Relationship between biofeedback and oxidative stress in patients with chronic migraine

SIRT1-regulated ROS generation activates NMDAR2B phosphorylation to promote central sensitization and allodynia in a male chronic migraine rat model

Background

Central sensitization is one of the pivotal pathological mechanisms in chronic migraine (CM). Silent information regulator 1 (SIRT1) was shown to be involved in CM, but its specific mechanism is unclear. Reactive oxygen species (ROS) are increasingly regarded as important signaling molecules in several models of pain. However, studies about the role of ROS in the central sensitization of CM model are rare. We thus explored the specific process of SIRT1 involvement in the central sensitization of CM, focusing on the ROS pathway.

Methods

Inflammatory soup was repeatedly administered to male Sprague-Dawley rats to establish a CM model. The SIRT1 expression level in trigeminal nucleus caudalis (TNC) tissues was assessed by qRT-PCR and Western blotting analysis. The levels of ROS were detected by a Tissue Reactive Oxygen Detection Kit, DHE staining, and the fluorescence signal intensity of 8-OHdG. A ROS scavenger (tempol), a SIRT1 activator (SRT1720), a SIRT1 inhibitor (EX527), and a mitochondrial fission inhibitor (Mdivi-1) were used to investigate the specific molecular mechanisms involved. NMDAR2B, CGRP, ERK, and mitochondrial fission-related protein were evaluated by Western blotting, and the CGRP level in frozen sections of the TNC was detected via immunofluorescence staining.

Results

After repeated inflammatory soup infusion and successful establishment of the CM rat model, SIRT1 expression was found to be significantly reduced, accompanied by elevated ROS levels. Treatment with Tempol, SRT1720, or Mdivi-1 alleviated allodynia and reduced the increase in NMDAR2B phosphorylation and CGRP and ERK phosphorylation in the CM rat. In contrast, EX527 had the opposite effect in CM rat. SRT1720 and EX527 decreased and increased ROS levels, respectively, in CM rats, and tempol reversed the aggravating effect of EX527 in CM rats. Furthermore, the regulatory effect of SIRT1 on ROS may include the involvement of the mitochondrial fission protein DRP1.

Conclusion

The results indicate the importance of SIRT1 in CM may be due to its role in regulating the production of ROS, which are involved in modulating central sensitization in CM. These findings could lead to new ideas for CM treatment with the use of SIRT1 agonists and antioxidants.

Oxidative Stress and Migraine

The pathogenesis of migraine is not completely understood, but inflammation and oxidative stress seem to be involved, according to data from an experimental model of the disease. This narrative review summarizes data from studies on oxidative stress markers in migraine patients, case-control association studies on the possible association of candidate genes related to oxidative stress with the risk for migraine, studies showing the presence of oxidative stress in experimental models of migraine, and studies on the efficacy of antioxidant drugs in migraine therapy. Many studies have addressed the value of concentrations of prooxidant and antioxidant substances or the activity of antioxidant enzymes in different tissues (mainly in serum/plasma or in blood cells) as possible biomarkers for migraine, being thiobarbituric acid (TBA) reactive substances (TBARS) such as malonyl dialdehyde acid (MDA) and 4-hydroxynonenal, and nitric oxide (this at least during migraine attacks in patients with migraine with aura (MWA) the most reliable. In addition, the possible usefulness of antioxidant treatment is not well established, although preliminary short-term studies suggest a beneficial action of some of them such as Coenzyme Q10 and riboflavin. Both topics require further prospective, multicenter studies with a long-term follow-up period involving a large number of migraine patients and controls.

Headaches treatment with EMG biofeedback: a focused systematic review and meta-analysis

INTRODUCTION

The aim of this paper was to present an up-to-date evaluation of the efficacy of EMG-biofeedback (EMG-BFB) for primary headaches and to address possible mediators of outcome.

EVIDENCE ACQUISITION

PubMed, Scopus, Embase and Pedro databases were searched from inception to May 1, 2023. All randomized controlled trials (RCT) studies using an EMG-BFB to treat headache have been included in this systematic review. The current systematic review was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations and was registered in the PROSPERO database (CRD42022312827). Methodological quality was assessed through the Risk of Bias tool 2 (RoB 2). The effect sizes and 95% confidence interval (CI) were calculated by random-effect models on frequency, intensity, and duration variables. Egger regression and the Begg-Mazumdar rank correlation test were used for publication bias.

EVIDENCE SYNTHESIS

A total of 3059 articles were identified through the database searches. 29 articles, involving 1342 participants, met the inclusion criteria for the systematic review; of them, 4 were included in the meta-analysis. Ten studies reported a significant improvement in the EMG-BFB group with respect to the control group. Meta-analyses show a reduction in the intensity of attacks in patients subjected to EMG-BFB (ES 0.21 [(95% CI=-0.02; 0.44), P value=0.07] based on 293 patients).

CONCLUSIONS

EMG-BFB represents a non-pharmacological approach to headache treatment as shown via qualitative synthesis, despite not impressive results, this technique can be particularly useful in paediatric or in adult patients who cannot undergo drug therapies. Quantitative synthesis revealed a promising effect in the intensity of headaches attacks. Moreover, no significant effect was found about the effectiveness of EMG-BFB in the reduction of frequency and durations of headache attacks. Future studies with new multimodal technologic assessment and following RCT guidelines can unmask the potentiality of EMG-BFB in the treatment of headache.

