Urinary 6-sulphatoxymelatonin levels are depressed in chronic migraine and several comorbidities

Sleep Symptoms in Migraine

PURPOSE OF REVIEW

To review replicated and highlight novel studies of sleep in children and adults with episodic and chronic migraine.

RECENT FINDINGS

Attack-related sleep symptoms are most common in the prodrome and may represent early activation of the hypothalamus rather than migraine triggers. Interictally, patients with migraine report poor sleep quality and high rates of insomnia symptoms. Cognitive behavioral therapy for insomnia in adults and adolescents with chronic migraine and comorbid insomnia results in significant improvement on their headache burden. Thus far, objective studies report that migraine per se is a not associated with sleep apnea. At the present time, there is minimal evidence that migraine is under circadian influence. The current body of evidence suggests that the insomnia symptoms and poor sleep quality commonly reported by patients with migraine are not attack-related but occur interictally and are a marker of worsening disease. The development of clinical guidelines to approach sleep symptoms and expansion of CBT-I trials in those with episodic migraine would be clinically valuable.

Involvement of Plasma Melatonin in Medication-Overuse Headache: A Cross-Sectional Study

OBJECTIVES

Patients with medication-overuse headache (MOH) are often complicated with anxiety, depression, and sleep disorders and are associated with dependence behavior and substance abuse. Melatonin has physiological properties including analgesia, regulation of circadian rhythms, soporific, and antidepressant and affects drug preference and addiction. This study aimed to investigate the role of melatonin in MOH compared with episodic migraine (EM) and healthy controls and to verify the relationship between plasma melatonin levels and psychiatric symptoms.

METHODS

Thirty patients affected by MOH, 30 patients with EM, and 30 matched healthy controls were enrolled. All subjects completed a detailed headache questionnaire and scales including the Hospital Anxiety and Depression Scale (HADS), the Pittsburgh Sleep Quality Index, the Leeds Dependence Questionnaire. Melatonin levels in plasma samples were measured by enzyme immunoassay method.

RESULTS

The levels of plasma melatonin were significantly different among 3 groups of subjects (MOH, 7.74 [5.40-9.89]; EM, 9.79 [8.23-10.62]; Control, 10.16 [8.60-17.57]; H = 13.433; P = 0.001). Significantly lower levels of melatonin were found in MOH patients compared with healthy controls ( P = 0.001). The level of plasma melatonin inversely correlated with the scores of HADS-Anxiety ( r = -0.318, P = 0.002), HADS-Depression ( r = -0.368, P < 0.001), Pittsburgh Sleep Quality Index ( r = -0.303, P = 0.004), and Leeds Dependence Questionnaire ( r = -0.312, P = 0.003).

CONCLUSIONS

This study innovatively detects the plasma melatonin levels in MOH patients and explores the association between melatonin levels and psychiatric symptoms. Melatonin may be potential complementary therapy in the treatment of MOH considering its comprehensive role in multiple aspects of MOH.

Exploring the Tryptophan Metabolic Pathways in Migraine-Related Mechanisms

Migraine is a complex neurovascular disorder, which causes intense socioeconomic problems worldwide. The pathophysiology of disease is enigmatic; accordingly, therapy is not sufficient. In recent years, migraine research focused on tryptophan, which is metabolized via two main pathways, the serotonin and kynurenine pathways, both of which produce neuroactive molecules that influence pain processing and stress response by disturbing neural and brain hypersensitivity and by interacting with molecules that control vascular and inflammatory actions. Serotonin has a role in trigeminal pain processing, and melatonin, which is another product of this pathway, also has a role in these processes. One of the end products of the kynurenine pathway is kynurenic acid (KYNA), which can decrease the overexpression of migraine-related neuropeptides in experimental conditions. However, the ability of KYNA to cross the blood-brain barrier is minimal, necessitating the development of synthetic analogs with potentially better pharmacokinetic properties to exploit its therapeutic potential. This review summarizes the main translational and clinical findings on tryptophan metabolism and certain neuropeptides, as well as therapeutic options that may be useful in the prevention and treatment of migraine.

