Migraine: possible role of shear-induced platelet aggregation with serotonin release

Association between serum vitamin D and severe headache or migraine: A population-based analysis

BACKGROUND

Vitamin D is thought to play a role in the development of migraine, but the nature of the relationship is still not fully understood. Although some studies have shown an association between vitamin D deficiency and migraine, other studies have had inconsistent or inconclusive results. Therefore, further research is needed to better understand the relationship between vitamin D and migraine headaches.

METHODS

We selected 9142 participants from the 2001-2004 National Health and Nutrition Examination Survey (NHANES). In our study, the term "serum vitamin D" refers to the concentration of 25OHD2 + 25OHD3 (nmol/L) in the blood. Migraine was assessed based on self-reports in the miscellaneous pain section of the NHANES questionnaire. Associations between vitamin D and the risk of migraine were examined using multiple logistic regression, smoothed curve fitting, and stratified analyses.

RESULTS

In our study, 20.53% of the participants suffered from migraine. The prevalence of migraine was higher in those with lower serum vitamin D levels. Participants in the highest quartile of serum vitamin D levels were found to have a 16% lower prevalence than those in the lowest quartile in the fully adjusted model (OR = 0.84, 95% CI 0.71-0.99). This result was supported by stratified analysis and smoothed curve fitting.

CONCLUSION

Our study showed a significant negative correlation between serum vitamin D levels and the prevalence of migraine in American adults.

Multiple Cerebral Infarcts Due to Severe Anemia Preceded by Migraine-like Headache with Aura

We herein report a 47-year-old woman who developed migraine-like headache with aura and subsequent multiple cerebral infarcts, likely due to severe iron deficiency anemia (IDA) from menorrhagia. The progression from IDA to ischemic stroke involves several pathophysiological mechanisms, including reduction of erythrocyte deformability, reactive thrombocytosis, and anemic hypoxia. We speculate that a microembolus first caused cortical spreading depression without infarcts and that a larger thromboembolus then caused multiple infarcts. This case highlights the transition from migraine-like headache to ischemic stroke. New-onset migraine-like headache is a warning of impending ischemic stroke, and IDA may be a potential underlying cause.

The pathogenic role of calcitonin gene-related peptide and predictors of new-onset migraine and long-term outcomes after transcatheter atrial septal defect closure

OBJECTIVE

To evaluate factors associated with new-onset migraine (NOM) after transcatheter atrial septal defect (ASD) closure and predictors of unremitting NOM. The pathogenic role of migraine biomarkers such as calcitonin gene-related peptide (CGRP) and neuropeptide Y (NPY) were also assessed.

BACKGROUND

New-onset migraine has been observed after transcatheter ASD closure. Neuropeptides like CGRP and NPY stored both in the brain and heart are implicated in migraine pathophysiology. The potential role of those migraine biomarkers in NOM, as well as the risk factors and long-term outcomes of NOM, remain largely unknown.

METHODS

We enrolled patients without previous migraine who underwent successful transcatheter ASD closure between 2001 and 2013. The parameters of transthoracic echocardiography, and plasma CGRP and NPY levels measured by enzyme-linked immunosorbent assay, were collected prospectively before and after ASD closure, and compared between patients with NOM and those without. Predictors of NOM were assessed. Telephone interviews were performed in 2022 to assess migraine status. Clinical and procedural characteristics were compared between patients with unremitting migraine and those with transient migraine that remitted within 1 year.

RESULTS

Of the 212 patients (median age, 21 years; 75.9% female), 43 (20.3%) had NOM. Potential predictors of NOM included a young age (adjusted odds ratio [aOR] 0.98, 95% confidence interval [CI] 0.96-0.99; p = 0.040), large ASD size (aOR 1.07, 95% CI 1.01-1.14; p = 0.022), and transient residual shunting after closure (aOR 2.78, 95% CI 1.05-7.36; p = 0.039). Post-closure plasma CGRP levels, but not NPY levels, were significantly higher than pre-closure levels (47.9 vs. 38.0 pg/mL, p = 0.023) among patients with NOM. Of the 27 patients with migraine who reported their migraine status at a median 14-year follow-up, 13 (48.1%) had unremitting migraine. Patients with unremitting migraine were more likely to have a smaller device-to-ASD size ratio (1.21 vs. 1.33, p = 0.039) and a larger pulmonary flow-to-systemic flow ratio (2.9 vs. 2.3, p = 0.012) than those with transient migraine.

