of microglial P2Y12R involvement in CM.

METHODS

Mice subjected to recurrent nitroglycerin (NTG) treatment were used as the CM model. Hyperalgesia were assessed by mechanical withdrawal threshold to electronic von Frey and thermal withdrawal latency to radiant heat. Western blot and immunohistochemical analyses were employed to detect the expression of P2Y12R, Iba-1, RhoA, and ROCK2 in the trigeminal nucleus caudalis (TNC). To confirm the role of P2Y12R and RhoA/ROCK in CM, we systemically administered P2Y12R antagonists (MRS2395 and clopidogrel) and a ROCK2 inhibitor (fasudil) and investigated their effects on microglial activation, c-fos, and calcitonin gene-related peptide (CGRP) expression in the TNC. To further confirm the effect of P2Y12R on microglial activation, we preincubated lipopolysaccharide (LPS)-treated BV-2 microglia with MRS2395 and clopidogrel. ELISA was used to evaluate the levels of inflammatory cytokines.

RESULTS

The protein levels of P2Y12R, GTP-RhoA, ROCK2, CGRP, c-fos, and inducible nitric oxide synthase (iNOS) in the TNC were increased after recurrent NTG injection. A double labeling study showed that P2Y12R was restricted to microglia in the TNC. MRS2395 and clopidogrel attenuated the development of tactile allodynia and suppressed the expression of CGRP, c-fos, and GTP-RhoA/ROCK2 in the TNC. Furthermore, fasudil also prevented hyperalgesia and suppressed the expression of CGRP in the TNC. In addition, inhibiting P2Y12R and ROCK2 activities suppressed NTG-induced microglial morphological changes (process retraction) and iNOS production in the TNC. In vitro, a double labeling study showed that P2Y12R was colocalized with BV-2 cells, and the levels of iNOS, IL-1β, and TNF-α in LPS-stimulated BV-2 microglia were reduced by P2Y12R inhibitors.

CONCLUSIONS

These data demonstrate that microglial P2Y12R in the TNC plays a critical role in the pathogenesis of CM by regulating microglial activation in the TNC via RhoA/ROCK pathway.

Neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio are associated with disease activity in polymyalgia rheumatica

Background

The neutrophil‐to‐lymphocyte ratio (NLR), platelet‐to‐lymphocyte ratio (PLR), and monocyte‐to‐lymphocyte ratio (MLR) are indicators of systemic inflammation and are useful as markers in systemic rheumatic diseases. In this study, we compared the NLR, PLR, and MLR among patients with polymyalgia rheumatica (PMR) and rheumatoid arthritis (RA), and explored possible associations with clinical features, disease activity, and prognosis in patients with PMR.

Methods

The study enrolled 94 patients with PMR and 242 patients with RA who were initially diagnosed at the rheumatology clinic of a university‐based tertiary hospital. Symptoms, physical examination, and medical histories were collected with the results of laboratory tests.

Results

Neutrophil‐to‐lymphocyte ratio (4.5 ± 3.3 vs 2.8 ± 1.8), PLR (222.7 ± 115.5 vs 159.7 ± 78.1), and MLR (0.4 ± 0.3 vs 0.3 ± 0.2) were higher in patients with PMR compared with patients with RA (all P < .001). NLR, PLR, and MLR were correlated with specific laboratory values, including CRP and albumin, in patients with PMR. After disease activity resolved, NLR (2.95 ± 2.32, P < .001), PLR (137.5 ± 82.3, P < .001), and MLR (0.26 ± 0.16, P < .001) decreased significantly. By comparing patients according to the disease course, swollen joint counts were higher in the chronic course group compared with the remission group (P = .03), while the NLR, PLR, and MLR were similar.

Conclusions

Neutrophil‐to‐lymphocyte ratio, platelet‐to‐lymphocyte ratio, and monocyte‐to‐lymphocyte ratio levels were associated with disease activity and specific clinical features, although they could not predict prognosis in patients with PMR.

Migraine during pregnancy and in the puerperium

Pregnancy can be seen as a positive time for women migraineurs because the elevated estrogen and endogenous opioid levels raise the pain threshold and the stable hormone levels, which no longer fluctuate, eliminate a major trigger factor for the attacks. In a great majority of cases, indeed, migraine symptoms spontaneously improve throughout pregnancy. Generally, migraine without aura (MO) improves better than migraine with aura (MA), which can occur ex novo in pregnancy more frequently than MO. After childbirth, the recurrence rate of migraine attacks increases, especially during the first month; breastfeeding exerts a protective effect against the reappearance of attacks. Migraine and pregnancy share a condition of hypercoagulability; therefore, attention must be paid to the risk of cardiovascular disorders, like venous thromboembolism and ischemic or hemorrhagic strokes. Some of these diseases can be linked to preeclampsia (PE), a serious complication of pregnancy, characterized by hypertension, proteinuria, or other findings of organ failure. This condition is more common in migraineurs compared with non-migraineurs; furthermore, women whose migraines worsen during pregnancy had a 13-fold higher risk of hypertensive disorders than those in which migraine remitted or improved. Pregnancy is generally recognized to exert a beneficial effect on migraine; nonetheless, clinicians should be on the alert for possible cardiovascular complications that appear to be more frequent in this patient population.

