Migraine and the extrapyramidal system

Prevalence and characteristics of rapid eye movement sleep behaviour disorder in adults with migraine: a cross-sectional screening study

BACKGROUND AND PURPOSE

Migraine and sleep disorders share a bidirectional relationship, but little is known about the specific association between migraine and rapid eye movement (REM) sleep behaviour disorder (RBD). The aim was to assess the prevalence of RBD and associated clinical characteristics in adults with migraine.

METHODS

This analysis is part of a cross-sectional survey study conducted at the Headache Centre of the Charité-Universitätsmedizin Berlin between August 2020 and March 2023. At the end of their regular medical consultation, patients with migraine filled out (1) the validated RBD Screening Questionnaire (RBDSQ), (2) a questionnaire on REM sleep intrusions and (3) the Depression, Anxiety and Stress Scale 21. The primary endpoint was the percentage of patients with a positive RBD screening. A multivariate analysis was performed to identify characteristics independently associated with features of RBD.

RESULTS

A total of 751 patients (44.1 ± 13.2 years; 87.4% female) with complete RBDSQ were included in this analysis, of which 443 (58.9%) screened positive for RBD. In multivariate analysis, a positive screening for RBD was associated with younger age (odds ratio [OR] 0.9, 95% confidence interval [CI] 0.8-0.9 per 10-year increase; p = 0.005) and with features suggestive of REM sleep intrusions (OR 4.3, 95% CI 1.8-10.4; p = 0.001). Migraine aura remained in the model without reaching statistical significance (OR 1.3, 95% CI 0.9-1.8; p = 0.079).

DISCUSSION

Symptoms of RBD are frequent in adults with migraine. Further studies including polysomnography are required to confirm this association, and to explore potential common pathophysiological mechanisms.

D2 dopamine receptor-mediated mechanisms of dopaminergic system modulation in in vivo and in vitro experimental models of migraine

The dopaminergic system is implicated in the pathophysiology of migraine. However, the underlying mechanisms remain unclear. We explored the effects and mechanisms of dopaminergic system modulation in the in vivo and in vitro rat models of migraine. Dopaminergic agonist apomorphine, D2 receptor antagonists metoclopramide and haloperidol and 5-HT3 receptor antagonist ondansetron alone and together were tested in nitroglycerin-induced migraine model, in vivo. Likewise, the combinations of drugs were also tested on basal calcitonin gene-related peptide (CGRP) release in vitro hemiskull preparations. Mechanical allodynia was tested by von Frey filaments. CGRP concentrations in trigeminovascular structures and in vitro superfusates and c-Fos levels in the brainstem were determined by enzyme-linked immunosorbent assay. Meningeal mast cells were evaluated with toluidine blue staining. Apomorphine further enhanced nitroglycerin-induced mechanical allodynia, brainstem c-fos expression, trigeminal ganglion and brainstem CGRP concentrations and meningeal mast cell degranulation, in vivo. Haloperidol completely antagonised all apomorphine-induced effects and also alleviated changes induced by nitroglycerin without apomorphine. Metoclopramide and ondansetron partially attenuated apomorphine- or nitroglycerin-induced effects. A combination of haloperidol and ondansetron decreased basal CGRP release, in vitro, whereas the other administrations were ineffective. Apomorphine-mediated dopaminergic activation exacerbated nitroglycerin-stimulated nociceptive reactions by further enhancing c-fos expression, CGRP release and mast cell degranulation in strategical structures associated with migraine pain. Metoclopramide partially attenuated the effects of apomorphine, most likely because it is also a 5-HT3 receptor antagonist. Haloperidol with pure D2 receptor antagonism feature appears to be more effective than metoclopramide in reducing migraine-related parameters in dopaminergic activation- and/or NTG-induced migraine-like conditions.

Evaluation of clinical relationship of serum niacin and dopamine levels in patients with fibromyalgia syndrome

Objectives

The aim of this study was to investigate the role of serum niacin and dopamine (DA) levels and their clinical importance in fibromyalgia syndrome (FMS) patients.