Nutraceuticals and Behavioral Therapy for Headache

PURPOSE OF REVIEW

Headache affects and disables at least 1 billion people worldwide. Patients and providers seek new therapies to relieve headache without the side effects and financial burden of current treatments. This narrative review highlights recent treatment advances in integrative headache medicine: nutraceuticals and behavioral therapies.

RECENT FINDINGS

Growing use of complementary and alternative medicine (CAM) therapies for headache (riboflavin, coenzyme Q10, magnesium, vitamin D, melatonin) alongside mainstream treatments is increasing with improving evidence of quality, safety, and tolerability. Increasing interest in medical cannabis is tempered by lack of evidence regarding safety and efficacy. Behavioral therapies including cognitive behavioral therapy (CBT), biofeedback, mindfulness-based stress reduction (MBSR), and acceptance and commitment therapy (ACT) improve patient resiliency and self-efficacy outcomes and reduce disability. The body of evidence for nutraceutical and behavioral CAM interventions for headache continues to grow and improve in quality. Providers and patients should educate themselves regarding CAM therapies as part of integrative headache management. Future studies should examine combinatorial trials of CAM therapies against current standards of headache care.

Diagnostic Accuracy of Serum Calcitonin Gene-Related Peptide and Apolipoprotein E in Migraine: A Preliminary Study

Background

A reliable, migraine-specific biomarker has not been identified so far. Calcitonin Gene-Related Peptide (CGRP) and Apolipoprotein E (ApoE) might serve as migraine biomarkers due to their roles in migraine pathophysiology. However, their diagnostic usefulness has not been explored yet. Present study explored the diagnostic accuracy of CGRP and ApoE in migraine.

Methods

A cross-sectional, case–control study was conducted from November 2019 to April 2020 at Physiology department of our university. Fourteen female migraine patients, 18–25 years old, with confirmed “Migraine” diagnosis by a neurologist, were recruited. Control group consisted of 14 age-matched healthy females with no personal/family history of migraine. Blood was drawn once from control subjects and twice from migraine patients (ictal and interictal phase). Serum CGRP and ApoE levels were assessed by ELISA. Statistical analysis involved paired t-test, one-way ANOVA, Receiver operating characteristic (ROC) curves and cross-tabs.

Results

ApoE (mg/dl) was higher significantly in interictal (1.90±0.50) and ictal (1.97±0.65) phases of migraine compared to control (1.07±0.26) (p ≤ 0.001). ROC curves for ApoE were significant in migraine ictal vs control (AUC= 0.91, AUC 95% CI: 0.78–1.0) and migraine interictal vs control (AUC=0.92, AUC 95% CI: 0.8–1.0) subjects. ROC curve for CGRP (pg/mL) was significant in migraine ictal vs control subjects only (AUC=0.79, AUC 95% CI: 0.6–0.97).

Conclusion

Serum ApoE has “excellent” accuracy to diagnose migraine patients whether in ictal or interictal phase, from healthy subjects. ApoE levels of patients in these two phases of migraine are raised significantly than healthy subjects. CGRP has “fair” diagnostic accuracy to discriminate between migraine ictal phase and healthy subjects. Its levels do not differ significantly among migraine ictal, interictal phase and healthy controls.

Complementary and Integrative Medicines as Prophylactic Agents for Pediatric Migraine: A Narrative Literature Review

Complementary and integrative medicines (CIMs) are increasingly used as a preventive antimigraine therapy. In this review, we aimed to summarize the evidence for the efficacy and safety of eight CIMs (riboflavin, coenzyme Q10, magnesium, melatonin, polyunsaturated fatty acids, and combination therapy of feverfew, vitamin D, and ginkgolide B) in pediatric migraine prevention. The level of evidence for riboflavin was relatively high; it was investigated by many studies with five/seven studies demonstrating its efficacy. Five studies investigated the use of melatonin, with one reporting negative results. There was insufficient evidence on the effectiveness of coenzyme Q10, magnesium, and polyunsaturated fatty acids. Combination therapy showed positive potential; however, reports on the individual antimigraine effects of the CIMs were lacking. A definitive conclusion was not reached regarding the specific integrative drugs clinicians should choose for pediatric migraines, owing to low-quality evidence and a limited number of studies. Integrative medications are becoming more common for pediatric migraine prevention as they do not produce serious side effects, and underlying research data suggest their efficacy in preventing migraine. Additional studies are warranted to confirm the role of CIMs in treating patients with migraines.