Potential Antimigraine Effects of Warfarin: An Exploration of Biological Mechanism with Survey of Patients

Case reports suggest a link between anticoagulant use and improved migraine symptoms, and a role for platelet-induced cerebral vasoconstriction in migraine pathobiology. Hence, we investigated the mechanism by which warfarin may affect migraine symptoms and whether there is a change in migraine symptomology in patients initiating oral anticoagulants, most commonly warfarin. The effects of warfarin on human platelet aggregation and secretion as well as platelet-induced rat cerebral artery vasoconstriction were studied. A survey of migraine and symptom change after starting or stopping oral anticoagulants was also conducted. Warfarin inhibited platelet aggregation and 5-hydroxytryptamine (5-HT) secretion in a concentration-dependent manner. Warfarin-inhibited platelet secretion products constricted middle cerebral arteries from male but not from female rats. For the survey, patient demographic information, migraine and medical history, and Migraine Disability Assessment Score (MIDAS) changes were collected. Out of 175 consenting, 40 respondents met the criteria for migraine and completed the survey. A total of 11 patients reported migraine symptom change, all coinciding with starting warfarin. Of those having symptom and MIDAS improvement, most were female with migraines with aura, whereas those worsening were male with fewer having migraine with aura. Of those reporting migraine symptom change with warfarin, female sex may be associated with improved MIDAS, and those experiencing an aura component are more likely to report a symptom change. Warfarin-mediated symptom improvement in females may occur due to inhibition of platelet 5-HT secretion and a lower sensitivity of female cerebral blood vessels to platelet-derived 5-HT-induced vasoconstriction.

Serotonin-estrogen interactions: What can we learn from pregnancy?

We have reviewed the scientific literature related to four diseases in which to serotonin (5-HT) is involved in the etiology, herein named 5-HT-linked diseases, and whose prevalence is influenced by estrogenic status: depression, migraine, irritable bowel syndrome and eating disorders. These diseases all have in common a sex-dimorphic prevalence, with women more frequently affected than men. The co-occurrence between these 5-HT-linked diseases suggests that they have common physiopathological mechanisms. In most 5-HT-linked diseases (except for anorexia nervosa and irritable bowel syndrome), a decrease in the serotonergic tone is observed and estrogens are thought to contribute to the improvement of symptoms by stimulating the serotonergic system. Human pregnancy is characterized by a unique 5-HT and estrogen synthesis by the placenta. Pregnancy-specific disorders, such as hyperemesis gravidarum, gestational diabetes mellitus and pre-eclampsia, are associated with a hyperserotonergic state and decreased estrogen levels. Fetal programming of 5-HT-linked diseases is a complex phenomenon that involves notably fetal-sex differences, which suggest the implication of sex steroids. From a mechanistic point of view, we hypothesize that estrogens regulate the serotonergic system, resulting in a protective effect against 5-HT-linked diseases, but that, in turn, 5-HT affects estrogen synthesis in an attempt to retrieve homeostasis. These two processes (5-HT and estrogen biosynthesis) are crucial for successful pregnancy outcomes, and thus, a disruption of this 5-HT-estrogen relationship may explain pregnancy-specific pathologies or pregnancy complications associated with 5-HT-linked diseases.

Estrogen, migraine, and vascular risk

Migraine has a predilection for female sex and the course of symptoms is influenced by life stage (presence of menstrual cycle, pregnancy, puerperium, menopause) and use of hormone therapy, such as hormonal contraception and hormone replacement therapy. Hormonal changes figure among common migraine triggers, especially sudden estrogen drop. Moreover, estrogens can modulate neuronal excitability, through serotonin, norepinephrine, dopamine, and endorphin regulation, and they interact with the vascular endothelium of the brain. The risk of vascular disease, and ischemic stroke in particular, is increased in women with migraine with aura (MA), but the link is unclear. One hypothesis posits for a causal association: migraine may cause clinical or subclinical brain lesions following repeated episodes of cortical spreading depression (CSD) and a second hypothesis that may explain the association between migraine and vascular diseases is the presence of common risk factors and comorbidities. Estrogens can play a differential role depending on their action on healthy or damaged endothelium, their endogenous or exogenous origin, and the duration of their treatment. Moreover, platelet activity is increased in migraineurs women, and it is further stimulated by estrogens.This review article describes the course of migraine during various life stages, with a special focus on its hormonal pathogenesis and the associated risk of vascular diseases.