A study of the relationship between serum uric acid levels and pain in patients with migraine

Serum uric acid (SUA), the end product of purine metabolism acts as an antioxidant and is related to oxidative stress. It has been reported that SUA may be involved in the pathogenesis of neurodegenerative diseases including Alzheimer disease, Huntington disease, Parkinson disease, and multiple sclerosis. However, studies evaluating SUA levels in migraine are scarce. This study aimed to explore the relationship between pain characteristics and SUA levels in patients with migraine and compare SUA levels in migraine patients during a headache attack and headache-free period with those control groups. This prospective, cross-sectional study included 78 patients with migraine and 78 healthy subjects who were randomly selected from hospital personnel as the control group. Headache characteristics (duration of attack, pain intensity, and headache frequency) and sociodemographic features were recorded. The SUA level was measured once in the control group and twice in the migraine patients, during the migraine attack and headache-free periods. Although the SUA levels of the migraine group in the headache-free period were higher than those of the control group, the difference was not statistically significant. Gender was not significantly related to the change in SUA levels between the attack and headache-free period. When the correlation between age, duration of migraine, frequency, duration, and intensity of pain was evaluated; the difference between SUA levels in female migraine patients was weakly correlated with headache intensity, whereas male patients had a moderate correlation. ( P < .05; R > 0.250, and R > 0.516, respectively). The difference in SUA level in the migraine attack period compared to the headache-free period showing a positive correlation with pain intensity suggested that SUA may have a role in migraine due to its antioxidant role.

Examining Migraine as a Predictor of Benign Paroxysmal Positional Vertigo Onset, Severity, Recurrence, and Associated Falls

Introduction: The comorbidity of migraine and benign paroxysmal positional vertigo (BPPV) is well-established, yet the impact of migraine on the BPPV phenotype remains understudied.

Methods: A retrospective analysis of patients at a tertiary dizziness/vertigo clinic diagnosed with BPPV from 2015 and 2020 was conducted. The study's primary outcomes were the age of BPPV onset, Dizziness Handicap Index (DHI), BPPV recurrence, and dizziness-related falls.

Results: In our cohort of 255 BPPV patients, 44.7% had a history of migraine. Those with migraine had an earlier age of BPPV onset than individuals without migraine (60.2 vs. 65.4, p = 0.0018). Migraineurs and non-migraineurs did not differ in their DHI (44.7 vs. 41.6, p= 0.44), recurrence rates (48.3% vs. 40.4%, p= 0.21), and falls (32.5% vs. 37.6%, p = 0.39). Among individuals with horizontal canal BPPV, a higher proportion of migraineurs experienced falls than non-migraineurs (50.0% vs. 6.3%, p = 0.02).

Conclusions: Migraineurs experience BPPV at a younger age than those without migraine. This finding suggests that migraine, which has been shown to cause inner ear damage, predisposes individuals to developing BPPV earlier. Migraine was also associated with a higher rate of falls among patients with horizontal canal BPPV, indicating that a migraine history may impact the phenotype of BPPV.

Identification of Determinants of Biofeedback Treatment's Efficacy in Treating Migraine and Oxidative Stress by ARIANNA (ARtificial Intelligent Assistant for Neural Network Analysis)

Migraines are a public health problem that impose severe socioeconomic burdens and causes related disabilities. Among the non-pharmacological therapeutic approaches, behavioral treatments such as biofeedback have proven effective for both adults and children. Oxidative stress is undoubtedly involved in the pathophysiology of migraines. Evidence shows a complex relationship between nitric oxide (NO) and superoxide anions, and their modification could lead to an effective treatment. Conventional analyses may fail in highlighting the complex, nonlinear relationship among factors and outcomes. The aim of the present study was to verify if an artificial neural network (ANN) named ARIANNA could verify if the serum levels of the decomposition products of NO-nitrite and nitrate (NOx)-the superoxide dismutase (SOD) serum levels, and the Migraine Disability Assessment Scores (MIDAS) could constitute prognostic variables predicting biofeedback's efficacy in migraine treatment. Twenty women affected by chronic migraine were enrolled and underwent an EMG-biofeedback treatment. The results show an accuracy for the ANN of 75% in predicting the post-treatment MIDAS score, highlighting a statistically significant correlation (R = -0.675, p = 0.011) between NOx (nitrite and nitrate) and MIDAS only when the peroxide levels in the serum were within a specific range. In conclusion, the ANN was proven to be an innovative methodology for interpreting the complex biological phenomena and biofeedback treatment in migraines.

The efficacy of alpha-lipoic acid in improving oxidative, inflammatory, and mood status in women with episodic migraine in a randomised, double-blind, placebo-controlled clinical trial

AIM

Migraine is a common neurovascular disorder, which is associated with severe to moderate disabling headaches. Oxidative stress and inflammation might play a role in migraine pathogenesis and the mood disorders. Considering the antioxidant and anti-inflammatory properties of alpha-lipoic acid (ALA), this study was designed to investigate its effect on oxidative, inflammatory, and mood conditions in women with episodic migraine.

METHODS

In total, 92 women with episodic migraine participated in the study. The patients were randomly divided into two groups, receiving a 300-mg capsule of ALA or placebo twice daily for 3 months. To assess the oxidative and inflammatory status, the serum levels of total antioxidant capacity (TAC), total oxidant status (TOS), glutathione (GSH), malondialdehyde (MDA), oxidative stress index (OSI), and C-reactive protein (CRP) were determined at the beginning and at the end of the intervention. A depression, anxiety, stress scale (DASS-21-items) questionnaire was used to evaluate mood status.