Patients and methods

Between April 2018 and October 2018, a total of 53 female patients (mean age: 38.3±5.5 years; range, 21 to 45 years) with a clinical diagnosis of FMS and 35 healthy female controls (mean age: 36.7±5.2 years; range, 25 to 44 years) were included in this cross-sectional study. The Visual Analog Scale (VAS), Beck Depression Inventory (BDI), and Fibromyalgia Impact Questionnaire (FIQ) were applied to the patients. Serum levels of niacin and DA were measured by high-performance liquid chromatography (HPLC) and enzyme-linked immunosorbent assay (ELISA) methods, respectively.

Results

Niacin and DA levels of the patient group were significantly lower than those of control group (p=0.003 and p=0.02, respectively). A very strong positive correlation was found between niacin and DA levels (r=0.96 p<0.001). Evaluation of the diagnostic performance of niacin and DA by the receiver operating characteristic analysis yielded an area under the curve (AUC) of 0.73 (p<0.001, 95% confidence interval [CI]: 0.62-0.85) and an AUC of 0.68 (p=0.004, 95% CI: 0.56-0.80), respectively.

Conclusion

Serum niacin and DA levels decrease in FMS patients in relation to the tender point numbers. It can be suggested that the levels of these two markers can be considered additional tools in the diagnosis of FMS.

Refractory migraine profile in CGRP-monoclonal antibodies scenario

Objective

Refractory migraine (Ref‐M) represents a conundrum that headache experts have to face with. We aim to investigate whether a peculiar profile may characterize patients with Ref‐M according to 2020 European Headache Federation criteria. Furthermore, to substantiate a dysfunctional dopaminergic pathway involvement in these patients, we explored the effectiveness of olanzapine.

Materials & Methods

Eighty‐four patients (fitting previous Ref‐M criteria of the 2014) were treated with erenumab for six months. Differences between clinical and demographic features of responder (Ref‐M according to 2014 criteria) and not‐responder (Ref‐M according to 2020 criteria) patients to CGRP‐mAbs were investigated and their predictive values assessed. In fifteen patients with Ref‐M not responders to CGRP‐mAbs, olanzapine was administered (5 mg/die) for 3 months and frequency and pain intensity of migraine attacks were estimated.

Results

Patients with Ref‐M not responsive to CGRP‐mAbs (29/84) when compared with Ref‐M responsive to CGRP‐mAbs showed higher baseline frequency of migraine attacks, medication overuse and pain catastrophizing scale (PCS) scores. Logistic regression analyses showed that frequency of attacks, medication overuse and PCS score represent independent negative predictors of CGRP‐mAbs response. A ≥50% reduction of headache days/month was observed after olanzapine treatment in 67% of patients with Ref‐M not responsive to CGRP‐mAbs.

Conclusions

We outline that higher frequency of migraine attacks, medication overuse and pain catastrophizing characterize patients with Ref‐M not responsive to CGRP‐mAbs. In this frame, olanzapine effectiveness on frequency and pain intensity of migraine attacks supports the hypothesis that migraine refractoriness may be subtended by a prominent involvement of the dopaminergic pathway.

Dopaminergic symptoms in migraine: A cross-sectional study on 1148 consecutive headache center-based patients

BACKGROUND

Dopaminergic symptoms may be extremely pronounced in some migraine patients during the attack, representing a major source of disability.

OBJECTIVES

We aimed to carefully characterize the clinical picture of migraine patients with dopaminergic symptoms in a large patients' population as a putative migraine endophenotype, allowing more precise disease management, treatment and outcome prediction.

METHODS

We screened 1148 consecutive tertiary care episodic and chronic migraine patients with face-to-face interviews collecting thorough data on lifestyle, socio-demographic factors, and clinical migraine features.

RESULTS

We identified 374 patients with migraine with dopaminergic symptoms (32.6%). The most frequent dopaminergic symptom was yawning followed by somnolence, nausea, vomiting, fatigue, mood changes and diuresis. Migraine patients with dopaminergic symptoms had longer attack duration (OR: 1.82; 95% CI: 1.41-2.36, p < 0.0001), more frequent osmophobia (OR: 2.01; 95% CI: 1.50-2.69, p < 0.0001), allodynia (OR: 1.43; 95% CI: 1.10-1.85, p = 0.0071) and unilateral cranial autonomic symptoms (OR: 1.31; 95% CI: 1.01-1.68, p = 0.045), but used less preventative treatments (OR: 0.74; 95% CI: 0.57-0.98, p = 0.033) than patients without dopaminergic symptoms.