The association between melatonin and episodic migraine: A pilot network meta-analysis of randomized controlled trials to compare the prophylactic effects with exogenous melatonin supplementation and pharmacotherapy

Although exogenous melatonin supplementation has been suggested to be effective for episodic migraine prophylaxis, there is no conclusive evidence comparing the efficacy of exogenous melatonin supplementation to the other FDA-approved pharmacotherapy for episodic migraine prophylaxis. The aim of the current network meta-analysis (NMA) was to compare the efficacy of exogenous melatonin supplementation in patients with episodic migraine. The randomized placebo-controlled trials or randomized controlled trials (RCTs) incorporating a placebo in the study designs were included in our analyses. All of the NMA procedures were conducted under the frequentist model. The primary outcome was changes in frequency of migraine days and response rate after migraine prophylaxis with melatonin supplementation or pharmacological interventions. We included 25 RCTs in total with 4499 patients (mean age = 36.0 years, mean female proportion = 78.9%). The NMA demonstrated that migraine prophylaxis with oral melatonin 3 mg/d (immediate-release) at bedtime was associated with the greatest improvement in migraine frequency [mean difference = -1.71 days, 95% confidence interval (CI): -3.27 to -0.14 days compared to placebo] and the second highest response rate (odds ratio = 4.19, 95% CI = 1.46 to 12.00 compared to placebo). Furthermore, oral melatonin 3 mg (immediate-release) at bedtime was the most preferred pharmacological intervention among all of the investigated interventions when improvements in migraine frequency, response rate, dropout rate, and rates of any adverse events were taken into account. This pilot NMA suggests the potential prophylactic role of exogenous melatonin supplementation in patients with episodic migraine.

Complementary and Integrative Health Treatments for Migraine

BACKGROUND

Migraine is a chronic disabling neurologic condition that can be treated with a combination of both pharmacologic and complementary and integrative health options.

EVIDENCE ACQUISITION

With the growing interest in the US population in the use of nonpharmacologic treatments, we reviewed the evidence for supplements and behavioral interventions used for migraine prevention.

RESULTS

Supplements reviewed included vitamins, minerals, and certain herbal preparations. Behavioral interventions reviewed included cognitive behavioral therapy, biofeedback, relaxation, the third-wave therapies, acupuncture, hypnosis, and aerobic exercise.

CONCLUSIONS

This article should provide an appreciation for the wide range of nonpharmacologic therapies that might be offered to patients in place of or in addition to migraine-preventive medications.

Current understanding of pineal gland structure and function in headache

PURPOSE

The pineal gland plays an important role in biological rhythms, circadian and circannual variations, which are key aspects in several headache disorders.

OVERVIEW

Melatonin, the main pineal secreting hormone, has been extensively studied in primary and secondary headache disorders. Altered melatonin secretion occurs in many headache syndromes. Experimental data show pineal gland and melatonin both interfere in headache animal models, decreasing trigeminal activation. Melatonin has been shown to regulate CGRP and control its release.

DISCUSSION

Melatonin has been used successfully as a treatment for migraine, cluster headaches and other headaches. There is a rationale for including the pineal gland as a relevant brain structure in the mechanisms of headache pathophysiology, and melatonin as a treatment option in primary headache.

Preliminary Evidence that Melatonin Is not a Biomarker in Children and Adolescents With Episodic Migraine

BACKGROUND

To date, there have not been reliable biomarkers to identify impending migraine episodes. A prior study in adults with migraine demonstrated a reduction in the urinary metabolic substrate of melatonin (urinary 6-sulfatoxymelatonin; aMT6s) during a migraine. The aim of this study was to examine whether evening urinary melatonin metabolite levels could predict migraine the next day in children and adolescents with migraine.

METHODS

Twenty-one children and adolescents with migraine (aged 5-17 years) were recruited to this observational study conducted at UC San Francisco to provide urine samples for 10 days and maintain a prospective headache diary during the same period. Nightly melatonin metabolite 6-sulfatoxymelatonin in urine was assayed and results from nights preceding migraine were compared to nights preceding a non-headache day.