Association of white matter hyperintensities with migraine features and prognosis

Background

White matter hyperintensities (WMHs) are frequently detected in migraine patients. However, their significance and correlation to migraine disease burden remain unclear. This study aims to examine the correlation of WMHs with migraine features and explore the relationship between WMHs and migraine prognosis.

Methods

A total of 69 migraineurs underwent MRI scans to evaluate WMHs. Migraine features were compared between patients with and without WMHs. After an average follow-up period of 3 years, these patients were divided into two groups, according to the reduction of headache frequency: improved and non-improved groups. The percentage and degree of WMHs were compared between these two groups.

Results

A total of 24 patients (34.8%) had WMHs. Patients with WMHs were significantly older (39.0 ± 7.9 vs. 30.6 ± 10.4 years, P < 0.001) and had a longer disease duration (median: 180.0 vs. 84.0 months, P = 0.013). Furthermore, 33 patients completed the follow up period (15 patients improved and 18 patients did not improve). Patients in the non-improved group had a higher frequency of WMHs (55.6% vs. 13.3%, P = 0.027) and median WMHs score (1.0 vs. 0.0, P = 0.030).

Conclusions

WMHs can predict unfavorable migraine prognosis. Furthermore, WMHs may have a closer association with age than migraine features.

Behavioral, cellular and molecular maladaptations covary with exposure to pyridostigmine bromide in a rat model of gulf war illness pain

Many veterans of Operation Desert Storm (ODS) struggle with the chronic pain of Gulf War Illness (GWI). Exposure to insecticides and pyridostigmine bromide (PB) have been implicated in the etiology of this multisymptom disease. We examined the influence of 3 (DEET (N,N-diethyl-meta-toluamide), permethrin, chlorpyrifos) or 4 GW agents (DEET, permethrin, chlorpyrifos, pyridostigmine bromide (PB)) on the post-exposure ambulatory and resting behaviors of rats. In three independent studies, rats that were exposed to all 4 agents consistently developed both immediate and delayed ambulatory deficits that persisted at least 16 weeks after exposures had ceased. Rats exposed to a 3 agent protocol (PB excluded) did not develop any ambulatory deficits. Cellular and molecular studies on nociceptors harvested from 16WP (weeks post-exposure) rats indicated that vascular nociceptor Na_v1.9 mediated currents were chronically potentiated following the 4 agent protocol but not following the 3 agent protocol. Muscarinic linkages to muscle nociceptor TRPA1 were also potentiated in the 4 agent but not the 3 agent, PB excluded, protocol. Although K_v7 activity changes diverged from the behavioral data, a K_v7 opener, retigabine, transiently reversed ambulation deficits. We concluded that PB played a critical role in the development of pain-like signs in a GWI rat model and that shifts in Na_v1.9 and TRPA1 activity were critical to the expression of these pain behaviors.

Redox Mechanisms in Migraine: Novel Therapeutics and Dietary Interventions

SIGNIFICANCE

Migraine represents the third most prevalent and the seventh most disabling human disorder. Approximately 30% of migraine patients experience transient, fully reversible, focal neurological symptoms (aura) preceding the attack. Recent Advances: Awareness of the hypothesis that migraine actually embodies a spectrum of illnesses-ranging from episodic to chronic forms-is progressively increasing and poses novel challenges for clarifying the underlying pathophysiological mechanisms of migraine as well as for the development of novel therapeutic interventions. Several theories have evolved to the current concept that a combination of genetic, epigenetic, and environmental factors may play a role in migraine pathogenesis, although their relative importance is still being debated.

CRITICAL ISSUES

One critical issue that deserves a particular attention is the role of oxidative stress in migraine. Indeed, potentially harmful oxidative events occur during the migraine attack and long-lasting or frequent migraine episodes may increase brain exposure to oxidative events that can lead to chronic transformation. Moreover, a wide variety of dietary, environmental, physiological, behavioral, and pharmacological migraine triggers may act through oxidative stress, with clear implications for migraine treatment and prophylaxis. Interestingly, almost all current prophylactic migraine agents exert antioxidant effects.

FUTURE DIRECTIONS

Increasing awareness of the role of oxidative stress and/or decreased antioxidant defenses in migraine pathogenesis and progression to a chronic condition lays the foundations for the design of novel prophylactic approaches, which, by reducing brain oxidative phenomena, could favorably modify the clinical course of migraine. Antioxid. Redox Signal. 28, 1144-1183.