CONCLUSIONS

Migraine patients with dopaminergic symptoms are characterized by a full-blown, more disabling migraine. Dopaminergic system modulation should be carefully considered in individuals with migraine with dopaminergic symptoms for both acute and preventative treatments in future ad hoc designed studies.

Headache in patients with Tourette syndrome: A systematic literature review

Aim:

To systematically review the available literature on the prevalence and clinical characteristics of headache in patients with Tourette syndrome (TS), a neurodevelopmental condition characterized by the chronic presence of motor and vocal tics.

Design:

We conducted a systematic literature review of original studies using three clinical databases (Medline, EMBASE and PsycInfo), according to the standards outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Outcome measures included both tic severity and tic frequency.

Results:

Our systematic literature review identified six studies on the prevalence and characteristics of headache in patients with TS (data on paediatric patients were available from five studies and data on adult patients from four studies). The proportion of patients with TS who had a diagnosis of headache ranged from 29% to 62%. Migraine was the most commonly investigated headache disorder in this patient population. The findings of the reviewed studies showed that the prevalence of migraine in patients with TS ranges between 13% and 43% and is significantly higher compared to the two control groups ( p < 0.05).

Discussion:

The prevalence of headache in patients with TS could be higher than in the general population, with the most reliable data being available for migraine. Overall, the literature on the prevalence and characteristics of headache in TS is sparse and highly heterogeneous. Further research on the prevalence and clinical correlates of migraine, tension-type headache and other types of headache in patients with TS across the lifespan is needed to inform clinical practice aimed at improving health-related quality of life in patients with tics.

Increased risk of essential tremor in migraine: A population-based retrospective cohort study

Purpose

To examine the long-term risk of essential tremor (ET) in migraine.

Methods

Using population-based administrative data from a subset of the National Health Insurance Research Database (NHIRD) of Taiwan, we identified 22,696 newly diagnosed migraineurs (mean age 44.5 years) and a matched migraine-free cohort of 90,784 individuals in the period 2000–2008. Multivariable Cox proportional hazards regression analysis was conducted for assessing the ET risk for the migraine cohort compared to the migraine-free cohort.

Results

After adjusting for covariates, the migraine cohort had a 1.83-fold increased risk (95% CI 1.50–2.23) of subsequent ET in comparison to the migraine-free cohort (8.97 vs. 4.81 per 10,000 person-years). In the subgroup analysis, patients with migraine were associated with higher risks of ET, regardless of gender, age or the existence of comorbidities.

Conclusion

Our findings demonstrated an association between migraine and ET, suggesting a possible shared pathophysiology underpinning both disorders.

Migraine Headache in Patients with Sydenham's Chorea

We compared the frequency of migraine among Sydenham's chorea (SC) patients, rheumatic fever (RF) patients without neurological symptoms and matched controls. Migraine was more frequent in SC patients (12/55, 21.8%) than in controls (9/110, 8.1%) and as common as in the RF group (10/55, 18.2%). Our data are in agreement with previous studies reporting higher frequency of migraine in other basal ganglia disorders, such as essential tremor and Tourette's syndrome.

Acquired equivalence and related memory processes in migraine without aura

Introduction

Interictal deficits of elementary visuo-cognitive functions are well documented in patients with migraine and are mostly explained in terms of neocortical hyperexcitability. It has been suggested that the basal ganglia and the hippocampi might also be affected in migraine. If so, a deterioration of learning and memory processes related to these structures is expected.

Methods

A visual learning paradigm thought to be capable of dissociating learning/memory processes mediated by the basal ganglia from processes mediated by the hippocampus (the Rutgers Acquired Equivalence Test) was applied to a group of patients with migraine without aura and to age- and sex-matched controls.

Results

Patients with migraine showed a significantly poorer performance in both main phases of the test and the deficit in the phase considered to be dependent on the hippocampi was especially marked.

Conclusions

These results can be interpreted as behavioural support for findings that have suggested the involvement of the basal ganglia and the hippocampi in migraine, but further research is needed to clarify these findings.

Headache and Tremor: Co-occurrences and Possible Associations

BACKGROUND

Tremor and headache are two of the most prevalent neurological conditions. This review addresses possible associations between various types of tremor and headache, and provides a differential diagnosis for patients presenting with both tremor and headache.

METHODS

Data were identified by searching MEDLINE in February 2015, with the terms "tremor" and terms representing the primary headache syndromes.