RESULTS

Finally, 79 patients reached the final analysis stage. At the end of the intervention, a significant decrease in the serum levels of MDA (means difference [MD]: -0.83, 95% confidence intervals (CI): -1.04, -0.62 nmol/mL vs MD: -0.32, CI: -0.48, -0.15 nmol/mL; P < .001) and CRP (MD: -0.78, CI: -1.17, -0.39 mg/L vs MD: -0.63, CI: -1.80, 0.52 mg/L; P < .001) was observed in the ALA as compared with the placebo group, but changes in serum GSH (P = .086), TAC (P = .068), TOS (P = .225), and OSI (P = .404) were not statistically significant. In addition, depression, anxiety, and stress (with P < .001, in all cases) had significantly decreased in the intervention as compared with the control group.

CONCLUSION

The results of this study suggest that ALA supplementation for 3 months has beneficial effects on improving the oxidative, inflammatory, and mood conditions of patients suffering from episodic migraine.

Mitochondrial function and oxidative stress markers in higher-frequency episodic migraine

Increasing evidence points towards the role of mitochondrial functioning, energy metabolism, and oxidative stress in migraine. However not all previous research has been conclusive and some mitochondrial function/oxidative stress markers have not yet been examined. To this end, alpha-lipoic acid (ALA), total thiols, total plasma antioxidant capacity (TAC), lipid peroxide (PerOx), oxidised LDL (oxLDL), HbA1c and lactate were determined in the serum of 32 higher frequency episodic migraineurs (5-14 migraine days/ months, 19 with aura, 28 females) in this cross-sectional study. The majority of patients had abnormally low ALA and lactate levels (87.5% and 78.1%, respectively). 46.9% of the patients had abnormally high PerOx values, while for thiols and TAC over one third of patients had abnormally low values (31.2% and 37.5%, respectively). 21.9% of patients had abnormally low HbA1c and none had an HbA1c level above 5.6%. oxLDL was normal in all but one patient. This study provides further evidence for a role of oxidative stress and altered metabolism in migraine pathophysiology, which might represent a suitable therapeutic target. ALA, being too low in almost 90% of patients, might represent a potential biomarker for migraine. Further research is needed to replicate these results, in particular a comparison with a control group.This study is part of the trial registration: ClinicalTrials.gov: NCT03132233, registered on 27.04.2017, https://clinicaltrials.gov/ct2/show/NCT03132233 .

Poststroke Pain

Pain is common but often underrecognized after stroke. Poststroke pain (PSP) hinders recovery, impairs quality of life, and is associated with the psychological state of patients with stroke. The most common subtypes of PSP include central PSP, complex regional pain syndrome, shoulder pain, spasticity-related pain, and headache. The pathophysiologies of these PSP subtypes are not yet clearly understood, and PSP is refractory to conventional treatment in many patients. However, recent studies have proposed potential pathophysiologies of PSP subtypes, which may help prioritize therapies that target specific mechanisms.

Risk Factors for the Recurrence of Benign Paroxysmal Positional Vertigo: A Systematic Review and Meta-Analysis

OBJECTIVE

Benign paroxysmal positional vertigo (BPPV) has a high recurrence rate, but the risk factor-associated recurrence are elusive.

METHODS

Searches were performed in PubMed, Embase, Cochrane library, Web of science, Chinese National Knowledge Infrastructure, and Sino Med up to November 3, 2019. The effect size was analyzed by odds ratio and 95% CI. Data from eligible studies were meta-analyzed using Stata version 15.0.

RESULTS

Our search resulted in a total of 4076 hits. Twenty-four outcomes of sixty articles were included in the meta-analysis. Risk factors for the recurrence of BPPV included female gender, age (≥65years), hyperlipidemia, diabetes, hypertension, migraine, cervical spondylosis, osteopenia/osteoporosis, head trauma, otitis media, abnormal vestibular evoked myogenic potential, and long use of computers. No significant differences were found in side, type of the involved semicircular canals, smoking, alcohol consumption, stroke, ear surgery, duration of vertigo before treatment, the times of repositioning, Meniere disease, sleep disorders, hypercholesterolemia, and 25-hydroxy vitamin D.

CONCLUSION

These findings strengthen clinical awareness of early warning to identify patients with potential relapse risk of BPPV and clinicians should counsel patients regarding the importance of follow-up after diagnosis of BPPV.