CONCLUSIONS

Calcitonin gene-related peptide may play a pathogenic role in NOM after transcatheter ASD closure. A young age, large ASD size, and transient residual shunting potentially predict migraine occurrence after ASD closure. NOM not reaching remission for years may result from a significant shunt before closure.

Construction and validation of a nomogram for predicting remission of migraine patients with patent foramen ovale after closure

OBJECTIVE

This study aimed to construct and validate a nomogram model that predicts the remission of migraine attacks by screening factors that affect the prognosis of migraine patients with patent foramen ovale (PFO) after closure.

METHOD

Retrospective analysis was conducted in migraine patients with PFO who underwent PFO closure in the Department of Cardiology of Jiangsu Province Hospital from September 2020 to April 2023. Based on the Migraine Disability Assessment (MIDAS) scores from the 1-year follow-up after PFO closure, all patients who met the inclusion criteria were categorized into a remission group and a non-remission group. The primary efficacy endpoint was remission of migraine headache. After collecting clinical data, transcranial doppler sonography (TCD) results and MIDAS scores, LASSO (least absolute shrinkage and selection operator) regression and multivariable logistic regression analysis were used to filter variables predictive to migraine remission and construct the nomogram model. The Nomogram's accuracy and consistency were respectively assessed through Receiver Operating Characteristic (ROC) curves and calibration curves. Additionally, an analysis of decision curves (DCA) was conducted to evaluate the clinical utility of this newly developed model.

RESULT

A total of 241 consecutive patients were included in the study. The remission group included 21 males and 93 females, with a median age of 39 (30.25,50) years. The non-remission group included 26 males and 101 females, with a median age of 35 (25.5,47.5) years. All Patients were randomly divided into a training cohort and a validation cohort. Multivariable logistic regression analysis showed that 5 independent predictors, including MIDAS before closure (p = 0.0002), mitigating factors (p = 0.0057), number of attacks/month (p = 0.0058), TCD (p = 0.0093) and Platelet Crit (PCT) (p = 0.0351), played a significant role in the prediction of remission of migraine patients with PFO after closure. Based on these independent predictors, the predictive nomogram model of migraine remission in PFO patients was constructed. The application of the nomogram in the training cohort exhibited good discrimination (area under the ROC curve was 0.7763[95% CI 0.7108-0.8418]), which was confirmed in the validation cohort (AUC was 0.704[95% CI 0.5533-0.8547]). The calibration curve showed that the nomogram model demonstrated good calibration performance. Additionally, the decision curve analysis indicated the clinical utility of the nomogram model.

CONCLUSION

The construction of the nomogram model had a considerable predictive accuracy for migraine remission in patients after PFO closure, which may provide constructive guidance for clinical decision making.

Exploring the serotonin-probiotics-gut health axis: A review of current evidence and potential mechanisms

Modulatory effects of serotonin (5-Hydroxytryptamine [5-HT]) have been seen in hepatic, neurological/psychiatric, and gastrointestinal (GI) disorders. Probiotics are live microorganisms that confer health benefits to their host. Recent research has suggested that probiotics can promote serotonin signaling, a crucial pathway in the regulation of mood, cognition, and other physiological processes. Reviewing the literature, we find that peripheral serotonin increases nutrient uptake and storage, regulates the composition of the gut microbiota, and is involved in mediating neuronal disorders. This review explores the mechanisms underlying the probiotic-mediated increase in serotonin signaling, highlighting the role of gut microbiota in the regulation of serotonin production and the modulation of neurotransmitter receptors. Additionally, this review discusses the potential clinical implications of probiotics as a therapeutic strategy for disorders associated with altered serotonin signaling, such as GI and neurological disorders. Overall, this review demonstrates the potential of probiotics as a promising avenue for the treatment of serotonin-related disorders and signaling of serotonin.

