Migraine and haemostasis

Do Mean Platelet Volume and Platelet Distribution Width Have An Association with White Matter Hyperintensities in Migraine Patients?

Objective

Increased prevalence of white matter hyperintensities (WMH) is reported in migraine patients; however, the pathophysiology and the progression of these lesions are not definitely clear. Mean platelet volume (MPV) and platelet distribution width (PDW) are easily obtained markers for platelet activity. The aim of this study is to evaluate the relationship between the presence of WMH and MPV and PDW in patients with migraine in order to determine the role of platelet activity in the pathophysiology of WMH.

Methods

Patients who were admitted to the neurology outpatient clinics of Baskent University Hospital from January 2011 to December 2015 with migraine and between 18 and 55 years of age were evaluated retrospectively. The blood samples were taken and total blood count parameters including MPV and PDW were analyzed. Brain magnetic resonance images were evaluated.

Results

Totally, 218 patients were evaluated in this study. Forty-eight (22.0%) patients had WMH in the brain magnetic resonance imaging. In patients with WMH, the median of age was higher than the patients without WMH and the difference was statistically significant (P < 0.05). There was no statistically significant difference between MPV, PDW values, and the presence of WMH.

Conclusions

There are multiple theories suggested for the mechanism of WMH, but the major cause and pathophysiology are still undetermined. Our data suggested that increased platelet activity is insufficient by itself to explain the pathophysiology of WMH in migraine patients and to improve the knowledge on this issue further large longitudinal studies should be performed.

Comparison of Thrombocyte Count Between Pediatric Patients With Migraine or Tension-Type Headache: A Retrospective Cohort Study

Hypercoagulability may explain the increased risk of thromboembolic cerebrovascular events in patients with migraine. Thrombocytes play a crucial part in the coagulation process, and some studies have demonstrated hyperaggregation of thrombocytes in adult migraineurs. We aimed to compare thrombocyte count between pediatric patients with migraine or tension-type headache and to evaluate the correlation of thrombocyte count with headache parameters. The electronic database of a tertiary pediatric headache clinic was retrospectively searched for all children and adolescents diagnosed with migraine or tension-type headache in 2016-2018. Data on thrombocyte counts were collected from the medical files and compared between the groups by parametric and nonparametric statistical tests. The cohort included 299 patients, 176 girls (59.0%) and 123 (412.0%) boys, of mean age 12.2 ± 3.4 years; 198 had migraine and 101 had tension-type headache. Among the laboratory parameters evaluated, a significantly lower mean thrombocyte number was found in the migraine group than in the tension-type headache group (282 ± 60 vs 304±71 ×10³/μL, P = .004). Within the migraine group, there was a significant negative correlation between the thrombocyte count and the duration of headache attacks in hours (P < .05). No significant between- or within-group differences were found in other laboratory parameters. The low relative thrombocyte count in pediatric headache clinic patients with migraine and its negative correlation with duration of migraine suggest that migraine may be associated with a different underlying pathogenesis from tension-type headache.

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.

A prospective study of migraine history and venous thromboembolism in older adults

BACKGROUND

Limited evidence suggests that migraine might be a risk factor for venous thromboembolism (VTE). We conducted an epidemiologic study to assess whether migraine history is associated prospectively with VTE or cross sectionally with hemostatic risk markers for VTE.

METHODS

In a population-based US cohort, 11 985 participants free of VTE reported headache symptoms in 1993-1995. We classified participants as having either migraines with or without aura, severe nonmigraine headaches, or no severe headaches. We followed them through 2015 for incident VTE verified by medical records.

RESULTS

Participants' mean age at baseline was 60 years (SD: 6). Eleven percent were classified as having a migraine history (932 without aura and 396 with aura). Over a mean of 18 years and 211 913 person-years at risk, 688 participants developed VTE. Participants with a migraine history had no greater risk of VTE compared with those free of severe headache (adjusted hazard ratio [HR]: 1.06, 95% confidence interval [CI]: 0.82-1.36). Those with migraine history with aura had an HR of 1.25 (95% CI: 0.85-1.85). Self-reported physician diagnosis of migraine carried an HR of 1.22 (0.96-1.55). At baseline, those with a history of migraine, furthermore, did not have a higher frequency of elevated hemostatic risk factors or a higher genetic risk score for VTE.

CONCLUSION

This study does not support the hypothesis that migraine history is an important risk factor for VTE in older adults.

Thrombophilia Testing in High Pediatric Migraine Risk Children With Migraine

This study sought to investigate the need for thrombophilia screening in pediatric migraineurs. The cohort included 45/824 children (5.5%) aged 3-18 years with migraine who were tested for thrombophilia at a tertiary pediatric headache clinic. Results were analyzed by background factors and indications for screening. Rates of thrombotic factors were compared with a healthy historical control group. At least 1 thrombotic factor was positive in 19/45 patients (42%). The total thrombophilia risk rate was higher in patients with aura (n = 32). Lipoprotein(a) was the factor most often abnormal in the thrombophilia group of all factors tested (8/19, 42%), regardless of migraine type or gender. It was the only factor with a significantly higher prevalence in the migraine than the historical control group. Full thrombophilia testing in migraine in pediatric headache clinics does not seem to be justified. The high prevalence of elevated lipoprotein(a) in children with migraine warrants further investigation.