Turbinate Submucosal Reduction Operation Reduced Migraine Admission among Patients with Chronic Hypertrophic Rhinitis

Rhinitis increases migraine risk. Chronic hypertrophic rhinitis can be treated with turbinate submucosal reduction operation. The relationship between migraine and chronic hypertrophic rhinitis after turbinate submucosal reduction operation is still unclear. The goal of this study was to evaluate the correlation between turbinate submucosal reduction operation and subsequent migraine admission in Asian chronic hypertrophic rhinitis patients. We identified patients suffering from chronic hypertrophic rhinitis and receiving turbinate submucosal reduction operation. The control group was selected from patients with chronic hypertrophic rhinitis without operation. The event was migraine admission. The risk factors of migraine admission were established using multivariate Cox proportional hazard regression. The risk of migraine admission after turbinate submucosal reduction operation is represented by a hazard ratio (HR) of 0.858 (95% confidence interval (CI): 0.633–0.962). The higher risk of migraine included depression with HR 4.348 (95% CI: 2.826–6.69), anxiety with HR 3.75 (95% CI: 2.267–6.203), fibromyalgia with HR of 7.326 (95% CI: 3.427–15.661), and asthma with HR 1.969 (95% CI: 1.11–3.491). Our study revealed that turbinate submucosal reduction operation led to a 14.2% reduction in migraine admission. Clinicians should understand the benefit of turbinate submucosal reduction operation and provide suitable treatments for comorbid conditions. Further prospective studies are required to confirm our findings.

Reduction in Migraine and Headache Frequency and Intensity With Combined Antioxidant Prophylaxis (N-acetylcysteine, Vitamin E, and Vitamin C): A Randomized Sham-Controlled Pilot Study

OBJECTIVE

To investigate the preventive effects of a combined antioxidant drug (N-acetylcysteine, vitamin E, and vitamin C [NEC]) on migraine outcomes. Migraine is characterized by increased oxidative stress and neurogenic inflammation in the brain; therefore, antioxidants may have a migraine preventive effect.

DESIGN

Randomized, double-blind, sham-controlled pilot study.

SETTING

Australian community.

SUBJECTS

Adults reporting 2 to 8 migraines per month for at least a year.

METHODS

After a 1-month baseline period, 35 subjects completed 3 months of treatment with NEC (n = 19) or sham (n = 16) capsules. The primary outcome was the difference in mean number of headaches per month between baseline and final month of the trial for NEC and sham groups; secondary outcomes are listed below.

RESULTS

For NEC there was a significant decrease in mean number of headaches by 3.0 per month (P = 0.004) compared with 1.4 for sham (P = 0.073); there was no significant difference in these changes between the 2 groups (P = 0.052). Average monthly headache (P = 0.041) and migraine frequency (P = 0.018) were significantly less for NEC vs. sham. In NEC subjects, there was a significant decrease in average monthly migraine days (-3.1), moderate/severe headache days (-3.2), migraine duration, headache pain scores, and acute headache medication use.

CONCLUSIONS

This is the first randomized controlled trial to find that combined antioxidant therapy with NEC reduces headaches and migraines in adult migraineurs. Given the limitations of this pilot study, an adequately powered randomized controlled trial is planned to further investigate antioxidant prophylaxis in migraine.

Association Between Migraine and Benign Paroxysmal Positional Vertigo Among Adults in South Korea

Importance

Patients with migraine often experience various types of vertigo, and several studies have suggested an epidemiologic and physiologic association of migraine and vertigo with vestibule. However, few researchers have investigated the association between migraine and benign paroxysmal positional vertigo (BPPV).

Objective

To determine the incidence of BPPV in individuals with migraine in a large national population-based sample.

Design, Setting, and Participants

This cohort study obtained data from the Korean Health Insurance Review and Assessment Service covering the period January 1, 2002, through December 31, 2013. These data included personal information, health insurance claim codes, diagnostic codes, death records, socioeconomic data, and medical examination data for each individual in the database. A 1:4 matching method was used to select individuals for the migraine group (n = 40 682) and the control group (n = 162 728). Individuals who had a history of BPPV before the index date, for whom a match could not be identified, and who received a migraine diagnosis before age 20 years were excluded from the analysis. Data analysis was conducted from September 1, 2015, to December 31, 2017.

Main Outcomes and Measures

The crude and adjusted (by age, sex, income, region of residence, and medical history [hypertension, diabetes, or dyslipidemia]) hazard ratios for migraine and BPPV were analyzed using the Cox proportional hazards regression model.

Results

Of the 40 682 individuals in the migraine group, 10 381 (25.5%) were male and 30 301 (74.5%) were female. Of the 162 728 controls, 41 524 (25.5%) were male and 121 204 (74.5%) were female. The incidence of BPPV was statistically significantly higher in the migraine group than in the control group (2431 [6.0%] vs 3677 [2.3%]). Migraine increased the risk of BPPV (adjusted hazard ratio, 2.54; 95% CI, 2.41-2.68). In a subgroup analysis, the incidence of BPPV in all age groups and in both men and women was statistically significantly higher in the migraine group than in the control group. The incidence of BPPV was the highest in men younger than 40 years (adjusted hazard ratio, 4.49; 95% CI, 3.05-6.62), and the HR decreased in both men and women as age increased.

Conclusions and Relevance

Migraine appeared to be statistically significantly associated with higher incidence of BPPV; future studies are needed to determine the association between BPPV and specific factors related to migraine.