RESULTS

Mean (±SD) aMT6s levels the night prior to a migraine attack were 56.2 ± 39.0 vs 55.4 ± 46.6 ng/mL (P = .915), and mean melatonin metabolite levels the night following migraine were 55.5 ± 46.9 vs 57.0 ± 37.7 ng/mL (P = .841). However, in post hoc exploratory analyses, aMT6s levels were lower the night before a migraine in those who experienced aura or premonitory symptoms.

CONCLUSION

While urinary melatonin metabolites do not predict migraine attacks in children and adolescents overall, they may be predictive in those who experience premonitory phase symptoms as part of their migraine attacks.

Therapeutic role of melatonin in migraine prophylaxis: A systematic review

BACKGROUND

Melatonin is the "clock factor" generated from pineal gland dominating regular circadian rhythm in humans. Migraine is one of the most severe and debilitating primary headache disorders. Thus far, many diseases have been found to associate with melatonin, including the migraine. Therefore, melatonin's therapeutic potential for migraine is drawing attention.

OBJECTIVES

The aim of this study is to offer a systematic review of extant data of melatonin in migraine prophylaxis and to provide clinical implications and specific recommendations for future studies.

DATA SOURCES AND STUDY METHODS

A systematic research was conducted in September 2018 by using PubMed and Google Scholar databases to search for science literature published after 1988.

RESULTS

In all, 7 eligible articles were identified, including 4 randomized controlled studies and 3 observational studies. Due to high heterogeneities and limited number of studies, meta-analysis was not feasible, and only systematic review was performed. The results show that present evidence cannot claim melatonin's effectiveness according to the conflicting outcomes; however, the two negative outcomes of melatonin not different from placebo and melatonin inferior to amitriptyline are possible under-powering because of methodological, pharmacological, and therapeutic shortcomings. Observational studies also support melatonin's efficacy in migraine. As a result, melatonin is very likely to benefit migraine in prophylaxis and may have a similar effectiveness to other main preventive medications. Immediate-release melatonin 3 mg was established as effective, melatonin receptor agonist (Agomelatine) 25 mg and prolonged-release melatonin 4 mg were observed efficacious in observational studies. Melatonin displayed ineffective in the 2-month trial; thus, 3 months or more may be an enough duration for migraine therapy. Despite melatonin being generally safe, emerging literature is illustrating that a few severe adverse effects can be caused by melatonin, for example, liver injuries, reproductive system dysfunctions, and detrimental immunostimulation.

CONCLUSIONS

Melatonin is very likely to be a promising alternative for migraine prophylaxis. Current literature examining melatonin's efficacy in migraine prevention is growing, but still limited. Future studies of perfect design in methodology, pharmacology, and therapeutics are needed to achieve a deeper awareness of melatonin's role in migraine as well as more studies to explore the safety issues of melatonin medicine.

Non-Rapid Eye Movement Sleep Parasomnias and Migraine: A Role of Orexinergic Projections

Introduction

Sleep and migraine share a common pathophysiological substrate, although the underlying mechanisms are unknown. The serotonergic and orexinergic systems are both involved in the regulation of sleep/wake cycle, and numerous studies show that both are involved in the migraine etiopathogenesis. These two systems are anatomically and functionally interconnected. Our hypothesis is that in migraine a dysfunction of orexinergic projections on the median raphe (MR) nuclei, interfering with serotonergic regulation, may cause Non-Rapid Eye Movement parasomnias, such as somnambulism.

Hypothesis/theory

Acting on the serotonergic neurons of the raphe nuclei, the dysfunction of orexinergic neurons would lead to a higher release of serotonin. The activation of serotonergic receptors located on the walls of large cerebral vessels would lead to abnormal vasodilatation and consequently increase transmural pressure. This process could activate the trigeminal nerve terminals that innervate vascular walls. As a consequence, there is activation of sensory nerve endings at the level of hard vessels in the meninges, with release of pro-inflammatory peptides (e.g., substance P and CGRP). Within this hypothetical frame, the released serotonin could also interact with trigeminovascular afferents to activate and/or facilitate the release of the neuropeptide at the level of the trigeminal ganglion. The dysregulation of the physiological negative feedback of serotonin on the orexinergic neurons, in turn, would contribute to an alteration of the whole system, altering the sleep–wake cycle.