RESULTS

Evidence for an association between migraine and essential tremor is conflicting. Other primary headaches are not associated with tremor. Conditions that may present with both tremor and headache include cervical dystonia, infectious diseases, hydrocephalus, spontaneous cerebrospinal fluid leaks, space-occupying lesions, and metabolic disease. Furthermore, both can be seen as a side effect of medication and in the use of recreational drugs.

DISCUSSION

No clear association between primary headaches and tremor has been found. Many conditions may feature both headache and tremor, but rarely as core clinical symptoms at presentation.

Midlife migraine and late-life parkinsonism: AGES-Reykjavik study

OBJECTIVE

In the present study, we tested the hypothesis that having migraine in middle age is related to late-life parkinsonism and a related disorder, restless legs syndrome (RLS), also known as Willis-Ekbom disease (WED).

METHODS

The AGES-Reykjavik cohort (born 1907-1935) has been followed since 1967. Headaches were classified based on symptoms assessed in middle age. From 2002 to 2006, 5,764 participants were reexamined to assess symptoms of parkinsonism, diagnosis of Parkinson disease (PD), family history of PD, and RLS/WED.

RESULTS

Subjects with midlife migraine, particularly migraine with aura (MA), were in later life more likely than others to report parkinsonian symptoms (odds ratio [OR]MA = 3.6 [95% CI 2.7-4.8]) and diagnosed PD (ORMA = 2.5 [95% CI 1.2-5.2]). Women with MA were more likely than others to have a parent (ORMA = 2.26 [95% CI 1.3-4.0]) or sibling (ORMA = 1.78 [95% CI 1.1-2.9]) with PD. Late-life RLS/WED was increased for headache generally. Associations were independent of cardiovascular disease and MRI-evident presumed ischemic lesions.

CONCLUSIONS

These findings suggest there may be a common vulnerability to, or consequences of, migraine and multiple indicators of parkinsonism. Additional genetic and longitudinal observational studies are needed to identify candidate pathways that may account for the comorbid constellation of symptoms.

Higher prevalence of migraine in essential tremor: a case-control study

BACKGROUND

The existence of an association between migraine and essential tremor has long been controversial. The prevalence of migraine in essential tremor patients was surveyed to explore the association between the two diseases.

METHODS

A case-control clinical study was conducted to investigate the prevalence of migraine in 150 consecutive essential tremor patients and in 150 matched controls without tremor. Detailed information about essential tremor and migraine was obtained using a structured questionnaire at a face-to-face interview. Moreover, a functional variant of the dopamine receptor D3 gene (Ser9Gly, rs6280) was studied in 46 essential tremor patients with and without migraine using direct sequencing analysis.

RESULTS

The prevalence of lifetime migraine in essential tremor patients was significantly higher than that in controls (22.0% vs. 12.7%; p=0.035; odds ratio=1.95; 95% confidence interval=1.05-3.60). No significant difference was found in the migraine features between the essential tremor and control groups and most tremor characteristics were no different in essential tremor patients with and without migraine. A higher male prevalence of essential tremor patients without migraine was observed. Moreover, 44 of 46 (95.7%) essential tremor patients had the dopamine receptor D3 Ser9Gly variant, but no significant difference was found in the frequencies of the variant between essential tremor patients with and without migraine (87.5% vs. 100.0%; p=0.22).

CONCLUSION

Our data suggest that essential tremor patients have a higher risk of lifetime migraine than do controls and the dopamine receptor D3 Ser9Gly variant may be lower in essential tremor with migraine than the general essential tremor patients.

Dopaminergic symptoms in migraine

Migraine pain is often preceded, accompanied and followed by dopaminergic symptoms (premonitory yawning and somnolence, accompanying nausea and vomiting, postdromal somnolence, euphoria and polyuria). After reviewing evidence from pharmacological, biochemical, genetic and animal experimental studies on the relationship between dopamine and migraine, and matching these data with patients' clinical features, we postulate that migraine attacks could be characterized by an ictal dopamine release in a subject with dopamine receptor hypersensitivity due to a chronic dopaminergic deficit synergistic to serotoninergic impairment. Our review suggests that when the attack begins, a low dopamine plasma concentration stimulates hypersensitive central presynaptic dopamine receptors thus causing prodromal symptoms such as yawning and somnolence. Increasing dopamine levels, though still insufficient to stop trigeminovascular activation, stimulate postsynaptic dopamine receptors thus inducing nausea, vomiting and hypotension. Finally, dopamine levels slowly return to baseline, giving rise to somnolence and fatigue, but, in some cases, continue to rise triggering postdromal symptoms such as euphoria and polyuria.