Plasma Levels of Oxidative Stress Markers, before and after BoNT/A Treatment, in Chronic Migraine

The pathophysiological mechanisms of migraine transformation are debated. Modifications of plasma oxidative stress biomarkers have been described in chronic migraine. OnabotulintoxinA (BoNT/A) treatment, approved for chronic migraine prophylaxis, possibly reduces pain neurotransmitters release and oxidative stress products. Aims of our study were to investigate differences in the levels of selected plasmatic oxidative stress biomarkers (Advanced Oxidation Protein Products (AOPP), Ferric Reducing Antioxidant Power (FRAP), Thiolic Groups (SH)) comparing chronic migraineurs (CM) and healthy controls (HC). We also explored possible clinical and biochemical modifications in the CM group after six months of treatment with BoNT/A. At the baseline, we found higher values of AOPP (p < 0.001), and lower values of SH (p < 0.001) and FRAP (p = 0.005) in the CM group. At the six-month follow-up we found a reduction of AOPP (p < 0.001) and an increase of FRAP (p < 0.001) and SH (p = 0.023) within the CM group. BoNT/A treatment improved migraine symptoms in the CM group. We confirmed previous reports of imbalanced antioxidant mechanisms in chronic migraine showing lower antioxidant capacities in patients than controls. BoNT/A improved the levels of plasma oxidative stress biomarkers and confirmed its role as an effective prophylactic treatment for CM. Other studies should investigate the potential antioxidant properties of BoNT/A treatment.

The metabolic face of migraine - from pathophysiology to treatment

Migraine can be regarded as a conserved, adaptive response that occurs in genetically predisposed individuals with a mismatch between the brain's energy reserve and workload. Given the high prevalence of migraine, genotypes associated with the condition seem likely to have conferred an evolutionary advantage. Technological advances have enabled the examination of different aspects of cerebral metabolism in patients with migraine, and complementary animal research has highlighted possible metabolic mechanisms in migraine pathophysiology. An increasing amount of evidence - much of it clinical - suggests that migraine is a response to cerebral energy deficiency or oxidative stress levels that exceed antioxidant capacity and that the attack itself helps to restore brain energy homeostasis and reduces harmful oxidative stress levels. Greater understanding of metabolism in migraine offers novel therapeutic opportunities. In this Review, we describe the evidence for abnormalities in energy metabolism and mitochondrial function in migraine, with a focus on clinical data (including neuroimaging, biochemical, genetic and therapeutic studies), and consider the relationship of these abnormalities with the abnormal sensory processing and cerebral hyper-responsivity observed in migraine. We discuss experimental data to consider potential mechanisms by which metabolic abnormalities could generate attacks. Finally, we highlight potential treatments that target cerebral metabolism, such as nutraceuticals, ketone bodies and dietary interventions.

Consensus of the Brazilian Headache Society on the treatment of chronic migraine

Chronic migraine poses a significant personal, social and economic burden and is characterized by headache present on 15 or more days per month for at least three months, with at least eight days of migrainous headache per month. It is frequently associated with analgesic or acute migraine medication overuse and this should not be overlooked. The present consensus was elaborated upon by a group of members of the Brazilian Headache Society in order to describe current evidence and to provide recommendations related to chronic migraine pharmacological and nonpharmacological treatment. Withdrawal strategies in medication overuse headache are also described, as well as treatment risks during pregnancy and breastfeeding. Oral topiramate and onabotulinum toxin A injections are the only treatments granted Class A recommendation, while valproate, gabapentin, and tizanidine received Class B recommendation, along with acupuncture, biofeedback, and mindfulness. The anti-CGRP or anti-CGRPr monoclonal antibodies, still unavailable in Brazil, are promising new drugs already approved elsewhere for migraine prophylactic treatment, the efficacy of which in chronic migraine is still to be definitively proven.

Potential Protective Mechanisms of Ketone Bodies in Migraine Prevention

An increasing amount of evidence suggests that migraines are a response to a cerebral energy deficiency or oxidative stress levels that exceed antioxidant capacity. The ketogenic diet (KD), a diet mimicking fasting that leads to the elevation of ketone bodies (KBs), is a therapeutic intervention targeting cerebral metabolism that has recently shown great promise in the prevention of migraines. KBs are an alternative fuel source for the brain, and are thus likely able to circumvent some of the abnormalities in glucose metabolism and transport found in migraines. Recent research has shown that KBs-D-β-hydroxybutyrate in particular-are more than metabolites. As signalling molecules, they have the potential to positively influence other pathways commonly believed to be part of migraine pathophysiology, namely: mitochondrial functioning, oxidative stress, cerebral excitability, inflammation and the gut microbiome. This review will describe the mechanisms by which the presence of KBs, D-BHB in particular, could influence those migraine pathophysiological mechanisms. To this end, common abnormalities in migraines are summarised with a particular focus on clinical data, including phenotypic, biochemical, genetic and therapeutic studies. Experimental animal data will be discussed to elaborate on the potential therapeutic mechanisms of elevated KBs in migraine pathophysiology, with a particular focus on the actions of D-BHB. In complex diseases such as migraines, a therapy that can target multiple possible pathogenic pathways seems advantageous. Further research is needed to establish whether the absence/restriction of dietary carbohydrates, the presence of KBs, or both, are of primary importance for the migraine protective effects of the KD.

A study of oxidative stress in migraine with special reference to prophylactic therapy

OBJECTIVE

The role of oxidative stress markers in migraine and effect of treatment on these has been reported.

SUBJECTS AND METHODS

One hundred and fifty patients having > four attacks of migraine headache/month were included. Headache severity, Migraine Index (MI) and frequency of headache were noted. 120 patients received repetitive transcranial magnetic stimulation (rTMS) therapy and 30 patients received Amitriptyline (AMT). Recovery was defined by 50% improvement in frequency, severity or reduction in MI. Oxidative stress and antioxidant markers have been estimated in patients before and after treatment and correlate the clinical and outcome parameters.