Conclusion

Serotonergic neurons of the MR nuclei receive an excitatory input from hypothalamic orexin/hypocretin neurons and reciprocally inhibit orexin/hypocretin neurons through the serotonin 1A receptor (or 5-HT1A receptor). Considering this complex system, if there is an alteration it may facilitate the pathophysiological mechanisms involved in the migraine, while it may produce at the same time an alteration of the sleep–wake rhythm, causing sleep disorders such as sleepwalking. Understanding the complex mechanisms underlying migraine and sleep disorders and how these mechanisms can interact with each other, it would be crucial to pave the way for new therapeutic strategies.

Genetic and biochemical changes of the serotonergic system in migraine pathobiology

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

The Role of Melatonin in the Treatment of Primary Headache Disorders

OBJECTIVE

To provide a summary of knowledge about the use of melatonin in the treatment of primary headache disorders.

BACKGROUND

Melatonin is secreted by the pineal gland; its production is regulated by the hypothalamus and increases during periods of darkness.

METHODS

We undertook a narrative review of the literature on the role of melatonin in the treatment of primary headache disorders.

RESULTS

There are randomized placebo-controlled trials examining melatonin for preventive treatment of migraine and cluster headache. For cluster headache, melatonin 10 mg was superior to placebo. For migraine, a randomized placebo-controlled trial of melatonin 3 mg (immediate release) was positive, though an underpowered trial of melatonin 2 mg (sustained release) was negative. Uncontrolled studies, case series, and case reports cover melatonin's role in treating tension-type headache, hypnic headache, hemicrania continua, SUNCT/SUNA and primary stabbing headache.

CONCLUSIONS

Melatonin may be effective in treating several primary headache disorders, particularly cluster headache and migraine. Future research should focus on elucidating the underlying mechanisms of benefit of melatonin in different headache disorders, as well as clarifying optimal dosing and formulation.

Melatonin and neurotrophins NT-3, BDNF, NGF in patients with varying levels of depression severity

BACKGROUND

Disrupted circadian rhythm of melatonin secretion in depression shows a relationship with the exacerbation of inflammatory processes. Proinflammatory mechanisms of depression are sustained by oxidative stress. This contributes to melatonin deficiency and to the malfunction of the defense mechanisms in the brain. Disrupted melatonin secretion in depression may have an influence on the concentrations of neurotrophic factors (NF), such as neurotrophin-3 (NT-3), brain-derived neurotrophic factor (BDNF) and nerve growth factor (NGF). Disturbance in neurotrophin release may affect synaptic plasticity and cause exacerbation of neurodegenerative processes in the central nervous system. The aim of this study was to assess the concentrations of melatonin and NF of the brain in patients with varying levels of depression severity.

METHOD

160 males and females were enrolled in the study, 120 of whom were diagnosed with various types of depression. The control group comprised 40 healthy individuals. At 3:00a.m. all patients had salivary melatonin concentrations determined utilizing a competitive enzyme immunoassay technique (ELISA). In addition, at 7:00a.m. all patients had serum neurotrophin (NT-3, BDNF, NGF) concentrations determined by means of ELISA.

RESULTS

The highest melatonin secretion was observed at 3:00a.m. in severely depressed females. In the groups with mild and moderate depression, melatonin secretion at 3:00a.m. was comparable between males and females. In addition, a decrease in the concentrations of neurotrophins was revealed in patients at all levels of depression severity.

CONCLUSION

Melatonin may be a significant marker of depression severity. Melatonin and NF in depressed patients show neuroprotective effects.