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.

Migraine and vascular disease biomarkers: A population-based case-control study

Background The underpinnings of the migraine-stroke association remain uncertain, but endothelial activation is a potential mechanism. We evaluated the association of migraine and vascular disease biomarkers in a community-based population. Methods Participants (300 women, 117 men) were recruited as a part of the Dutch CAMERA 1 (Cerebral Abnormalities in Migraine, an Epidemiologic Risk Analysis) study. Participants were aged 30-60 (mean 48) years, 155 migraine had with aura (MA), 128 migraine without aura (MO), and 134 were controls with no severe headaches. Plasma concentrations of fibrinogen, Factor II, D-dimer, high sensitivity C-reactive protein (hs-CRP), and von Willebrand factor antigen were compared between groups, also stratifying by sex. Results Fibrinogen and hs-CRP were elevated in migraineurs compared to controls. In logistic regression analyses, MO and MA had increased likelihood of elevated fibrinogen, and MA had increased likelihood of elevated Factor II and hs-CRP. Fibrinogen and Factor II were associated with MA in women but not men. In the migraine subgroup, the total number of years of aura, but not headache, predicted elevated hs-CRP, and the average number of aura, but not headache, attacks predicted all biomarkers but Factor II. Conclusions Elevated vascular biomarkers were associated with migraine, particularly MA, as well as with years of aura and number of aura attacks.

Migraine and risk of perioperative ischemic stroke and hospital readmission: hospital based registry study

OBJECTIVE

 To evaluate whether patients with migraine are at increased risk of perioperative ischemic stroke and whether this may lead to an increased hospital readmission rate.

DESIGN

 Prospective hospital registry study.

SETTING

 Massachusetts General Hospital and two satellite campuses between January 2007 and August 2014.

PARTICIPANTS

 124 558 surgical patients (mean age 52.6 years; 54.5% women).

MAIN OUTCOME MEASURES

 The primary outcome was perioperative ischemic stroke occurring within 30 days after surgery in patients with and without migraine and migraine aura. The secondary outcome was hospital readmission within 30 days of surgery. Exploratory outcomes included post-discharge stroke and strata of neuroanatomical stroke location.

RESULTS

 10 179 (8.2%) patients had any migraine diagnosis, of whom 1278 (12.6%) had migraine with aura and 8901 (87.4%) had migraine without aura. 771 (0.6%) perioperative ischemic strokes occurred within 30 days of surgery. Patients with migraine were at increased risk of perioperative ischemic stroke (adjusted odds ratio 1.75, 95% confidence interval 1.39 to 2.21) compared with patients without migraine. The risk was higher in patients with migraine with aura (adjusted odds ratio 2.61, 1.59 to 4.29) than in those with migraine without aura (1.62, 1.26 to 2.09). The predicted absolute risk is 2.4 (2.1 to 2.8) perioperative ischemic strokes for every 1000 surgical patients. This increases to 4.3 (3.2 to 5.3) for every 1000 patients with any migraine diagnosis, 3.9 (2.9 to 5.0) for migraine without aura, and 6.3 (3.2 to 9.5) for migraine with aura. : Patients with migraine had a higher rate of readmission to hospital within 30 days of discharge (adjusted odds ratio 1.31, 1.22 to 1.41).

CONCLUSIONS

 Surgical patients with a history of migraine are at increased risk of perioperative ischemic stroke and have an increased 30 day hospital readmission rate. Migraine should be considered in the risk assessment for perioperative ischemic stroke.

Are Vascular Disorders More Prevalent in the Relatives of Children and Adolescents with Migraine?

The objective of the study was to assess whether a family history of vascular disorders is more common in children and adolescents with migraine than in the general population. Family history of stroke, arterial hypertension, myocardial infarction and diabetes was investigated by history taking in relatives of ambulatory children and young adults with migraine and in a control group. The odds ratios (ORs) with 95% confidence intervals (95% CI) were used as a risk measure. Using univariate and multivariate (logistic regression) analysis, family history was assessed in the whole sample and in subgroups by sex and age, degree of relationship (parents and grandparents vs. relatives), disease type (migraine with and without aura), and type of vascular disorder. The sample included 143 cases (migraine with aura 35, migraine without aura 108) and 164 controls aged 324 years (mean 12 ± 3.8 years). Patients with migraine were at increased risk of vascular disorders in parents and grandparents but not in all relatives. Multivariate analysis indicated family history of stroke as most common only in boys. In conclusion, our study provides some clues to the assumption that migraine and vascular disorders have common pathogenic mechanisms and that genetic susceptibility plays a role in increasing the risk of migraine in the offspring of families with one or more cerebrovascular or cardiovascular conditions.