RESULTS

Glutathione (GSH) (P < 0.001), glutathione-S-transferase (GST) (P = 0.049) and total antioxidant activity (TAC) (P < 0.001) level were significantly reduced in migraine patients. GSH (P = 0.02), GST (P = 0.05) and TAC (P < 0.001) were reduced in ictal migraineurs compared to controls. GSH (P < 0.001) and TAC (P = 0.003) levels increased after treatment compared to the base line. There is an increase in GSH levels in the patients who had improved following rTMS (P = 0.003); placebo (P = 0.001) and AMT (P = 0.013). TAC levels were also increased following rTMS (P = 0.009) and AMT (P = 0.020).

CONCLUSION

There is evidence of oxidative stress in migraine pathophysiology. Following treatment, oxidative stress declined following both pharmacological and rTMS.

Recombinant protein transduction domain-Cu/Zn superoxide dismutase alleviates bone cancer pain via peroxiredoxin 4 modulation and antioxidation

Bone cancer pain (BCP) is a serious chronic clinical condition and reactive oxygen species (ROS) were considered to be involved in its development and persistency. Normally, superoxide dismutase (SOD) converts superoxide anions to hydrogen peroxide (H₂O₂) and H₂O₂ is then naturalized to be water by peroxiredoxin 4. We reported previously that recombinant protein transduction domain (PTD)-Cu/Zn SOD effectively scavenged excessive ROS and prevented cardiomyocytes from hypoxia-reoxygenation damage. However, whether PTD-Cu/Zn SOD would prevent BCP development is unknown. In the current study, we found that an implanted carcinoma in the rat tibia induced remarkable hyperalgesia, increased H₂O₂ levels and decreased SOD and peroxiredoxin 4 levels. After administration of recombinant PTD-Cu/Zn SOD to these tumor-burden rats, their hyperalgesia was significantly attenuated and peroxiredoxin 4 expression was significantly increased. In addition, an increased expression of N-methyl-d-aspartic acid (NMDA) receptors and a decreased expression of γ-aminobutyric acid (GABA) receptors in this cancer pain were prevented by PTD-Cu/Zn SOD administration or peroxiredoxin 4 overexpression. Our data suggested that reactive oxygen species, at least in part, play a role in cancer metastatic pain development and persistency which can be attenuated by the adminstration of recombinant PTD-Cu/Zn SOD via the peroxiredoxin 4 modulation from oxidative stress.

Migraine Triggers and Oxidative Stress: A Narrative Review and Synthesis

BACKGROUND

Blau theorized that migraine triggers are exposures that in higher amounts would damage the brain. The recent discovery that the TRPA1 ion channel transduces oxidative stress and triggers neurogenic inflammation suggests that oxidative stress may be the common denominator underlying migraine triggers.

OBJECTIVE

The aim of this review is to present and discuss the available literature on the capacity of common migraine triggers to generate oxidative stress in the brain.

METHODS

A Medline search was conducted crossing the terms "oxidative stress" and "brain" with "alcohol," "dehydration," "water deprivation," "monosodium glutamate," "aspartame," "tyramine," "phenylethylamine," "dietary nitrates," "nitrosamines," "noise," "weather," "air pollutants," "hypoglycemia," "hypoxia," "infection," "estrogen," "circadian," "sleep deprivation," "information processing," "psychosocial stress," or "nitroglycerin and tolerance." "Flavonoids" was crossed with "prooxidant." The reference lists of the resulting articles were examined for further relevant studies. The focus was on empirical studies, in vitro and of animals, of individual triggers, indicating whether and/or by what mechanism they can generate oxidative stress.

RESULTS

In all cases except pericranial pain, common migraine triggers are capable of generating oxidative stress. Depending on the trigger, mechanisms include a high rate of energy production by the mitochondria, toxicity or altered membrane properties of the mitochondria, calcium overload and excitotoxicity, neuroinflammation and activation of microglia, and activation of neuronal nicotinamide adenine dinucleotide phosphate (NADPH) oxidase. For some triggers, oxidants also arise as a byproduct of monoamine oxidase or cytochrome P450 processing, or from uncoupling of nitric oxide synthase.

CONCLUSIONS

Oxidative stress is a plausible unifying principle behind the types of migraine triggers encountered in clinical practice. The possible implications for prevention and for understanding the nature of the migraine attack are discussed.

Evidences of Reduced Antioxidant Activity in Patients With Chronic Migraine and Medication-Overuse Headache

BACKGROUND

Migraine is a complex multifactorial, neurobiological disorder, whose pathogenesis is not fully understood, nor are the mechanisms associated with migraine transformation from episodic to chronic pattern. A possible role of impaired oxidative mitochondrial metabolism in migraine pathogenesis has been hypothesized, and increased levels of peripheral markers of oxidative stress have been reported in migraine patients, although the literature data are limited and heterogeneous.

OBJECTIVES

The aim of this cross-sectional study was to determine plasmatic levels of advanced oxidation protein products, ferric-reducing antioxidant power and total plasmatic thiol groups, all plasmatic markers related to oxidative stress, in a sample of chronic migraine patients and medication-overuse headache, compared to a control group of healthy subjects.