Roads Less Traveled: Sexual Dimorphism and Mast Cell Contributions to Migraine Pathology

Migraine is a common, little understood, and debilitating disease. It is much more prominent in women than in men (~2/3 are women) but the reasons for female preponderance are not clear. Migraineurs frequently experience severe comorbidities, such as allergies, depression, irritable bowel syndrome, and others; many of the comorbidities are more common in females. Current treatments for migraine are not gender specific, and rarely are migraine and its comorbidities considered and treated by the same specialist. Thus, migraine treatments represent a huge unmet medical need, which will only be addressed with greater understanding of its underlying pathophysiology. We discuss the current knowledge about sex differences in migraine and its comorbidities, and focus on the potential role of mast cells (MCs) in both. Sex-based differences in pain recognition and drug responses, fluid balance, and the blood–brain barrier are recognized but their impact on migraine is not well studied. Furthermore, MCs are well recognized for their prominent role in allergies but much less is known about their contributions to pain pathways in general and migraine specifically. MC-neuron bidirectional communication uniquely positions these cells as potential initiators and/or perpetuators of pain. MCs can secrete nociceptor sensitizing and activating agents, such as serotonin, prostaglandins, histamine, and proteolytic enzymes that can also activate the pain-mediating transient receptor potential vanilloid channels. MCs express receptors for both estrogen and progesterone that induce degranulation upon binding. Furthermore, environmental estrogens, such as Bisphenol A, activate MCs in preclinical models but their impact on pain pathways or migraine is understudied. We hope that this discussion will encourage scientists and physicians alike to bridge the knowledge gaps linking sex, MCs, and migraine to develop better, more comprehensive treatments for migraine patients.

Urinary 6-sulphatoxymelatonin levels and sleep disorders in children with migraine

We conducted the present study to assess melatonin secretion in a sample of children with migraine, to describe their sleep patterns and problems, and to examine the impact of sleep problems on migraine disability. The parents of 18 children with migraine completed the Children's Sleep Habits Questionnaire and Pediatric Migraine Disability Assessment Score in Arabic. The parents of 18 healthy controls also completed the Children's Sleep Habits Questionnaire. Urinary 6-sulphatoxymelatonin levels were determined with the enzyme-linked immunosorbent assay method. There was no significant difference in urinary 6-sulphatoxymelatonin between the migraine and control groups (Z = -0.127, P = .889). There were no significant differences between groups in Children's Sleep Habits Questionnaire subscales or total scores. There were significant correlations between bedtime resistance, parasomnias subscales, and migraine disability. Our findings indicate that nocturnal production of melatonin is not reduced in children with migraine, and sleep disturbances impact the degree of migraine disability.

Corticosteroids alter CGRP and melatonin release in cluster headache episodes

BACKGROUND

Calcitonin gene-related peptide (CGRP) is a marker of trigeminal activation in acute cluster headache (CH). Melatonin production is altered in CH patients and may reflect hypothalamic dysfunction. We assessed the effects of short-term CH prevention with corticosteroids on CGRP and melatonin release in a prospective observational cohort study hypothesizing that corticosteroids influence the interictal activity of both systems indicated by the change of these biomarkers.

METHODS

Episodic CH subjects (n = 9) in the bout and controls with multiple sclerosis (n = 6) received 1000 mg/d methylprednisolone (MPD) i.v. for three days followed by oral tapering with prednisone. We determined CGRP plasma levels in external jugular vein blood outside an attack and 6-sulfatoxymelatonin (aMT6s) - the stable metabolite of melatonin - in 12-hour day- and nighttime urine collection prior to and several times after MPD therapy and again when CH subjects were outside the bout in complete remission. CH patients recorded the frequency of attacks.

RESULTS

In parallel to the reduction of headache frequency, administration of corticosteroids resulted in significantly decreased CGRP plasma levels and increased nocturnal aMT6s urine excretion in CH subjects. No significant changes were observed in controls.

CONCLUSION

Corticosteroids alter CGRP plasma and aMT6s urine levels in a cluster bout. These changes may indicate an effect of corticosteroids on trigeminal activation and hypothalamic dysfunction.

Biomarkers associated with migraine and their potential role in migraine management

OBJECTIVE

The focus of this review is to review potential diagnostic and therapeutic biomarkers associated with migraine.

BACKGROUND

Migraine headache is a common disease that affects millions of individuals worldwide. Although well-accepted diagnostic criteria exist for migraine, it is still a complex disorder that remains both underdiagnosed and misdiagnosed. The causes of migraine are likely a mix of genetic, epigenetic, and environmental factors that, together with the individual's life history, translate into the observed clinical heterogeneity. Inherent clinical heterogeneity is an obstacle in developing more effective treatments. The lack of appropriate biomarkers is also an impediment to developing more effective therapeutic/preventive approaches. Ultimately, biomarkers may facilitate the goal of individualized medicine by enabling clinicians to more accurately diagnose and treat migraine and other types of headache.