Heart-brain axis: Association of congenital heart abnormality and brain diseases

Brain diseases are a major burden on human health worldwide, and little is known about how most brain diseases develop. It is believed that cardiovascular diseases can affect the function of the brain, and many brain diseases are associated with heart dysfunction, which is called the heart-brain axis. Congenital heart abnormalities with anomalous hemodynamics are common treatable cardiovascular diseases. With the development of cardiovascular surgeries and interventions, the long-term survival of patients with congenital heart abnormalities continues to improve. However, physicians have reported that patients with congenital heart abnormalities have an increased risk of brain diseases in adulthood. To understand the complex association between congenital heart abnormalities and brain diseases, the paper reviews relevant clinical literature. Studies have shown that congenital heart abnormalities are associated with most brain diseases, including stroke, migraine, dementia, infection of the central nervous system, epilepsy, white matter lesions, and affective disorders. However, whether surgeries or other interventions could benefit patients with congenital heart abnormalities and brain diseases remains unclear because of limited evidence.

Recent progress in patent foramen ovale and related neurological diseases: A narrative review

Patent foramen ovale (PFO) is a common congenital cardiac abnormality when the opening of the interatrial septum is not closed in adulthood. This abnormality affects 25% of the general population. With the development of precision medicine, an increasing number of clinical studies have reported that PFO is closely related to various neurological diseases such as stroke, migraine, obstructive sleep apnea, and decompression syndrome. It has also been suggested that PFO closure could be effective for preventing and treating these neurological diseases. Therefore, increasing attention has been given to the prevention, diagnosis, and treatment of PFO-related neurological diseases. By reviewing existing literature, this article focuses on the pathogenesis, epidemiology, and clinical characteristics of PFO-related neurological diseases, as well as the prevention and treatment of different neurological diseases to discuss, and aims to provide current progress for this field and decision-making evidence for clinical practice.

Stroke territory and atherosclerosis in ischemic stroke patients with a history of migraine with aura

Introduction

The mechanisms subtending the increased stroke risk in migraine with aura (MA) are not fully understood. Our study aims to evaluate if the clinical profile in stroke patients with MA differentiates from those without MA.

Methods

We retrieved the prospective registered electronic clinical dossiers of adult patients younger than 60 years with acute ischemic stroke admitted in four hospitals between January 2016 and June 2022. Patients were classified by the history of MA (MA+ and MA-).

Results

We identified 851 stroke patients (59 MA+, 6.9%). Compared to MA-, MA+ patients were characterized by younger age (44.0 ± 10.6 vs 50.1 ± 8.2 years), female sex (59.3% vs 29.0%), and affected by cryptogenic (OR 2.594 95% CI 1.483-4.537), and cerebellar stroke (OR 3.218 95% CI 1.657-6.250; p ≤ 0.001 for all comparisons). After adjusting for age and sex, MA+ patients presented less frequently hypertension (OR 0.349 95% CI 0.167-0.470; p=0.005) and dyslipidemia (OR 0.523 95% CI 0.280-0.974; p = 0.041). After adjusting also for risk factors, the MA+ group had less frequently symptomatic large vessel stenosis (OR 0.126 95% CI 0.017-0,924; p = 0.042) and clinical atherosclerosis (OR 0.103 95% CI 0.014-0.761; p = 0.026), while intima-media thickness did not differ (p = 0.395).

Discussion

Cryptogenic and cerebellar stroke and fewer vascular risk factors and clinical atherosclerosis seem to characterize stroke patients with MA.

Hemorrhagic stroke as a rare complication of a migraine without aura

Background

Migraine is a chronic neurological disorder, characterized by recurrent headache attacks featuring specific clinical characteristics. Two-thirds of the migraineurs are women. It takes the second place among the world’s causes of disability, and is one of the leading causes for direct and indirect government expenses. Migraine is well known to be associated with cerebrovascular diseases, in particular with stroke. Due to the recent studies, the risk of hemorrhagic stroke (HS) is 50% higher in between migraineurs in comparison to non-migraineurs, whereas only one study showed association of migraine without aura (MwtA) with increased HS incidence.

Case presentation

We present a case of 57-year-old White woman, who is a 20-year migraine sufferer admitted to the hospital with the signs of migraineous stroke. Upon evaluation after she had contrast enhancing brain magnetic resonance imaging (MRI), she was diagnosed with a neoplasm accompanied by a hemorrhage. However, the following magnetic resonance spectroscopy (MRS) as well as repeated contrast MRI did not prove the diagnosis. The patient was treated for 10 days, and discharged with complete clinical improvement.

Conclusion

The presented case highlights the importance of the accurate evaluation of the patients, suspicious of complicated migraine, even though suffering from MwtA, having no comorbidities and absent family history of cerebrovascular diseases.