METHODS

Thirty-three patients with a diagnosis of both chronic migraine and medication-overuse headache (International Classification of Headache Disorders,3rd edition, beta version) and 33 healthy, headache-free subjects were enrolled. Patients with comorbid/coexisting conditions were excluded, as well as patients in treatment with migraine preventive drugs. Plasmatic levels of advanced oxidation protein products, ferric-reducing antioxidant power, and total thiol groups were determined in migraine patients and controls; moreover, oxidative stress biomarkers were compared in migraine patients with triptan compared to non-steroidal anti-inflammatory drug overuse.

RESULTS

The statistical analysis showed significantly lower levels of ferric-reducing antioxidant power and total plasmatic thiol groups, both expression of antioxidant power, in patients with chronic migraine and medication-overuse headache compared to controls (respectively, ferric antioxidant power median [interquartile range] 0.53 [0.22] vs 0.82 [0.11] mmol/L, P < .001; total thiol groups 0.25 [0.08] vs 0.51 [0.11] μmol/L, P < .001). Moreover, no statistically significant differences in oxidative stress biomarkers were detected between patients with triptan and nonsteroidal anti-inflammatory drug overuse.

CONCLUSIONS

The data from the present study suggest that antioxidant capacity is lower in chronic migraine patients and medication-overuse headache compared to healthy headache-free subjects, with no differences between patients with triptan or nonsteroidal anti-inflammatory drug overuse. Further investigation is certainly necessary in order to define the causal or consequential role of an imbalance between pro-oxidants and antioxidant defenses in migraine pathogenesis and "chronification" and the possible therapeutic implications in clinical practice.

Lack of association between oxidative stress-related gene polymorphisms and chronic migraine in an Italian population

Migraine patients present increased risks of vascular diseases such as high blood pressure, insulin resistance, metabolic syndrome, stroke and coronary heart disease. Oxidative stress (OS) is increasingly being studied in relation to the pathophysiology of migraine, stimulated by the described association with the most frequent migraine comorbidities. Because many of the gene-encoded players of the OS balance are characterized by functional polymorphisms, it is supposed that the individual genomic profile could affect susceptibility to OS and to related pathophysiological conditions. This study aimed to characterize a panel of 10 polymorphisms in 8 OS-related genes in a chronic migraine (CM) population and healthy controls, to recognize a genetic risk in the process of migraine chronification. The sample consisted of 45 healthy women and 96 women diagnosed with CM. No deviations from the Hardy-Weinberg equilibrium were detected, or in the overall population, or in the CM group or in the control group.

A meta-analysis of biomarkers related to oxidative stress and nitric oxide pathway in migraine

Background

Oxidative and nitrosative stress are considered key events in the still unclear pathophysiology of migraine.

Methods

Studies comparing the level of biomarkers related to nitric oxide (NO) pathway/oxidative stress in the blood/urine of migraineurs vs. unaffected controls were extracted from the PubMed database. Summary estimates of mean ratios (MR) were carried out whenever a minimum of three papers were available. Nineteen studies were included in the meta-analyses, accounting for more than 1000 patients and controls, and compared with existing literature.

Results

Most studies measuring superoxide dismutase (SOD) showed lower activity in cases, although the meta-analysis in erythrocytes gave null results. On the contrary, plasma levels of thiobarbituric acid reactive substances (TBARS), an aspecific biomarker of oxidative damage, showed a meta-MR of 2.20 (95% CI: 1.65–2.93). As for NOs, no significant results were found in plasma, serum and urine. However, higher levels were shown during attacks, in patients with aura, and an effect of diet was found. The analysis of glutathione precursor homocysteine and asymmetric dimethylarginine (ADMA), an NO synthase inhibitor, gave inconclusive results.

Conclusions

The role of the oxidative pathway in migraine is still uncertain. Interesting evidence emerged for TBARS and SOD, and concerning the possible role of diet in the control of NOx levels.

Complementary and alternative treatments in sports medicine

Many patients suffering from pain and dysfunction attributable to musculoskeletal conditions will use some form of complementary and alternative medicine (CAM). Unfortunately, there is a paucity of both the quantity and quality of CAM treatments for specific musculoskeletal conditions. Many CAM treatments are used for a variety of musculoskeletal conditions, but may be more commonly used for specific conditions. This article addresses the use of CAM for specific musculoskeletal conditions, followed by a review of other CAM treatments and their potential indications for a multitude of conditions, based on the current medical literature and traditional use.

Oxidative stress is not involved in motion sickness in mice

AIMS

Some indirect evidences indicate a possible correlation between oxidative stress and motion sickness. The aim of this research was to investigate whether oxidative stress contributing to motion sickness in mice or not.

METHODS

We examined the mRNA levels of peroxiredoxin 6 (PRDX6), catalase, and enzyme superoxide dismutase 1 (SOD1); reactive oxygen species (ROS); and total antioxidant capacity and SOD activity in different brain regions after rotary stimulation. Mice motion sickness index was recorded after rotation when pretreated with paraquat, vitamin C, or vitamin E.

RESULTS

The ROS level and antioxidant capacity were both increased in cerebellum plus brainstem (CB) after rotation, a critical region determines motion sickness. However, manipulation of oxidants or antioxidants using pharmacological method in vivo had no influence on motion sickness index in mice.

CONCLUSION

Oxidative stress is not involved in the development of motion sickness in mice.