Harnessing migraines for neural regeneration

The success of naturalistic or therapeutic neuroregeneration likely depends on an internal milieu that facilitates the survival, proliferation, migration, and differentiation of stem cells and their assimilation into neural networks. Migraine attacks are an integrated sequence of physiological processes that may protect the brain from oxidative stress by releasing growth factors, suppressing apoptosis, stimulating neurogenesis, encouraging mitochondrial biogenesis, reducing the production of oxidants, and upregulating antioxidant defenses. Thus, the migraine attack may constitute a physiologic environment conducive to stem cells. In this paper, key components of migraine are reviewed – neurogenic inflammation with release of calcitonin gene-related peptide (CGRP) and substance P, plasma protein extravasation, platelet activation, release of serotonin by platelets and likely by the dorsal raphe nucleus, activation of endothelial nitric oxide synthase (eNOS), production of brain-derived neurotrophic factor (BDNF) and, in migraine aura, cortical spreading depression – along with their potential neurorestorative aspects. The possibility is considered of using these components to facilitate successful stem cell transplantation. Potential methods for doing so are discussed, including chemical stimulation of the TRPA1 ion channel, conjoint activation of a subset of migraine components, invasive and noninvasive deep brain stimulation of the dorsal raphe nucleus, transcranial focused ultrasound, and stimulation of the Zusanli (ST36) acupuncture point.

Genetic and biochemical changes of the serotonergic system in migraine pathobiology

Migraine is a brain disorder characterized by a piercing headache which affects one side of the head, located mainly at the temples and in the area around the eye. Migraine imparts substantial suffering to the family in addition to the sufferer, particularly as it affects three times more women than men and is most prevalent between the ages of 25 and 45, the years of child rearing. Migraine typically occurs in individuals with a genetic predisposition and is aggravated by specific environmental triggers. Attempts to study the biochemistry of migraine began as early as the 1960s and were primarily directed at serotonin metabolism after an increase of 5-hydroxyindoleacetic acid (5-HIAA), the main metabolite of serotonin was observed in urine of migraineurs. Genetic and biochemical studies have primarily focused on the neurotransmitter serotonin, considering receptor binding, transport and synthesis of serotonin and have investigated serotonergic mediators including enzymes, receptors as well as intermediary metabolites. These studies have been mainly assayed in blood, CSF and urine as the most accessible fluids. More recently PET imaging technology integrated with a metabolomics and a systems biology platform are being applied to study serotonergic biology. The general trend observed is that migraine patients have alterations of neurotransmitter metabolism detected in biological fluids with different biochemistry from controls, however the interpretation of the biological significance of these peripheral changes is unresolved. In this review we present the biology of the serotonergic system and metabolic routes for serotonin and discuss results of biochemical studies with regard to alterations in serotonin in brain, cerebrospinal fluid, saliva, platelets, plasma and urine of migraine patients.

A Case of Migraine With Aura Resolving on Warfarin But Not on Apixaban

Several case reports have associated anticoagulants such as heparin and vitamin K antagonists with reduced symptoms in migraine, but no data exist for direct acting oral factor Xa inhibitors. We report the case of a 55-year-old female who experienced complete remission of migraine with aura for 12 years while on warfarin, with return of symptoms within 3 weeks of switching to apixaban, and resolution of symptoms once again within days of warfarin resumption. Our case suggests that anticoagulation alone is not sufficient to improve migraine symptoms. Further study of vitamin K-dependent proteins not involved in anticoagulation, such as the relatively novel growth arrest-specific gene 6, may clarify the link between warfarin and migraine symptoms.

Predictive role of neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio in normal-tension glaucoma

As a type of primary open-angle glaucoma, normal-tension glaucoma (NTG) is a health problem that manifests itself with low intraocular pressure (IOP) levels and preserves its importance for public health care. In population-based screenings, which take the IOP levels of 21mmHg as a cut-off for the diagnosis of glaucoma, the diagnosis is usually delayed, and the treatment is started in an advanced stage by the referred ophthalmologists. NTG is associated with some autoimmune conditions and systemic diseases, such as paraproteinemia, nocturnal hypotension, and migraine. Recently, a simple and cheap test (namely the hemogram) was defined as measure of systemic inflammation, measuring the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR). A recent study displayed an altered platelet function in NTG patients. We hypothesize that an automated hemogram analysis for NLR together with IOP measurements may be used to screen NTG patients who are admitted to primary care clinics if any relationship between NTG and NLR could be demonstrated in future researches.