Comorbidity of Migraine

Migraine is a common neurological disorder and can be severely disabling during attacks. The highest prevalence occurs between the ages of 25 and 55 years. Prior studies have found that migraine occurs together with other illnesses at a greater coincidental rate than is seen in the general population. These occurrences are called "comorbidities". To delineate the comorbidities of migraine is important, because it can help improve treatment strategies and the understanding of the possible pathophysiology of migraine.

The digiti quinti sign in hemiplegic migraine

The digiti quinti sign (DQS), described originally as a clinical indication of subtle motor deficit, consists of a relatively greater abduction of the fifth finger on the affected side when both arms are extended forwards. This sign was previously observed interictally in three consecutive hemiplegic migraine (HM) patients.

PATIENTS AND METHODS

To verify whether the DQS specifically discriminates HM from non-hemiplegic migraine (nHM), the angle between the fourth and fifth fingers (ANG) was measured interictally in 10 HM patients, 44 migraine with aura and migraine without aura patients, and 45 healthy controls.

RESULTS

The ANG was significantly wider at the symptomatic side in HM as compared with nHM and controls. The differences between the symptomatic and non-symptomatic (for HM) or between the right and left sides (absolute values for nHM and controls) were, respectively, 10.10° ± 9.58°, 4.15° ± 3.95° and 5.37° ± 4.74° (p = .007). The optimal cutoff point for ANG was 15° at the symptomatic side (sensitivity and specificity of 80.0% and 72.2%, respectively), 10.5° at the non-symptomatic side (sensitivity and specificity of 60.0% and 52.3%), and 3° for the difference between sides (sensitivity and specificity of 90.0% and 79.5%).

CONCLUSION

Data show that the DQS discriminates HM from nHM and controls.

No association between essential tremor and migraine: a case-control study

Essential tremor (ET) and migraine headache are considered comorbid diseases on the basis of uncontrolled studies. We investigated the frequency of migraine in patients with ET by enrolling 110 patients with ET and 110 age- and sex-matched healthy controls in a case-control study. We found no significant differences in the frequency of lifetime and current migraine between patients and controls, even in patients stratified for age. Tremor had similar clinical features in patients with ET with and without migraine except that females predominated in patients with ET and migraine. Migraine also had similar characteristics in both patients with ET and migraine and in controls with migraine. Our study excludes a comorbid association between ET and migraine. When ET and migraine coexist their clinical phenotype and evolution remain almost unchanged.

Shortened cortical silent period in facial muscles of patients with migraine

Despite intensive neurophysiological research, evidence is lacking to show whether abnormal cortical excitability in migraine reflects a primary cortical disturbance or reduced control by thalamo-cortical loops. One way to contribute to the scientific discussion on this topic is to deliver transcranial magnetic stimulation (TMS) and test the cortical silent period (SP) recorded in facial muscles. The facial-muscle SP is a purely cortical phenomenon that reflects the excitability of inhibitory interneurons, and can disclose changes in cortical inhibition even in patients without documented primary lesions of the motor cortices. To test the interictal excitability of cortical motor inhibitory interneurons in migraine, we investigated the facial-SP in patients with migraine with and without aura between attacks. In 26 patients and 15 age-matched controls, high-intensity magnetic stimuli were delivered with a round coil centered at the vertex during a maximal muscle contraction. Electromyographic responses were recorded from surface electrodes placed over the subjects' perioral muscles. Facial SPs were significantly shorter in patients than in controls. The SP shortening provides neurophysiological evidence showing hypoexcitability of cortical inhibitory neurons in patients with migraine between attacks. Despite a possible primary deficit of cortical inhibitory interneurons in migraine, we favor the interpretation of a secondary disfacilitation by hypoactive thalamo-cortical loops. Based on this interpretation, the interictal reduced cortical inhibition documented by the shortened SP could be considered the motor counterpart of the reduced preactivation excitability level in the sensory cortices purported to explain why cortical evoked responses habituate poorly in patients with migraine.