Sneddon's Syndrome

Sneddon's syndrome refers to the enigmatic association of ischaemic stroke and livedo reticularis. We review the Sneddon's syndrome literature examining the association of this condition with headache, including migraine. Case reports and series are stratified into two groups based on headache reference. In the group without a reference to headache, there are 208 persons, with a female to male ratio of 3 : 1. In the headache reference group, there are 175 persons, with a female to male ratio of 3.5 : 1. The proportion with headache in this second group is 58% (102 individuals), with headache described as migraine in 28 (27.5%) of the headache subjects, including six with migraine with aura. The frequency of headache is not significantly higher in persons with positive anti-phospholipid antibodies compared with the negative cohort (43% vs. 32%, P = 0.07). A review of the histopathological, radiological and serological data in Sneddon's syndrome and migraine underscores the plausibility of an association. Considered in the context of increased risk of stroke with migraine, a higher frequency of livedo in migraineurs with stroke, and the association of migraine and livedo reticularis, the question of whether livedo reticularis may be a risk marker for stroke in migraineurs is an area for further study.

Insulin Resistance and High Sensitivity C-Reactive Protein in Migraine

Background:

A relationship between migraine and vascular disorders such as hypertension, stroke, and coronary ischemia has been recently reported. Insulin resistance and endothelial dysfunction, which commonly underlies these disorders, have not been widely investigated in migraine patients. In this study, we aimed to investigate the existence of insulin resistance and endothelial dysfunction, and their relationship to vascular risk factors in patients with migraine.

Methods:

We evaluated insulin resistance and high-sensitivity C-reactive protein (hs-CRP), a marker of endothelial dysfunction, in 60 migraine patients and 25 healthy control subjects. Multiple analysis of covariance test was used to adjust for known confounding factors that can influence insulin metabolism and endothelial function, such as obesity, blood pressure, and lipid parameters.

Results:

Insulin resistance, as measured homeostasis model assessment (HOMA)-R levels, was significantly higher in the migraine group (p<0.001). After adjustment for confounding variables, the relationship between migraine and the HOMA-R levels remained significant (p<0.001). The hs-CRP levels did not differ between the migraine and control groups.

Conclusions:

Our data show that insulin resistance is present in migraine patients. Endothelial dysfunction is not found during the headache-free period. Further studies are needed to explain the role of insulin resistance in migraine pathogenesis.

Progress in Clinical Neurosciences: Migraine-Stroke: A Causal Relationship, but Which Direction?

A significant association between migraine and ischemic stroke has been demonstrated in population and case-control studies. The risk of ischemic stroke appears to be higher in migraine with aura (MWA) than migraine without aura (MwoA). Migraine-stroke comprises a number of distinct entities, including migrainous infarction, in which ischemic stroke occurs during an attack of MWA and migraine-related stroke, in which the causal link is less clear. Migrainous infarction accounts for only one-third of migraine-stroke, strokes may occur during attacks of MwoA, and a number of cerebrovascular disorders may present as MWA or MwoA. Migraine may occur as a consequence of conditions that are known to cause stroke; therefore it remains to be determined whether migraine predisposes to stroke in the absence of any known disease associations, if it is an epiphenomenon of an underlying stroke diathesis, or if it requires the presence of another stroke risk factor to produce cerebral ischemia. Furthermore, it is unclear if ischemia results in migraine more often than migraine results in ischemia. Careful clinical studies that evaluate this bidirectional relationship are needed to determine why migraine patients are subject to a higher risk of ischemic stroke.

Lipoprotein a levels in pediatric migraine

The purpose of this study was to examine the lipoprotein (a) [Lp(a)] levels in children with migraine to see a possible relationship between migraine and stroke via high Lp(a) levels. Plasma levels of Lp(a) were determined in 63 patients and age-matched control subjects. The mean age in the control group was 10.57 ± 3.63 years and 11.51 ± 3.19 years in the migraine patient group. The mean Lp(a) levels in control group were 10.36 ± 10.41 ng/mL and 17.09 ± 12.12 ng/mL in migraine group (P < 0.05). The median Lp(a) level in the control group was 49.38 ng/mL and was 77.62 ng/mL in the migraine group (P < 0.05). Twelve patients (19%) had Lp(a) levels of >30 ng/mL in the migraine group and 4 (6.3%) in the control group (P < 0.05). Several prothrombotic factors related to an increased risk of stroke have been studied in migraine patients. It has recently been reported that high Lp(a) concentrations represent a risk factor for migraine, thus establishing a novel plausible link between migraine and stroke. The current study suggests evidence of high Lp(a) concentrations in childhood migraine; perhaps a novel link exists between migraine and stroke.