METHODS

A comprehensive review was conducted of PubMed citations containing the key word "marker" OR "biomarker" combined with "migraine" OR "headache." Other key words included "serum," "saliva," "cerebrospinal fluid," "genes," "blood," and "inflammation." The only restriction was English-language publication. The abstracts of all articles meeting these criteria were reviewed, and full text was retrieved and examined for relevant references.

RESULTS

Data from human studies have begun to identify genetic mutations/polymorphisms and altered levels of specific proinflammatory and neuromodulatory molecules that strongly correlate with migraine as well as symptom severity. Results from a smaller number of studies have identified parameters, such as the neuropeptide calcitonin gene-related peptide (CGRP), which are significantly associated with response to specific treatments for acute migraine attacks and prophylaxis. Epigenetic mechanisms may also be involved in the development of migraine, and understanding environmentally induced genetic changes associated with this disease may eventually guide the development of therapies capable of reversing these pathophysiological changes in gene function.

CONCLUSIONS

The understanding of the etiology of migraine is incomplete. Although the identification and validation of biomarkers has greatly advanced diagnostic precision and measures of therapeutic efficacy in other diseases, there are no currently accepted biomarkers for chronic or episodic migraine. However, the continued investigation and identification of genetic, epigenetic, and molecular biomarkers is likely to facilitate the goal of individualizing medicine by enabling clinicians to more accurately diagnose and treat migraine and other headache disorders.

Social anxiety score is high in adolescents with chronic migraine

BACKGROUND

Social anxiety disorder, also known as social phobia, is a marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. It usually begins in mid-adolescence and has a chronic course and interferes in academic, social, family and personal functioning. Recent studies have shown that social anxiety disorder is more prevalent in adults with migraine. Little evidence on this subject is available for the adolescent population.

METHODS

This study was performed between August 2009 and August 2010; all patients were recruited in schools, pediatric or neuropediatric facilities, and were submitted to a detailed headache questionnaire, which consisted of demographic and clinical data. To evaluate social anxiety, the Social Phobia Inventory was used.

RESULTS

A total of 151 subjects were evaluated: 50 had chronic migraine, 50 had episodic migraine and 51 were control subjects. In the chronic migraine group, the mean score in the Social Phobia Inventory was 18.5 ± 12.4, which was significantly higher than in the episodic migraine group (12.1 ± 8.1) and in the control group (13.8 ± 10.8; F(2131) = 4.8, P= 0.010). The mean score, however, was not significantly different between the control and episodic migraine groups.

CONCLUSIONS

Chronic migraine is strongly associated with high social anxiety score, regardless of demographic data and pain intensity. The total burden of migraine may be increased with social anxiety disorder comorbidity.

Diurnal melatonin patterns in children: ready to apply in clinical practice?

Experimental and clinical studies suggest that endogenous melatonin plays an important role in pediatric sleep regulation. This finding led to the introduction of exogenous melatonin to treat sleep disturbances. Optimizing the treatment algorithm involves a review of melatonin measurements and interpretations in clinical practice. Diurnal patterns of salivary melatonin and urinary metabolite 6-sulfatoxymelatonin were investigated in 29 children and adolescents (age, 5.5-17.3 years) by measuring concentrations every 3 hours. Relationships between melatonin parameters (peak concentrations and area under the time curve) and anthropometric measures (height, weight, and body mass index), age, and sleep scores (Sleep Disturbance Scale for Children) were investigated. High interindividual variability was evident in melatonin diurnal profiles. Melatonin production (adjusted to body weight) decreased with age and sexual maturation (P < 0.00). Both salivary melatonin and its urinary metabolite measurements can be used to evaluate the melatonin system in children. However, the high interindividual variability of diurnal melatonin concentrations challenges clinical applications in regard to diagnostic purposes and the criteria for initiating exogenous melatonin therapy. Further investigations and the development of criteria for clinical evaluations of the pediatric melatonin system are needed.