Review of comorbidities and risk factors for the development of migraine complications (infarct and chronic migraine)

Evaluation of Cardiovascular Outcomes in Adult Patients With Episodic or Chronic Migraine Treated With Galcanezumab: Data From Three Phase 3, Randomized, Double-Blind, Placebo-Controlled EVOLVE-1, EVOLVE-2, and REGAIN Studies

OBJECTIVE

Blood pressure (BP), pulse, electrocardiogram (ECG), and clinical cardiovascular (CV) outcomes in patients with episodic or chronic migraine treated for up to 6 months with galcanezumab compared to placebo were evaluated.

BACKGROUND

Calcitonin gene-related peptide, a potent microvascular vasodilator, has a hypothesized protective role in CV health. Increased CV risks have been reported in patients with migraine.

METHODS

In 2 similarly designed episodic migraine 6-month studies and 1 chronic migraine 3-month study, data from patients randomized (1:1:2) to subcutaneous injection of galcanezumab 120 mg/month (following initial 240 mg loading dose) or 240 mg/month or placebo were pooled. Treatment comparisons for cardiovascular treatment-emergent adverse events (CV TEAE) and categorical and mean changes in BP, pulse, and ECG were evaluated using the Cochran-Mantel-Haenszel test. Mean changes from baseline in BP, pulse, and ECG were evaluated using the analysis of covariance model.

RESULTS

Overall, among galcanezumab 120 mg (n = 705) and 240 mg (n = 730), and placebo (n = 1451) groups, the percentage of patients reporting ≥1 CV TEAE was low and was similar between the galcanezumab 120 mg (2.6%; odds ratio [OR] = 0.9; 95% confidence interval [CI]: 0.5,1.5) and galcanezumab 240 mg (3.3%; OR = 1.1; 95% CI: 0.7,1.9), and placebo (2.9%) groups. The frequency of any individual CV TEAE, broad or narrow term, was ≤1.4%. The CV-related serious adverse events that occurred in the galcanezumab 240 mg group (n = 3; acute myocardial infarction, pulmonary embolism, and transient ischemic attack) and placebo group (n = 3; pulmonary embolism, deep vein thrombosis, and myocardial infarction) were not considered treatment related. Four placebo- and 1 galcanezumab-treated patient discontinued due to a CV TEAE. Least squares mean and categorical changes from baseline in BP, pulse, and QT interval corrected using Fridericia's correction were similar across treatment groups.

CONCLUSIONS

In this 6-month treatment trial, the percentages of galcanezumab- and placebo-treated patients that reported CV TEAEs or serious adverse events were low and similar between groups with few discontinuations. Thus, no clinically meaningful treatment group differences were observed for changes in BP, pulse, or ECG parameters. Additional longer-term studies in a broader and larger cohort are required to better characterize CV safety.

Bariatric Surgery Promising in Migraine Control: a Controlled Trial on Weight Loss and Its Effect on Migraine Headache

INTRODUCTION

There is evidence that substantial weight loss through bariatric surgery (BS) may result in short-term improvement of migraine severity. However, it still remains to be seen whether smaller amounts of weight loss have a similar effect on migraine headache. This study has been designed to compare the effects of weight reduction through BS and non-surgical modifications.

MATERIALS AND METHODS

Migraine characteristics were assessed at 1 month before (T0), 1 month (T1), and 6 months (T2) after BS (vertical sleeve gastrectomy (VSG) (n = 25) or behavioral therapy (BT) (n = 26) in obese women (aged 18-60 years) with migraine headache. Migraine was diagnosed using the International Classification of Headache Disorders (ICHDIIβ) criteria.

RESULTS

There was significant reduction in the visual analog scale (VAS) from the baseline to T1 and T2 in both groups. The number of migraine-free days showed a significant increase within each group (p < 0.001). The BS group had a significant reduction in attack duration (p < 0.001) while there were no changes observed within the BT group. Following the adjustment of ANCOVA models for baseline values of migraine characteristics, age, changes in weight, BMI, body fat, and fat-free mass from T0 to T2, the BS group showed statistically significant lower VAS and duration of migraine attacks and a significantly higher number of migraine-free days than the BT group at T1 and T2 (p ≤ 0.028).

CONCLUSION

Our results indicated that far before significant weight reduction after BS (VSG), there was marked alleviation in the severity and duration of migraine and a significant increase in the number of migraine-free days in obese female migraineurs. However, the effects in the BT group were not comparable with the effects in the BS group.

