Aspirin's effect on platelet inhibition in migraineurs

Potential predictors for the efficacy of non-steroidal anti-inflammatory drugs in patients with migraine

Objectives

To explore potential predictors of the efficacy of non-steroidal anti-inflammatory drugs (NSAIDs) in patients with migraine.

Methods

Consecutive migraine patients were recruited and divided into responders and non-responders to NSAIDs according to follow-up for at least three months. Demographic data, migraine-related disabilities and characteristics, and psychiatric comorbidities were evaluated and used to build multivariable logistic regression models. Subsequently, we generated receiver operating characteristic (ROC) curves to explore the performance of these traits in predicting NSAIDs efficacy.

Results

A total of 567 patients with migraine who completed at least three months of follow-up were enrolled. In the multivariate regression analysis, five factors were identified as potential predictors for NSAIDs efficacy in treating migraine. Namely, attack duration (odds ratio (OR) = 0.959; p < 0.001), headache impact (OR = 0.966; p = 0.015), depression (OR = 0.889; p < 0.001), anxiety (OR = 0.748; p < 0.001), and education level (OR = 1.362; p < 0.001) were associated with response to NSAIDs treatment. The area under the curve, sensitivity, and specificity combining these five factors for predicting the efficacy of NSAIDs were 0.834, 0.909 and 0.676.

Conclusions

These findings suggest that migraine-related and psychiatric factors are associated with the response to NSAIDs in migraine management. Identifying such key factors may help to optimize individualized migraine management strategy.

The improved targeting of an aspirin prodrug albumin-based nanosystem for visualizing and inhibiting lung metastasis of breast cancer

Lung metastasis is the principal reason for the majority of deaths from breast cancer. The nonsteroidal anti-inflammatory drug aspirin can prevent lung metastasis in breast tumors via inhibiting heparanase. However, the lack of specific targets and limited accumulation at the site of the tumor have thus far hindered the use of aspirin in oncotherapy. In this study, we developed the nanoplatform FA-BSA@DA and loaded it with the versatile aspirin prodrug DA to visualize and inhibit breast cancer metastasis via targeting heparanase. This nanosystem can be effectively targeted to folic acid (FA)-positive tumor cells, and would then subsequently release a high dose of DA, whose ester bond is specifically ruptured by H₂O₂ in the tumor microenvironment to afford the therapeutic drug aspirin and near-infrared (NIR) fluorescent reporter DCM. The released aspirin can effectively prevent breast cancer lung metastasis through the inhibition of heparanase activity, and the NIR fluorescent signals emitted from DCM can be used to monitor and evaluate the metastasis levels of breast cancer. Our results showed that the expression of heparanase was significantly decreased, and lung metastasis from breast cancer was effectively monitored and inhibited after treatment with FA-BSA@DA. Furthermore, the collaborative therapy nanoplatform FA-BSA@DA/DOX exhibited strong therapeutic effects in the treatment of breast cancer in vitro and in vivo via the introduction of doxorubicin (DOX) to the system, which resulted in an even stronger result due to its synergistic effects with aspirin. This heparanase-reliant strategy has profound significance for the extended development of nanoplatforms based on versatile aspirin prodrugs, which may offer a solution to clinically prevent breast cancer recurrence and lung metastasis.

Acute Migraine Prescription Patterns Vary by Baseline Cardiovascular Risk and Clinical Characteristics: A Real-World Evidence Study

Introduction

Migraine is a debilitating neurological disease and one of the most common disorders in the world. Although the triptans, potent 5-HT1B/1D receptor agonists, are an effective and widely used acute treatment of migraine, few studies have assessed how their cardiovascular risk warnings could impact prescription patterns. This study characterized cardiovascular risk factors and other aspects of people with migraine in real-world settings and confirmed patterns of acute migraine care.

Methods

This retrospective study included five cohorts: people with migraine prescribed acute treatments [triptans, opiates, prescription nonsteroidal anti-inflammatory drugs (NSAIDs)], untreated people with migraine, and individuals without migraine diagnosis. Baseline demographic and clinical characteristics were used to develop and validate a 1-year myocardial infarction (MI) risk prediction model among untreated people with migraine. This validated prediction model generated disease risk scores (DRSs) for MI among untreated cohorts.