Enxaqueca de alta frequência refratária a tratamento farmacológico usual e anticorpo e responsiva a canabidiol de amplo espectro: relato de caso

O uso de derivados da Cannabis sp. no tratamento de certas condições médicas, como dor neuropática, epilepsia e esclerose múltipla já é bem conhecido. Porém, estudos sobre seu benefício em cefaleias ainda são de baixa abrangência, sendo constituídos, em sua maior parte, por relatos e séries de casos. Apresentamos o caso de paciente masculino de 74 anos, portador de enxaqueca de alta frequência (2 a 3 vezes/semana) há vários anos, com importante limitação funcional associada a diversos gatilhos, fazendo uso apenas de triptanos durante as crises. Apresentou intolerância a 2 medicamentos profiláticos (topiramato e propranolol). Realizou 2 aplicações de Erenumabe 70 mg, havendo considerável melhora inicial seguida de novo aumento na frequência das crises após a segunda aplicação, com interrupção do tratamento. Fez uso de nutracêuticos por 6 meses, sem grande melhora. Após introdução de óleo de canabidiol, as crises reduziram em frequência (1 episódio/mês) e intensidade, com intervalo recorde de 30 dias seguidos sem dor, associado a eliminação de gatilhos. Estudos pré-clínicos avaliando a relação entre o sistema endocanabinoide e a fisiopatologia da migrânea apontam para os derivados da Cannabis sp. como potenciais armas para o tratamento dessa condição. No entanto, o papel desses derivados como profilaxia das crises de enxaqueca ainda é especulativo, necessitando de estudos controlados para maior definição.

The Patent Foramen Ovale and Migraine: Associated Mechanisms and Perspectives from MRI Evidence

Migraine is a common neurological disease with a still-unclear etiology and pathogenesis. Patent foramen ovale (PFO) is a kind of congenital heart disease that leads to a right-to-left shunt (RLS). Although previous studies have shown that PFO has an effect on migraine, a clear conclusion about the link between PFO and migraine is lacking. We first summarized the PFO potential mechanisms associated with migraine, including microembolus-triggered cortical spreading depression (CSD), the vasoactive substance hypothesis, impaired cerebral autoregulation (CA), and a common genetic basis. Further, we analyzed the changes in brain structure and function in migraine patients and migraine patients with PFO. We found that in migraine patients with PFO, the presence of PFO may affect the structure of the cerebral cortex and the integrity of white matter, which is mainly locked in subcortical, deep white matter, and posterior circulation, and may lead to changes in brain function, such as cerebellum and colliculus, which are involved in the processing and transmission of pain. In summary, this paper provides neuroimaging evidence and new insights into the correlation between PFO and migraine, which will help to clarify the etiology and pathogenesis of migraine, and aid in the diagnosis and treatment of migraine in the future.

Cerebral Hemodynamics, Right-to-Left Shunt and White Matter Hyperintensities in Patients with Migraine with Aura, Young Stroke Patients and Controls

Background: Migraine with aura (MA) patients present an increased risk of cerebrovascular events. However, whether these patients present an increased white matter hyperintensities (WMHs) load compared to the general population is still under debate. Our study aimed to evaluate the relationship between cerebral hemodynamics, right-to-left shunt (RLS) and WMHs in MA patients, young patients with cryptogenic stroke or motor transient ischemic attack (TIA) and controls. Methods: We enrolled 30 MA patients, 20 young (<60 years) patients with cryptogenic stroke/motor TIA, and 10 controls. All the subjects underwent a transcranial Doppler bubble test to detect RLS and cerebral hemodynamics assessed by the breath holding index (BHI) for the middle (MCA) and posterior (PCA) cerebral arteries. Vascular risk factors were collected. The WMHs load on FLAIR MRI sequences was quantitatively assessed. Results: The stroke/TIA patients presented a higher prevalence of RLS (100%) compared with the other groups (p < 0.001). The MA patients presented a higher BHI compared with the other groups in the PCA (p = 0.010) and higher RLS prevalence (60%) than controls (30%) (p < 0.001). The WMHs load did not differ across groups. BHI and RLS were not correlated to the WMHs load in the groups. Conclusions: A preserved or more reactive cerebral hemodynamics and the presence of a RLS are likely not involved in the genesis of WMHs in MA patients. A higher BHI may counteract the risk related to their higher prevalence of RLS. These results need to be confirmed by further studies to be able to effectively identify the protective role of cerebral hemodynamics in the increased RLS frequency in MA patients.