Responsivity of Periaqueductal Gray Connectivity Is Related to Headache Frequency in Episodic Migraine

Migraineurs show hypersensitivity to sensory stimuli at various stages throughout the migraine cycle. A number of putative processes have been implicated including a dysfunction in the descending pain modulatory system in which the periaqueductal gray (PAG) is considered to play a crucial role. Recurring migraine attacks could progressively perturb this system, lowering the threshold for future attacks, and contribute to disease chronification. Here, we investigated PAG connectivity with other brain regions during a noxious thermal stimulus to determine changes in migraineurs, and associations with migraine frequency. 21 episodic migraine patients and 22 matched controls were included in the study. During functional MRI, a thermode was placed on the subjects' temple delivering noxious and non-noxious heat stimuli. A psychophysiological interaction (PPI) analysis was carried out to examine pain-induced connectivity of the PAG with other brain regions. The PPI analysis showed increased PAG connectivity with the S1 face representation area and the supplementary motor area, an area involved with pain expectancy, in patients with higher frequency of migraine attacks. PAG connectivity with regions involved with the descending pain modulatory system (i.e., prefrontal cortex) was decreased in the migraineurs versus healthy individuals. Our results suggest that high frequency migraineurs may have diminished resistance to cephalic pain and a less efficient inhibitory pain modulatory response to external stressor (i.e., noxious heat). The findings support the notion that in migraine there is less effective pain modulation (viz., decreased pain inhibition or increased pain facilitation), potentially contributing to increased occurrence of attacks/chronification of migraine.

The Rorschach Test Evaluation in Chronic Childhood Migraine: A Preliminary Multicenter Case-Control Study

OBJECT

About 1.2-3.2% of children at 7 years of age with increasing age up to 4-19% in adolescents are suffering from migraine without aura (MwA). The aim of the present study is investigating the personality style associated with children and adolescents affected by MwA, administrating the Rorschach test, and comparing with typical developing healthy controls (TD).

METHODS

137 patients (74 males), aged 7.3-17.4 years (mean age 11.4, SD 3.02 years), affected by MwA according to the IHs-3 criteria. The Rorschach variables were treated as numerical variables and statistically tested with t-Student's analysis.

RESULTS

No statistical differences were found between the MwA and TD for age (p = 0.55), and gender (p = 0.804). From the comparison between the two samples, MwA group shows lower W responses (p < 0.001), good quality W responses (p < 0.001), high frequency of detailed responses (p < 0.001), the presence of even minor form of good quality responses (p < 0.001), increased presence of animals answers (A%) (p < 0.001), more frequent trivial answers (Ban%) (p < 0.001).

DISCUSSION

Rorschach interpretation pinpointed many interesting and, perhaps, peculiar aspects in our MwA population such as a trend predisposition for: analytical reasoning rather than synthetic, ease/practicality rather than creativity, oppositionality rather than external adaptation to the environment that may be interpreted as effect of general maladaptivity.

[Strategies on the improvement of chronic migraine treatment efficacy]

OBJECTIVE

To determine the efficacy of type A botulinum toxin (lantox) in the treatment of chronic migraine.

MATERIAL AND METHODS

Authors examined 22 patients with chronic migraine at baseline and 4 and 12 weeks after the introduction of 150 U of lantox in head and cervical muscles using "follow the pain method". The drug was introduced into the following muscles: m. corrugator, m. procerus, m. frontalis, m. temporalis and m. оccipitalis. Clinical/neurological examinations, a study of the emotional sphere (anxiety and depression), daily activities, quality-of-life, patient's completion of questionnaires on the subjective satisfaction with treatment were carried out.

RESULTS AND CONCLUSION

There was a significant positive effect of treatment on the frequency of headache attacks that was important for reverse transformation of chronic pain to episodic headache. Barriers in compliance may be overcome by solving psychological problems, in particular, overcoming depression. The prescription of the drug with no side-effects and fast results allows to support the adherence of the patient to treatment.

Migraine: maladaptive brain responses to stress

Migraine offers a unique model to understand the consequences of repeated stressors on the brain. Repeated stressors can alter the normal response of physiological systems, and this concept has been termed "allostatic load." In the case of the brain, the effects of repeated stress may lead to alteration in brain networks both functionally and structurally. As a result, the brain responds abnormally to environmental conditions (psychological or physiological). Here, we present an alternative perspective on migraine disease and propose that changes in brain states may occur as a result of repeated migraine attacks through maladaptive coping mechanisms. The cascade of these effects can lead to further deterioration of adaptation and thus lead to transformation or chronification of the disease.

Trauma exposure versus posttraumatic stress disorder: relative associations with migraine

BACKGROUND

Recent research has uncovered associations between migraine and experiencing traumatic events, the latter of which in some cases eventuates in the development of posttraumatic stress disorder (PTSD). However, existing studies have not attempted to explore the relative associations with migraine between experiencing trauma and suffering from PTSD.