Results

Patients in the study included 436,642 prescribed a triptan, 55,234 prescribed opiates, and 334,152 prescribed NSAIDs; as well as 1,168,212 untreated persons with migraine and 11,735,009 nonmigraine participants. Those prescribed triptans were younger, had fewer cardiovascular risk factors and hospitalizations, and lower concomitant medication use than those in the NSAID and opiate cohorts. The distribution of the DRS showed that compared to patients prescribed NSAIDs (4.2%) or opiates (3.5%), a smaller proportion of patients prescribed triptans (1.3%) were at high risk for MI at 1 year (> 10%).

Conclusion

People with migraine who had more cardiovascular risk factors and greater 1-year MI risk score were disproportionately prescribed opiates and NSAIDs compared to triptans. Future research should explore unmet needs for patients with disorders for which triptan therapy is contraindicated.

Sex-Specific Pharmacotherapy for Migraine: A Narrative Review

Migraine is a common neurological disorder characterized by recurrent headache episodes that accompany sensory-motor disturbances, such as higher sensitivity to touch and light, extremity heaviness or weakness, and speech or language disabilities. Worldwide, migraine is one of the top 10 causes of disability and hence poses a huge economic burden to society. On average, migraine occurs in 12% of population but its occurrence is sexually dimorphic, as it is two to three times more prevalent in women than in men. This female to male ratio of migraine prevalence is age- and sex hormone-dependent. Advancements in understanding migraine pathogenesis have also revealed an association with both genetics and epigenetics. The severity of migraine, in terms of its attack duration, headache intensity, frequency, and occurrence of migraine-associated symptoms, has generally been reported to be greater in women. Sex differences in migraine disability and comorbidities, such as psychiatric disorders, have also been noted in some population-based studies. However, research on sex-related differences in response to migraine treatments is relatively scarce. Although a general observation is that women consume more medication than men for migraine treatment, strategies for the use of abortive and preventive medications for migraine are generally similar in both sexes. This narrative review summarizes available findings on sexually distinct responses to abortive and prophylactic pharmacotherapy of migraine. Basic experimental data and clinical findings will be presented, and potential mechanisms underlying sex-based responses will be discussed to highlight the importance and value of sex-based treatment in migraine research and practice.

History of Migraine and Volume of Brain Infarcts: The Italian Project on Stroke at Young Age (IPSYS)

Background and Purpose

Migraine has been shown to increase cerebral excitability, promote rapid infarct expansion into tissue with perfusion deficits, and result in larger infarcts in animal models of focal cerebral ischemia. Whether these effects occur in humans has never been properly investigated.

Methods

In a series of consecutive patients with acute ischemic stroke, enrolled in the setting of the Italian Project on Stroke at Young Age, we assessed acute as well as chronic infarct volumes by volumetric magnetic resonance imaging, and compared these among different subgroups identified by migraine status.

Results

A cohort of 591 patients (male, 53.8%; mean age, 37.5±6.4 years) qualified for the analysis. Migraineurs had larger acute infarcts than non-migraineurs (median, 5.9 cm³ [interquartile range (IQR), 1.4 to 15.5] vs. 2.6 cm³ [IQR, 0.8 to 10.1], P<0.001), and the largest volumes were observed in patients with migraine with aura (median, 9.0 cm³ [IQR, 3.4 to 16.6]). In a linear regression model, migraine was an independent predictor of increased log (acute infarct volumes) (median ratio [MR], 1.64; 95% confidence interval [CI], 1.22 to 2.20), an effect that was more prominent for migraine with aura (MR, 2.92; 95% CI, 1.88 to 4.54).

Conclusions

These findings reinforce the experimental observation of larger acute cerebral infarcts in migraineurs, extend animal data to human disease, and support the hypothesis of increased vulnerability to ischemic brain injury in people suffering migraine.

Migraine and cerebrovascular disease: still a dangerous connection?

Migraine is a common type of headache in young adults, with an estimated prevalence of 4% before puberty and as high as 25% in women by their mid to late 30s. About one third of migraineurs experience transient neurological symptoms known as auras, which characterize a variant known as migraine with aura. Many evidences have shown an increased risk of vascular events in patients affected by migraine, particularly among women and among migraine patients with aura. Potential underlying mechanisms include endothelial dysfunction, hypercoagulability, platelet aggregation, vasospasm, cardiovascular risk factors, paradoxical embolism, spreading depolarization, shared genetic risk, use of non-steroidal anti-inflammatory drugs, and immobilization. The risk of vascular events in migraine patients is also linked by concomitant oral contraception; moreover, the common finding of increased incidence of right to left cardiac shunt in migraine patients might have a pathogenetic role. Finally, many MRI studies in migraine patients, particularly in migraine with aura, have shown subcortical lesions particularly in the cerebellum as a common finding. In this review, we analyzed the more recent findings regarding the topic of migraine as a risk factor in stroke.