Increased vulnerability to oxidative stress in pediatric migraine patients

Little is known about the role of oxidative stress in the pathogenesis of pediatric migraine. The objective of the present study was to investigate, during a headache-free period, the activities of erythrocyte antioxidant enzymes in children and adolescents diagnosed with migraine. In all, 47 migraine patients (age range, 8-17 years; mean, 14.1 +/- 2.4 years, 14 with aura) and 35 control subjects were included. Superoxide dismutase, glutathione peroxidase, and catalase activities were measured in erythrocytes. Although superoxide dismutase activities did not differ between groups, both catalase and glutathione peroxidase activities were significantly lower in migraine patients (P = 0.001 and P = 0.009, respectively). Activities of all three antioxidant enzymes were similar across migraine subgroups; there was no correlation with age and sex. These results confirm vulnerability to oxidative stress in pediatric migraine. Further studies and search for new therapeutic agents with antioxidant properties are needed.

Cerebral blood flow regulation by nitric oxide in neurological disorders

There has been a rapid increase in the amount of information on the physiological and pathophysiological roles of nitric oxide (NO) in the brain. This molecule, which is formed by the constitutive isoforms of NO synthase, endothelial (eNOS) and neuronal (nNOS), plays an obligatory role in the regulation of cerebral blood flow and cell viability and in the protection of nerve cells or fibres against pathogenic factors associated with Alzheimer's disease, Huntington's disease, seizures, and migraine. Cerebral blood flow is impaired by decreased formation of NO from endothelial cells, autonomic nitrergic nerves, or brain neurons and also by increased production of reactive oxygen species (ROS). The NO-ROS interaction is an important topic in discussing blood flow and cell viability in the brain. Excessive production of NO by inducible NOS (iNOS) and nNOS in the brain participates in neurotoxicity. Recent studies on brain circulation have provided useful information about the involvement of impaired NO availability or uncontrolled NO production in cerebral pathogenesis, including Alzheimer's disease, seizures, vascular headaches, and inflammatory disorders. Insight into the role of NO in the brain will contribute to our better understanding of cerebral hemodynamic dysfunction and will aid in developing novel therapeutic measures in diseases of the central nervous system.

Comparison of oxidative stress among migraineurs, tension-type headache subjects, and a control group

BACKGROUND

A primary headache, particularly migraine, is associated with oxidative stress during the attack. However, data regarding the interictal state in migraineurs and in those with tension-type headache (TTH) is limited.

OBJECTIVES

(1) To assess the oxidative stress in migraineurs and TTH subjects in between the episodes and (2) to see if there is a difference in the degree of oxidative stress in the different subtypes of migraine and TTH.

MATERIALS AND METHODS

Fifty migraineurs, 50 patients with TTH, and 50 control subjects were included in this study after screening for the exclusion criteria. Diagnosis of headache was made according to the International Classification of Headache Disorders (ICHD)-2 criteria. A venous blood sample was collected from the antecubital vein at least 3 days after the last attack of headache. The sample was centrifuged immediately and the plasma was stored at -70 degrees C. The ferric reducing activity of plasma (FRAP) and the malondialdehyde (MDA) levels were assessed using colorimetric methods. Statistical analysis was done with the help of SPSS for Windows, v 11.0. One way ANOVA with post hoc Tukey test, independent sample t test, univariate regression, and multivariate regression analysis were done as indicated.

RESULTS

Migraineurs had higher values of MDA and FRAP than the subjects in the other two groups (P<0.001). No difference was observed between the TTH group and the control group. FRAP levels were significantly higher in subjects who had mixed migraine (migraine with aura and without aura) as compared to those with only migraine without aura (mean difference 196.1; 95% CI = 27.3 to 364.9; P = 0.01). Similarly, oxidative stress was significantly higher in patients with episodic TTH as compared to those with chronic TTH (FRAP t = 3.16; P = 0.003 and MDA t = 2.75; P = 0.008).

CONCLUSIONS

This study suggests that oxidative stress continues even between headache episodes in migraineurs but not in those with TTH. This could probably be consequent to the different pathophysiological mechanisms of TTH and migraine.

Inflammatory and oxidative and nitrosative stress pathways underpinning chronic fatigue, somatization and psychosomatic symptoms

PURPOSE OF REVIEW

The aim of this paper is to review recent findings on inflammatory and oxidative and nitrosative stress (IO&NS) pathways in chronic fatigue and somatization disorder.

RECENT FINDINGS

Activation of IO&NS pathways is the key phenomenon underpinning chronic fatigue syndrome (CFS): intracellular inflammation, with an increased production of nuclear factor kappa beta (NFkappabeta), cyclo-oxygenase-2 (COX-2) and inducible NO synthase (iNOS); and damage caused by O&NS to membrane fatty acids and functional proteins. These IO&NS pathways are induced by a number of trigger factors, for example psychological stress, strenuous exercise, viral infections and an increased translocation of LPS from gram-bacteria (leaky gut). The 'psychosomatic' symptoms experienced by CFS patients are caused by intracellular inflammation (aches and pain, muscular tension, fatigue, irritability, sadness, and the subjective feeling of infection); damage caused by O&NS (aches and pain, muscular tension and fatigue); and gut-derived inflammation (complaints of irritable bowel). Inflammatory pathways (monocytic activation) are also detected in somatizing disorder.

SUMMARY

'Functional' symptoms, as occurring in CFS and somatization, have a genuine organic cause, that is activation of peripheral and central IO&NS pathways and gut-derived inflammation. The development of new drugs, aimed at treating those disorders, should target these IO&NS pathways.