Platelet P2Y12 Inhibitor in the Treatment and Prevention of Migraine: A Systematic Review and Meta-Analysis

There have been speculation and research linking migraine with abnormalities of platelet aggregation and activation. The role of the P2Y12 platelet inhibitor in the treatment of migraine has not been established. We aim to evaluate the efficacy of the platelet P2Y12 inhibitor in the treatment of migraine and prevention of new-onset migraine headache (MHA) following transcatheter atrial septal defect closure (ASDC). We searched the PubMed, Web of Science, and Cochrane Library databases for relevant studies. The primary outcomes were the headache responder rate and the rate of new-onset migraine attacks following ASDC. Four studies for a total of 262 migraine patients with or without patent foramen ovale (PFO) and three studies involving 539 patients with antiplatelet treatment in the prevention of new-onset migraine following ASDC were included. The pooled responder rate of the P2Y12 inhibitor for migraine was 0.64 (95% CI: 0.43 to 0.81). For patients who underwent ASDC, the use of antiplatelet regimens including the P2Y12 inhibitor, compared with regimens excluding P2Y12 inhibitor, resulted in a lower rate of new-onset migraine (OR: 0.41, 95% CI: 0.22 to 0.77, P = 0.005). We concluded that the P2Y12 platelet inhibitor may have a primary prophylactic role in migraine patients with or without PFO and prevent new-onset MHA after ASDC. The responsiveness of the P2Y12 inhibitor could help select candidates who would benefit from PFO closure. It warrants further large-scale research to explore the role of the P2Y12 inhibitor, particularly in a proportion of migraine patients.

Migraine and Stroke: In Search of Shared Pathways, Mechanisms, and Risk Factors

Migraines are one of the emerging causes of disabilities experienced worldwide, and strokes are the second leading cause of death globally. Migraines with aura have been reported to be associated with a higher risk of ischemic strokes, whereas hemorrhagic strokes are more closely associated with migraines without aura, possible mechanisms that link migraines to strokes. These can be categorized into vascular mechanisms such as vasospasm, endothelial and platelet dysfunction, and alteration in the vessel wall seen in migraineurs, further perpetrated by vascular risk factors such as hypertension and hyperlipidemias. Cerebral hypoperfusion that occurs in migraines can cause an electrical aberrance, leading to a phenomenon known as "spreading depression" which can contribute to strokes. In this review, we discuss bloodstream elevation in procoagulants such as antiphospholipid antibodies, homocysteine, von Willebrand factor, and prothrombin. Maintaining pregnant women who actively experience migraines with aura under close observation may be of some value in achieving better outcomes. Women who experience migraines after starting hormonal contraception are at a higher risk of experiencing strokes and stand to benefit from being switched to non-hormonal methods. In this article, we discuss the mechanisms linking migraines and strokes, briefly discuss the pathogenesis, and explore the risk factors contributing to the association therein. In addition, we examine the relationship between migraines and ischemic strokes, as well as hemorrhagic strokes, and review management considerations.

Role of herbal medicine for prevention and treatment of migraine

Migraine is a disabling neurovascular disease with unilateral or bilateral pulsatile headache, which intensively affects human health and quality of life due to high morbidity worldwide. Migraine is commonly accompanied by abnormal pain sensitization, neuroinflammatory response, and vasomotor dysfunction. Owing to the management dilemmas of migraine, there is an urgent need to develop effective and low-cost therapies. In recent years, herbal medicines as a promising strategy with analgesic activity and minor side effect, have been proposed for the prevention and treatment of migraine. Considering the lack of a review integrating experimental studies regarding the herbal treatment of migraine, this review systematically summarizes the important potential applications of herbal medicines in ameliorating migraine via multiple therapeutic targets and pathways, as well as provides a reference for further development of novel antimigraine drugs.

Involvement of P2Y12 receptors in an NTG-induced model of migraine in male mice

BACKGROUND AND PURPOSE

P2Y₁₂ receptors (P2Y₁₂ Rs) are known to regulate different forms of pain and inflammation. In this study we investigated the participation of P2Y₁₂ Rs in an animal model of migraine.

EXPERIMENTAL APPROACH

We tested the effect of the centrally administered selective P2Y₁₂ R antagonist PSB-0739, and P2Y₁₂ R gene deficiency in acute nitroglycerin (NTG)-treated mice. Additionally, platelet depletion was used to investigate the role of platelet P2Y₁₂ Rs during migraine-like pain.