Migraine is associated with an increased risk of deep white matter lesions, subclinical posterior circulation infarcts and brain iron accumulation: the population-based MRI CAMERA study

Previous studies have suggested that migraine is a risk factor for brain lesions, but methodological issues hampered drawing definite conclusions. Therefore, we initiated the magnetic resonance imaging (MRI) ‘CAMERA’ (Cerebral Abnormalities in Migraine, an Epidemiological Risk Analysis) study. We summarize our previously published results. A total of 295 migraineurs and 140 controls were randomly selected from a previously diagnosed population-based sample (n = 6039), who underwent an interview, physical examination and a brain MRI scan. Migraineurs, notably those with aura, had higher prevalence of subclinical infarcts in the posterior circulation [odds ratio (OR) 13.7; 95% confidence interval (CI) 1.7, 112]. Female migraineurs were at independent increased risk of white matter lesions (WMLs; OR 2.1; 95% CI 1.0, 4.1), and migraineurs had a higher prevalence of brainstem hyperintense lesions (4.4% vs. 0.7%, P = 0.04). We observed a higher lifetime prevalence of (frequent) syncope and orthostatic insufficiency in migraineurs; future research needs to clarify whether autonomic nervous system dysfunction could explain (part of) the increased risk of WMLs in female migraineurs. Finally, in migraineurs aged < 50 years, compared with controls, we found evidence of increased iron concentrations in putamen (P = 0.02), globus pallidus (P = 0.03) and red nucleus (P = 0.03). Higher risks in those with higher attack frequency or longer disease duration were found consistent with a causal relationship between migraine and lesions. This summary of our population-based data illustrates that migraine is associated with a significantly increased risk of brain lesions. Longitudinal studies are needed to assess whether these lesions are progressive and have relevant (long-term) functional correlates.

Endothelial function in migraine: a cross-sectional study

Background

Migraine has been associated with cardiovascular disorders. Endothelial dysfunction may be a mechanism underlying this association. The present study tested the hypothesis that endothelium-dependent vasodilation, basal endothelial nitric oxide release and endothelial fibrinolytic capacity are impaired in migraine patients.

Methods

Graded doses of sodium nitroprusside (SNP, 0.2 to 0.8 μg.min^-1.dL^-1 forearm), substance P (0.2 to 0.8 pmol.min^-1.dL^-1 forearm) and N^G-monomethyl-L-arginine (L-NMMA, 0.1 to 0.4 μmol.min^-1.dL^-1 forearm) were infused into the brachial artery of 16 migraine patients with or without aura during a headache-free interval and 16 age- and sex-matched subjects without a history of migraine. Forearm blood flow (FBF) was measured by strain-gauge venous occlusion plethysmography. Local forearm release of tissue plasminogen activator (t-PA) in response to substance P infusion was assessed using the arteriovenous plasma concentration gradient. Responses to infused drugs were compared between patients and matched controls by analysis of variance.

Results

In both migraine patients and control subjects, SNP and substance P caused a dose-dependent increase, and L-NMMA a dose-dependent decrease in FBF (P < 0.001 for all responses). In both groups, substance P caused an increase in t-PA release (P < 0.001). FBF responses and t-PA release were comparable between migraine patients and control subjects.

Conclusions

The absence of differences in endothelium-dependent vasodilation, basal endothelial nitric oxide production and stimulated t-PA release between migraine patients and healthy control subjects argues against the presence of endothelial dysfunction in forearm resistance vessels of migraine patients.

Dementia, stroke and migraine--some common pathological mechanisms

Dementia, stroke and migraine are very common neurological disorders affecting a large percentage of the population, and leading to a high degree of disability. Often, adequate therapy is not available. Although the symptoms, the progression and the outcome differ in these disorders, to some extent they may share some common pathophysiological mechanisms. The genetic background, an energy deficit, and excitotoxicity, vascular and thrombotic properties can influence all three disorders, resulting in a neuronal dysfunction, increased cellular vulnerability, neurodegeneration and ultimately cell death. All these cellular events occur in dementias and stroke, moreover recent studies suggest that, besides a dysfunction, neuronal damage may be an issue in migraine too. One of the most central events in the multiple mechanisms involved in the pathogenesis of these disorders is a metabolic disturbance of certain brain cells. As mitochondria provide the cells with energy, realization of the importance of these organelles in the aetiopathogenesis of several disorders has emerged in recent years. This review surveys the most important features of the pathogenesis of dementia, stroke and migraine from the aspect of mitochondrial malfunction highlighting some of the considerable connections between these neurological disorders.

The risks of women with migraine during pregnancy

Most epidemiological studies demonstrate that women suffering from migraine note a significant improvement in their headaches during pregnancy. Both headache specialists and gynecologists commonly hold that migraine does not involve any risks to either the mother, or the fetus. Despite this, recent studies into the medical complications of pregnancy in migrainous women have cast doubts on this assumption. Indeed, most of these studies have revealed a significant association between migraine and hypertension in pregnancy (i.e. preeclampsia and gestational hypertension). Migraine has also been recently postulated as one of the major risk factors for stroke during pregnancy and the puerperium. Therefore, there is an urgent need for prospective studies on large numbers of pregnant women to determine the real existence and extent of the risks posed by migraine during pregnancy. In the meantime, while awaiting verification of this hypothesis, a pregnant woman with migraine must be subject to a particularly attentive screening by both the obstetrician and the headache specialist.

Mitral valve prolapse and abnormalities of haemostasis in children and adolescents with migraine with aura and other idiopathic headaches: a pilot study

OBJECTIVE

To investigate the prevalence of mitral valve prolapse (MVP) and abnormalities of haemostasis in children and adolescents with migraine with aura (MA) compared with peers affected by other idiopathic headaches.