Migraine and risk of cardiovascular diseases: Danish population based matched cohort study

OBJECTIVE

To examine the risks of myocardial infarction, stroke (ischaemic and haemorrhagic), peripheral artery disease, venous thromboembolism, atrial fibrillation or atrial flutter, and heart failure in patients with migraine and in a general population comparison cohort.

DESIGN

Nationwide, population based cohort study.

SETTING

All Danish hospitals and hospital outpatient clinics from 1995 to 2013.

PARTICIPANTS

51 032 patients with migraine and 510 320 people from the general population matched on age, sex, and calendar year.

MAIN OUTCOME MEASURES

Comorbidity adjusted hazard ratios of cardiovascular outcomes based on Cox regression analysis.

RESULTS

Higher absolute risks were observed among patients with incident migraine than in the general population across most outcomes and follow-up periods. After 19 years of follow-up, the cumulative incidences per 1000 people for the migraine cohort compared with the general population were 25 v 17 for myocardial infarction, 45 v 25 for ischaemic stroke, 11 v 6 for haemorrhagic stroke, 13 v 11 for peripheral artery disease, 27 v 18 for venous thromboembolism, 47 v 34 for atrial fibrillation or atrial flutter, and 19 v 18 for heart failure. Correspondingly, migraine was positively associated with myocardial infarction (adjusted hazard ratio 1.49, 95% confidence interval 1.36 to 1.64), ischaemic stroke (2.26, 2.11 to 2.41), and haemorrhagic stroke (1.94, 1.68 to 2.23), as well as venous thromboembolism (1.59, 1.45 to 1.74) and atrial fibrillation or atrial flutter (1.25, 1.16 to 1.36). No meaningful association was found with peripheral artery disease (adjusted hazard ratio 1.12, 0.96 to 1.30) or heart failure (1.04, 0.93 to 1.16). The associations, particularly for stroke outcomes, were stronger during the short term (0-1 years) after diagnosis than the long term (up to 19 years), in patients with aura than in those without aura, and in women than in men. In a subcohort of patients, the associations persisted after additional multivariable adjustment for body mass index and smoking.

CONCLUSIONS

Migraine was associated with increased risks of myocardial infarction, ischaemic stroke, haemorrhagic stroke, venous thromboembolism, and atrial fibrillation or atrial flutter. Migraine may be an important risk factor for most cardiovascular diseases.

Hypercoagulability and Migraine

BACKGROUND

A growing body of literature suggests that migraineurs, particularly those with aura, have an increased risk for ischemic stroke, but not via enhanced atherosclerosis. The theory that micro-emboli induced ischemia provokes cortical spreading depression (ie, symptomatic aura) in migraineurs but transient ischemic attacks in others highlights a potential role for hypercoagulability as a link between migraine (with aura) and stroke.

AIM

Our objective is to summarize the literature evaluating the association of migraine with various acquired or inheritable thrombophilic states, including those related to elevated estrogen levels, endothelial activation and dysfunction, antiphospholipid antibodies (aPL), deficiency of coagulation inhibitors, and presence of certain genetic polymorphisms.

FINDINGS

Although definitive studies are lacking, a preponderance of available evidence links migraine, and especially aura, to increased levels of estradiol (eg, oral contraceptive pill [OCP] use, pregnancy), thrombo- and erythrocytosis, von Willebrand factor (vWF) antigen, fibrinogen, tissue plasminogen activator (tPA) antigen, and endothelial microparticles. Studies of a link to migraine are conflicting for aPL, homocysteine, Protein S, and the methylenetetrahydrofolate reductase (MTHFR) C677T polymorphism. No association with migraine was found in meta-analyses of Factor V Leiden, and of prothrombin gene mutation. Within a large, young ischemic stroke sample, migraine with aura was associated with a thrombophilic state and with patent foramen ovale (PFO). In the non-stroke population, meta-analyses show an association of PFO and migraine with aura (MA), but two population-based studies do not support the link.

RECOMMENDATIONS

For persons with MA and (1) a personal history or family history of thrombosis, or (2) MRI evidence of micro-vascular ischemia or of stroke, an evaluation for hypercoagulability is warranted. In cases of MA alone, consider screening for markers of endothelial activation (eg, vWF, high sensitivity c-reactive protein [hs CRP], and fibrinogen). Rigorous management of other stroke risk factors is paramount, but efficacy of anti-thrombotic agents in the treatment of migraine is unproven. Closure of PFO is not routinely recommended based on negative randomized trials.