OBJECTIVES

The aim of this cross-sectional study was to assess the predictive utility of trauma exposure vs PTSD in predicting migraine status and headache frequency, severity, and disability.

METHODS

One thousand fifty-one young adults (mean age = 18.9 years [SD = 1.4]; 63.1% female; 20.6% non-Caucasian) without secondary causes of headache provided data from measures of headache symptomatology and disability, trauma and PTSD symptomatology, and depression and anxiety. Three hundred met diagnostic criteria for migraine and were compared on trauma exposure and PTSD prevalence with 751 participants without migraine.

RESULTS

Seven hundred twenty-eight participants (69.3%) reported experiencing at least 1 traumatic event consistent with Criterion A for PTSD, of whom 184 also met diagnostic criteria for PTSD. Migraineurs were almost twice as likely as controls to meet criteria for PTSD (25.7% vs 14.2%, P < .0001) and reported a higher number of traumatic event types that happened to them personally (3.0 vs 2.4, P < .0001). However, experiencing a Criterion A event only was not a significant predictor of migraine either alone (odds ratio [OR] = 1.17, P = nonsignificant) or after adjustment for covariates. By comparison, the OR of migraine for those with a PTSD diagnosis (vs no Criterion A event) was 2.30 (P < .0001), which remained significant after controlling for relevant covariates (OR = 1.75, P = .009). When using continuous variables of trauma and PTSD symptomatology, PTSD was again most strongly associated with migraine. Numerous sensitivity analyses confirmed these findings. PTSD symptomatology, but not the number of traumas, was modestly but significantly associated with headache frequency, severity, and disability in univariate analyses.

CONCLUSIONS

Consistently across analyses, PTSD was a robust predictor of migraine, whereas trauma exposure alone was not. These data support the notion that it is not exposure to trauma itself that is principally associated with migraine, but rather the development and severity of PTSD symptoms resulting from such exposure.

White matter lesions progression in migraine with aura: a clinical and MRI longitudinal study

OBJECTIVE

To prospectively evaluate longitudinal changes in white matter lesions (WMLs) in migraineurs with aura, by magnetic resonance imaging (MRI), and to correlate WMLs modifications with patients' clinical characteristics.

METHODS

Forty-one consecutive migraineurs with aura were followed for a mean time of 33.2 months. Patients underwent MRI at baseline and follow-up and were evaluated for cerebrovascular risk factors. Presence of WMLs on MRI was assessed by two neuroradiologists.

RESULTS

WMLs were present in 26 subjects (63.4%) at baseline MRI. At follow-up a total of 8 patients had new WMLs (19.5%). There was a significant correlation between aura duration and number of new WMLs, and between the number of migraine attacks with aura and new WMLs.

CONCLUSIONS

Our study demonstrates that in migraine with aura WMLs number can progress over time and suggests an association between aura features and WMLs progression. Studies with a higher number of patients are required to confirm these findings.

Polymorphism of the Glutamate Transporter Protein EAAT2 and Migraine Transformation into Chronic Daily Headache

Background and Purpose

The progression of migraine into chronic daily headache involves multiple risk factors, but the main contributor is not known. Glutamate is the major excitatory neurotransmitter in central sensitization, which is an important process in the pathogenesis of migraine transformation. The glutamate transporter protein excitatory amino acid transporter 2 (EAAT2) is the primary modulator of glutamatergic neurotransmission, and genetic polymorphisms of its gene, EEAT2, have been identified. The aim of this study was to determine the effect of EAAT2 polymorphisms on migraine transformation into chronic daily headache.

Methods

We included 74 migraine patients with episodic attack (M-E) and 59 migraine patients with chronic daily headache (M-CDH). After amplifying EAAT2 by polymerase chain reaction, we assessed its genotype frequencies based on restriction fragment length polymorphisms. We reclassified all migraine patients into two groups according to their EAAT2 genotype, either with the A allele (n=62) or without it (n=71), and compared the clinical variables between the two groups.

Results

The genotype frequencies of EAAT2 polymorphisms did not differ between the M-E and M-CDH groups. Comparison between EEAT2 genotypes revealed that the frequency of analgesic usage was significantly higher among migraine patients with the A allele (12.9±1.6 days/month) than in those without the A allele (8.1±1.2 days/month; p=0.019). The other clinical variables of migraine did not differ between the two groups.

Conclusions

The results suggest that EEAT2 polymorphism contributes to the tendency toward frequent analgesic usage in migraine patients. This implies a potential genetic influence on the progression of migraine into chronic daily headache through the development of medication-overuse headache.