MATERIALS AND METHODS

We recruited 20 MA patients (10 men and 10 women; age range 8-17 years) and 20 sex- and age-matched subjects with other idiopathic headaches. Both groups underwent colour Doppler transthoracic echocardiography to detect MVP and the following laboratory work-up: plasma prothrombin time, activated partial thromboplastin time, thrombin time, fibrinogen, protein C, protein S, homocysteine, lupus anticoagulant, von Willebrand factor (vWF) ristocetin cofactor activity, immunoglobulins (Ig) G and M anticardiolipin antibodies (aCL). Factor V Leiden, factor II and methylenetetrahydrofolate reductase were investigated (we did not test the entire genes, but screened for specific point mutations).

RESULTS

The prevalence of MVP was significantly higher in the MA subjects than in the patients affected by other idiopathic headaches (40% vs 10%; P < 0.05). Moreover, the MA patients showed a higher rate of above-normal IgM aCL titres (45% vs 10%; P < 0.05). Finally, in the group of patients with MVP we found a higher prevalence of aCL in those with MA compared with those affected by other idiopathic headaches.

CONCLUSIONS

A proportion, at least, of the MA patients showed a more complex phenotype characterized by MVP and/or positive aCL titres. The pathogenetic role of these associations is obscure and larger studies are needed to confirm the usefulness of echocardiographic and laboratory investigations in this area and to identify possible new treatment approaches that might be explored in this group of MA patients.

Headache in thrombotic thrombocytopenic purpura: two cases with pathophysiological considerations

Headache is one of the most common neurological symptoms reported by patients with thrombotic thrombocytopenic purpura (TTP). Reports of headache characteristics in patients with TTP are rare. We report 2 cases of headache in a setting of TTP and review previous reports. Headache in TTP can have features in common with both migraine and tension-type headache. Although the pathophysiology of headache in TTP is not certain, platelet aggregation and activation may play a key role.

Migraine as a systemic vasculopathy

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

Migraines during pregnancy linked to stroke and vascular diseases: US population based case-control study

OBJECTIVE

To examine the association between migraine and cardiovascular diseases during pregnancy. Design US population based case-control study.

SETTING

Nationwide inpatient sample, from the Healthcare Cost and Utilization Project of the Agency for Healthcare Research and Quality. Population 18,345,538 pregnancy related discharges from 2000 to 2003.

MAIN OUTCOME MEASURES

Diagnosis of migraine, as identified by ICD-9 codes 346.0 and 346.1. Stroke and other vascular diseases were identified by using standard ICD-9 codes.

RESULTS

From the hospital discharges with a pregnancy discharge code, 33 956 migraine codes were identified: 185 per 100 000 deliveries. Diagnoses that were jointly associated with migraine codes during pregnancy (excluding pre-eclampsia) were stroke (odds ratio 15.05, 95% confidence interval 8.26 to 27.4), myocardial infarction/heart disease (2.11, 1.76 to 2.54), pulmonary embolus/venous thromboembolism (3.23, 2.06 to 7.07), and hypertension (8.61, 6.43 to 11.54), as well as pre-eclampsia/gestational hypertension (2.29, 2.13 to 2.46), smoking (2.85, 2.53 to 3.21), and diabetes (1.96, 1.64 to 2.35). However, migraine was not associated with several non-vascular diagnoses (pneumonia, transfusions, postpartum infection or haemorrhage).

CONCLUSIONS

In this large, population based sample of pregnant women admitted to hospital, a strong relation existed between active peripartum migraine and vascular diagnoses during pregnancy. Because these data do not allow determination of which came first, migraine or the vascular condition, prospective studies of pregnant women are needed to explore this association further.

Migraine and ischemic stroke: a debated question

Numerous epidemiologic observations reporting high prevalence of migraine among young individuals with stroke as well as dysfunction of cerebral arteries during migraine attacks prompt speculation on the existence of a comorbidity between the two disorders. The recent finding of silent infarct-like brain lesions in migraineurs reinforced this hypothesis and raised questions on whether migraine may be a progressive disorder rather than simply an episodic disorder. Stroke can occur during the course of migraine attacks with aura, supporting the assumption of a causal relation between the two diseases. Migraine may accentuate other existing risk factors for stroke, and both jointly increase the risk of cerebral ischemia outside of migraine attacks. In this regard, the role of migraine might be that of predisposing condition for cerebral ischemia. Migraine and ischemic stroke may be the end phenotype of common pathogenic mechanisms. Evidence of a migraine-stroke relation in cases of specific disorders, such as CADASIL (cerebral autosomal-dominant arteriopathy with subcortical infarcts and leukoencephalopathy) and MELAS (mitochondrial myopathy, encephalopathy, lactic acidosis, and stroke-like episodes), strongly supports this concept. Finally, acute focal cerebral ischemia can trigger migraine attacks, and, thus, migraine may be the consequence of stroke. In this paper, we will review contemporary epidemiologic studies, discuss potential mechanisms of migraine-induced stroke and comorbid ischemic stroke, and pose new research questions.