KEY RESULTS

NTG induced sensory hypersensitivity of C57BL/6 wild-type (P2ry12^+/+ ) mice, accompanied by an increase in c-fos and CGRP expression in the upper cervical spinal cord (C1-C2) and trigeminal nucleus caudalis (TNC). Similar changes were also observed in P2Y₁₂ R gene-deficient (P2ry12^-/- ) mice. Prophylactic intrathecal application of PSB-0739 reversed thermal hyperalgesia and head grooming time in wild-type mice but had no effect in P2ry12^-/- mice; furthermore, it was also effective when applied as a post-treatment. PSB-0739 administration suppressed the expression of c-fos in C1-C2 and TNC, and decrease C1-C2 levels of dopamine and serotonin in wild-type mice. NTG treatment itself did not change adenosine diphosphate (ADP)-induced platelet activation measured by CD62P upregulation in wild-type mice. Platelet depletion by anti-mouse CD41 antibody and clopidogrel attenuated NTG-induced thermal hypersensitivity and head grooming time in mice.

CONCLUSION AND IMPLICATIONS

Taken together, our findings show that acute inhibition of P2Y₁₂ Rs alleviates migraine-like pain in mice, by modulating the expression of c-fos, and platelet P2Y₁₂ Rs might contribute to this effect. Hence, it is suggested that the blockade of P2Y₁₂ Rs may have therapeutic potential against migraine.

Patent foramen ovale closure in stroke patients with migraine in the CLOSE trial. The CLOSE-MIG study

BACKGROUND AND PURPOSE

The efficacy of patent foramen ovale (PFO) closure to reduce the frequency of migraine attacks remains controversial.

METHODS

This was a planned sub-study in migraine patients enrolled in a randomized, clinical trial designed to assess the superiority of PFO closure plus antiplatelet therapy over antiplatelet therapy alone to prevent stroke recurrence in patients younger than 60 years with a PFO-associated cryptogenic ischaemic stroke. The main outcome was the mean annual number of migraine attacks in migraine patients with aura and in those without aura, as recorded at each follow-up visit by study neurologists.

RESULTS

Of 473 patients randomized to PFO closure or antiplatelet therapy, 145 (mean age 41.9 years; women 58.6%) had migraine (75 with aura and 70 without aura). Sixty-seven patients were randomized to PFO closure and 78 to antiplatelet therapy. During a mean follow-up of about 5 years, there were no differences between antiplatelet-only and PFO closure groups in the mean annual number of migraine attacks, both in migraine patients with aura (9.2 [11.9] vs. 12.0 [19.1], p = 0.81) and in those without aura (12.1 [16.1] vs. 11.8 [18.4], p > 0.999). There were no differences between treatment groups regarding cessation of migraine attacks, migraine-related disability at 2 years and use of migraine-preventive drugs during follow-up.

CONCLUSIONS

In young and middle-aged adults with PFO-associated cryptogenic stroke and migraine, PFO closure plus antiplatelet therapy did not reduce the mean annual number of migraine attacks compared to antiplatelet therapy alone, in migraine patients both with and without aura.

Pathophysiological Bases of Comorbidity in Migraine

Despite that it is commonly accepted that migraine is a disorder of the nervous system with a prominent genetic basis, it is comorbid with a plethora of medical conditions. Several studies have found bidirectional comorbidity between migraine and different disorders including neurological, psychiatric, cardio- and cerebrovascular, gastrointestinal, metaboloendocrine, and immunological conditions. Each of these has its own genetic load and shares some common characteristics with migraine. The bidirectional mechanisms that are likely to underlie this extensive comorbidity between migraine and other diseases are manifold. Comorbid pathologies can induce and promote thalamocortical network dysexcitability, multi-organ transient or persistent pro-inflammatory state, and disproportionate energetic needs in a variable combination, which in turn may be causative mechanisms of the activation of an ample defensive system with includes the trigeminovascular system in conjunction with the neuroendocrine hypothalamic system. This strategy is designed to maintain brain homeostasis by regulating homeostatic needs, such as normal subcortico-cortical excitability, energy balance, osmoregulation, and emotional response. In this light, the treatment of migraine should always involves a multidisciplinary approach, aimed at identifying and, if necessary, eliminating possible risk and comorbidity factors.