Resting brain glucose uptake in headache-free migraineurs

BACKGROUND AND OBJECTIVE

To compare metabolism in the brains of migraineurs during headache-free periods with those obtained from healthy volunteers.

METHODS

Eleven migraineurs (defined by the International Headache Society's criteria) presented during spontaneous headache-free intervals to undergo (18)FDG PET brain imaging of glucose metabolism. The control group consisted of 14 healthy volunteers. Comparison of images was done using Statistical Parametric Mapping to detect significant (P < .05) differences in brain glucose metabolism between the 2 groups.

RESULTS

Two regions of significant increase in glucose uptake were identified in migraineurs relative to the control population. The 2 regions were mapped predominantly to the posterior white matter of the cerebrum and cerebellum.

CONCLUSIONS

Our study demonstrates the presence of what may be a primary metabolic disturbance in the posterior white matter of the brain in migraineurs.

Concurrent hemichorea and migrainous aura--a perfusion study on the basal ganglia using xenon-computed tomography

A variety of etiologies underlie the neurophysiological imbalance resulting in chorea. We report a 57-year-old woman with a long-history of migraine who suddenly experienced concurrent scintillating scotoma and rapid involuntary movement of her neck and right extremities. Diffusion-weighted magnetic resonance imaging (MRI) failed to detect any fresh ischemic and/or hemorrhagic lesions. Xenon-computed tomography (CT) disclosed gross reduction in the cerebral blood flow (CBF) of the left occipital area. With precise mapping to the brain atlas, extreme hyperperfusion in the motor thalamus was found on the left side. Asymmetrical CBF reduction of the left subthalamic nucleus was also noted. Her symptoms gradually improved and completely disappeared within 15 days. Repeated xenon-CT 1 month post-onset demonstrated normalized CBF in the affected areas. Our study suggests that vascular event underlies the migrainous aura in this case and secondarily provokes a loss of inhibitory control of the motor thalamus resulting in the manifestation of hemichorea.

Stroke and migraine

Young patients with migraine are at increased risk for stroke, particularly patients with an aura of focal neurologic deficits. Other causes of ischemia are often identified in patients with migraine, including patent foramen ovale, lupus anticoagulant, cervical carotid dissection, arteriovenous malformation, and hyperactivity of the clotting system. Migrainous stroke is only diagnosed when all other possible causes of stroke have been eliminated and the patient has irreversibility of the usual aura, associated with an ischemic infarct in the appropriate brain territory. Prophylactic therapy of migraine with aura may be beneficial in preventing migrainous stroke.

Patent foramen ovale and migraine

Results from several observational studies indicate an association between migraine and patent foramen ovale (PFO). Several biological mechanisms have been proposed to explain this link, including shared genetic inheritance. However, there is currently insufficient evidence to support a causal link between PFO and migraine. Although the results of uncontrolled observational studies suggest the PFO closure may have a beneficial effect on migraine frequency, a large randomized trial failed to support such a conclusion. Until there is more evidence from ongoing large controlled trials, PFO closure should not be performed in clinical practice for the prophylaxis of migraine.

Endometriosis Is Associated With Prevalence of Comorbid Conditions in Migraine

OBJECTIVE

To examine the headache characteristics of women with migraine and endometriosis (EM), and differences in the prevalence of comorbid conditions between female migraineurs with EM, without EM and nonheadache controls.

BACKGROUND

Migraine and EM are common conditions in women of reproductive age, and both are influenced by ovarian hormones. The comorbidity of migraine and EM is newly recognized, but reasons for the association are uncertain.

METHODS

This is a cross-sectional study of female headache outpatients and healthy controls conducted at University of Toledo and Duke University in 2005 and 2006. After a headache specialist determined headache frequency and diagnosis (based on criteria of the second International Classification of Headache Disorders), patients completed a self-administered electronic survey with information on demographics, headache-related disability, menstrual disorders, premenstrual dysphoric disorder (PMDD), vascular event risk, and comorbid conditions, including irritable bowel syndrome (IBS), fibromyalgia (FM), chronic fatigue syndrome (CFS), interstitial cystitis (IC), depression, and anxiety.

RESULTS

Study enrolled 171 women with migraine and 104 controls. EM was reported more commonly in migraineurs than in controls (22% vs 9.6%, P < .01). Frequency of chronic headache was higher in migraineurs with EM compared to without EM (P= .002) and median headache-related disability scores were also higher in the EM group (P= .025). Symptoms of PMDD were more common in migraineurs, but frequency did not differ by EM status. Migraineurs with EM reported more menorrhagia, dysmenorrhea, and infertility compared to the migraine cohort without EM and to controls. Depression, anxiety, IBS, FM, CFS, and IC were more common in migraine with EM group than in controls. Anxiety (OR = 2.2, 95% CI 1.0-4.7), IC (OR = 10.6, 95% CI 1.9-56.5), and CFS (OR = 3.6, 95% CI 1.1-11.5) were more common in migraine with EM group, than in the cohort with migraine without EM.

CONCLUSION

Prevalence of EM is higher in women with migraine than in nonheadache controls. Migraineurs with EM have more frequent and disabling headaches, and are more likely to have other comorbid conditions affecting mood and pain, compared to migraineurs without EM.

Patent foramen ovale, stroke, and cardiovascular disease in migraine

PURPOSE OF REVIEW

We will review the literature on the association between migraine with patent foramen ovale, stroke, and coronary heart disease.

RECENT FINDINGS

The prevalence of patent foramen ovale in patients with migraine with aura is significantly higher than in nonmigraine controls and migraineurs without aura. However, there is currently no evidence to support a causal relationship. Migraine with aura has been consistently associated with increased risk of ischemic stroke in several epidemiologic studies. Migraine with aura is associated with a more unfavourable cardiovascular risk profile and recent data suggest that the association between migraine with aura and stroke may extend to overall cardiovascular disease. Identification of migraine patients at particular risk for stroke or other vascular events is impossible based on current knowledge.

SUMMARY

Migraine with aura and patent foramen ovale have higher coincidences than expected by chance only. It is possible that both conditions are inherited together. Until now there has been no evidence from placebo-controlled randomized trials that closure of patent foramen ovale improves migraine with aura. There is increasing evidence that migraine with aura is not only a risk factor for ischemic stroke but also for myocardial infarction and other ischemic vascular events.

Brain MRI white matter lesions in migraine patients: is there a relationship with antiphospholipid antibodies and coagulation parameters?

Brain magnetic resonance imaging (MRI) studies in migraine patients have demonstrated lesions consisting of focal regions of increased signal intensity within the white matter. Antiphospholipid antibodies are known to have a role in many diseases including migraine. The aim of the present study was to ascertain the relationship between MRI-visualized cerebral focal hyperintense lesions and serum antiphospholipid antibody levels, as well as blood coagulation parameters in migraine patients. One hundred and two (77 females, 25 males, mean age 33.8 +/- 11.1) consecutive migraine patients and a control group of 94 (70 females, 24 males, mean age 33.2 +/- 10.8) healthy subjects were enrolled. All individuals underwent brain MRI. Complete blood examinations, autoantibodies, antiphospholipids antibodies including anticardiolipin and lupus anticoagulant (aCL, LAC), antithrombin III, Protein C and S serum levels were ascertained in the subjects who presented white matter lesions on MRI. Twenty-seven (26.4%) migraine patients and six (6.3%) healthy subjects in the control group showed focal regions of increased intensity signal within cerebral white matter (odds ratio 5.3, 95% CI: 1.98-16.36). In migraine patients with white matter lesions, antiphospholipid antibodies were not detected and serum levels of antithrombin III, and proteins C and S were normal. White matter lesions in migraine patients are fairly common. This finding is not associated with antiphospholipid antibodies or abnormal coagulation parameters. The significance of such lesions at present remains unclear.

Foramen ovale perméable et migraine

Recent epidemiological data suggest a bidirectional link between patent foramen ovale (PFO) and migraine with aura (MA) with a relative risk of 2 for PFO in subjects with MA and for MA in subjects with PFO. There is no evidence for a link between PFO and migraine without aura. This link is not systematic and applies only to subsets of PFO, mostly large ones, and to subsets of patients with MA. Although comorbidity cannot be ruled out, it may be that this link is partly causal and that some large PFOs may favor MA attacks in genetically predisposed subjects, by allowing vasoactive substances, platelet emboli or paradoxical emboli to bypass the lung filter and trigger the cortical spreading depression of the aura. The first double blind randomised trial of PFO closure in refractory MA, "MIST", has failed to show a benefit on the primary efficacy end point: cessation of attacks during the analysis period included between 3 and 6 months after the procedure. There is thus at present no scientific reason to look for PFO or to close PFO in migraine patients.

Migraine Is Associated with Enhanced Arterial Stiffness

Migraine is a common subtype of headache. Epidemiological studies have revealed that migraine could be an independent risk factor for ischemic stroke even in elderly subjects. Arterial stiffness is one of the major pathophysiological bases of stroke. In the present study, we cross-sectionally investigated the possible relationship between migraine and arterial stiffness in community-dwelling subjects. The study subjects were independently recruited from two sources (Group A, n=134, 68+/-5 years; Group B, n=138, 68+/-7 years). Augmentation index (AI), the ratio of augmented pressure by the reflection pressure wave to the pulse pressure, was obtained from the radial arterial waveform as an index of arterial stiffness. Brachial blood pressure was also measured simultaneously. Migraine was diagnosed using a previously validated questionnaire. The prevalence of migraine was 5.2% (Group A) and 16.7% (Group B). Subjects with migraine had higher radial AI in both Group A (migraine, 101+/-15%; other headache, 88+/-12%; no headache, 86+/-12%, p=0.003) and Group B (95+/-11%, 90+/-11%, 91+/-14%, p=0.058). Multiple linear regression analysis revealed that migraine was an independent determinant of AI (beta=0.154, p=0.002) after adjustment for other confounding factors: age (beta=-0.024, p=0.654); sex (beta=0.141, p=0.069); body height (beta=-0.215, p=0.005); systolic blood pressure (beta=0.174, p=0.001); medication for hypertension, hyperlipidemia, and diabetes mellitus (beta=-0.014, p=0.787); and heart rate (beta=-0.539, p<0.001). In a separate analysis by sex, migraine was also a significant determinant for AI (male, beta=0.246, p=0.019; female, beta=0.159, p=0.008). Migraine in the elderly could be a clinical manifestation of enhanced arterial stiffness.

Practical considerations for the treatment of elderly patients with migraine

Treatment of migraine presents special problems in the elderly. Co-morbid diseases may prohibit the use of some medications. Moreover, even when these contraindications do not exist, older patients are more likely than younger ones to develop adverse events. Managing older migraine patients, therefore, necessitates particular caution, including taking into account possible pharmacological interactions associated with the greater use of drugs for concomitant diseases in the elderly. Paracetamol (acetaminophen) is the safest drug for symptomatic treatment of migraine in the elderly. Use of selective serotonin 5-HT(1B/1D) receptor agonists ('triptans') is not recommended, even in the absence of cardiovascular or cerebrovascular risk, and NSAID use should be limited because of potential gastrointestinal adverse effects. Prophylactic treatments include antidepressants, beta-adrenoceptor antagonists, calcium channel antagonists and antiepileptics. Selection of a drug from one of these classes should be dictated by the patient's co-morbidities. Beta-adrenoceptor antagonists are appropriate in patients with hypertension but are contraindicated in those with chronic obstructive pulmonary disease, diabetes mellitus, heart failure and peripheral vascular disease. Use of antidepressants in low doses is, in general, well tolerated by elderly people and as effective, overall, as in young adults. This approach is preferred in patients with concomitant mood disorders. However, prostatism, glaucoma and heart disease make the use of tricyclic antidepressants more difficult. Fewer efficacy data in the elderly are available for selective serotonin reuptake inhibitors, which can be tried in particular cases because of their good tolerability profile. Calcium channel antagonists are contraindicated in patients with hypotension, heart failure, atrioventricular block, Parkinson's disease or depression (flunarizine), and in those taking beta-adrenoceptor antagonists and monoamine oxidase inhibitors (verapamil). Antiepileptic drug use should be limited to migraine with high frequency of attacks and refractoriness to other treatments. Promising additional strategies include ACE inhibitors and angiotensin II type 1 receptor antagonists because of their effectiveness and good tolerability in patients with migraine, particularly in those with hypertension. Because of its favourable compliance and safety profile, botulinum toxin type A can be considered an alternative treatment in elderly migraine patients who have not responded to other currently available migraine prophylactic agents. Pharmacological treatment of migraine poses special problems in regard to both symptomatic and prophylactic treatment. Contraindications to triptan use, adverse effects of NSAIDs, and unwanted reactions to some antiemetics reduce the list of drugs available for the treatment of migraine attacks in elderly patients. The choice of prophylactic treatment (beta-adrenoceptor antagonists, calcium channel antagonists, antiepileptics, and more recently, some antihypertensive drugs) is influenced by co-morbidities and should be directed at those drugs that are believed to have fewer adverse effects and a better safety profile. Unfortunately, for most of these drugs, efficacy studies are lacking in the elderly.

Complications of migraine: migrainous infarction

Migraine and cerebrovascular disorders are comorbid diseases and the overlap of their clinical symptoms has relevant diagnostic and therapeutic implications. The prototypic condition of this relationship is reproduced by a clinical event named migrainous infarction (MI), listed by the ICHD-II among the "complication of migraine." We discuss the diagnostic criteria proposed for this rare condition with regard to the epidemiological studies and the clinicopathogenetic implications. In the clinical setting therefore, "possible" cases of migrainous infarction should undergo an extended diagnostic workup to rule out symptomatic migraine due to extra/intra-cranial vascular pathology (artery dissection/malformations, venous thrombosis) and to exclude a causal role for other conditions. These include patent foramen ovale and thrombophylic status that may become critical risk factors for stroke, particularly among migraineurs, in coincidence with precipitating factors that should be more accurately considered in each single case.

Migraine and white matter hyperintensities

Patients with migraine are at increased risk for white matter hyperintensities detected on magnetic resonance imaging. The presence of nonspecific white matter hyperintensities may cause uncertainty for physicians and anxiety for patients. The pathophysiology and long-term consequences of these lesions are unknown. Occasionally, white matter lesions in a migraineur may indicate an underlying disease such as cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL), mitochondrial encephalopathy with lactic acidosis and stroke-like episodes (MELAS), or central nervous system vasculitis. The ability to distinguish between nonspecific and disease-specific patterns of white matter hyperintensities in migraine sufferers is important for the practicing clinician.

Antithrombotic Therapy for Stroke in Young Adults

Stroke in young adults is a markedly heterogeneous disease, and remains an understudied phenomenon. While advances are being made in our understanding of the pathophysiology of its underlying conditions, treatment concerns are controversial, and clinical trials are sorely lacking. This review presents an overview of some of the relevant management issues in hypercoagulable states, migraine, patent foramen ovale, vascular dissection and venous sinus thrombosis.