Review of aromatherapy essential oils and their mechanism of action against migraines

ETHNOPHARMACOLOGICAL RELEVANCE

Migraines have become a major threat to human health, as they significantly affect human health and quality of life due to a high prevalence rate, attack rate and pain intensity. Aromatherapy, with its comfortable and pleasant natural characteristics and rapid and efficient characteristics, is widely favored by patients in the folk. Chinese folk also have the application history and related records of aromatic plants in the treatment of migraine.

AIM OF THE STUDY

This study was conducted to review the pathogenesis of migraine, the application of plant essential oils in the treatment of migraine, and further explore the material basis and mechanism of action of plant essential oils against migraine.

MATERIALS AND METHODS

Search the electronic literature of essential oils with anti-migraine effect in Google Scholar, PubMed and China National Knowledge Infrastructure, and further search the research situation of the monomer components of essential oils in migraine, inflammation, pain and other aspects.

RESULTS

studies show that there are 10 types of plant essential oils that could relieve migraine symptoms, and that 16 monomers may play a role in migraine treatment by effectively inhibiting neurogenic inflammation, hyperalgesia and balancing vasorelaxation.

CONCLUSION

Aromatic plant essential oils can relieve migraine effectively, these findings can be used as an important part of the development of anti-migraine drugs.

Phytotherapy Perspectives for Treating Fungal Infections, Migraine, Sebhorreic Dermatitis and Hyperpigmentations with the Plants of the Centaureinae Subtribe (Asteraceae)

Sesquiterpene lactones, coumarins, phytoecdysones and phenolic compounds are characteristic of the species from the subtribe Centaureinae (Asteraceae). Many of the compounds isolated from plants of the Centaureinae subtribe have strong pharmacological properties. It may be suggested that these compounds' chemical structure might be an indicator of these pharmacological properties. The aim of the study was to describe recent studies in the field of phytotherapy, focusing on compounds isolated from chosen plants of Centaureinae and the possibilities of using them to treat antifungal infections, inhibit serotonin and ease symptoms of seborrhea dermatitis and hyperpigmentation. The results of these biological studies have shown that in the future, extracts from the above-mentioned plant material may be used as active substances in new safe and effective drugs.

Headache and Left Ventricular Efficiency After Transcatheter Closure of Atrial Septal Defect

OBJECTIVE/BACKGROUND

This study aimed to clarify the relationship between migraine-like headache and ventriculo-arterial coupling after transcatheter closure of the atrial septal defect in children. We hypothesized that migraine headache after defect closure would be related to an abnormal hemodynamic response against an increased left ventricular filling.

DESIGN

A retrospective cohort study.

METHODS

We calculated the end-ventricular systolic elastance (Ees), effective arterial elastance (Ea), and ventricular energy efficiency approximated based on echocardiography before and after defect closure, and compared these parameters between the subjects with and without headache after defect closure.

RESULTS

A total of 167 subjects were studied. Age at the procedure, defect diameter, and pulmonary to systemic blood flow ratio were 11 (9-17) years, 12.8 (9.2-16.0) mm, and 1.8 (1.6-2.3), respectively. We identified 47 (28%) subjects with migraine headache after defect closure. Although there was no significant difference in the Ees, Ea, and ventricular energy efficiency before defect closure between the groups, the Ees (4.0 [3.4-4.9] vs 4.8 [3.7-6.1], P = .014) and ventricular energy efficiency (0.79 [0.76-0.82] vs 0.83 [0.79-0.85], P = .001) after defect closure in subjects with headache were significantly lower than those in subjects without headache. Migraine headache after defect closure was significantly associated with age (odds ratio: 0.97, 95% confidential interval: 0.94-1.00, P = .036) and a decrease in the ventricular energy efficiency after defect closure (odds ratio: 6.42, 95% confidential interval: 2.76-14.90, P < .001).

CONCLUSION

A loss of ventricular energy efficiency was common in pediatric subjects with migraine-like headache after transcatheter closure of the atrial septal defect, which suggested that the left ventricular function maladaptation was related to headache development after defect closure. We advocate that an impaired ventriculo-arterial coupling may be one of the mechanisms for developing attacks in not only this population but also in other patients with migraine.

Clinical features of right-to-left shunt in the different subgroups of migraine

OBJECTIVE

Several investigations have documented an association between migraine and right-to-left shunt (RLS). However, whether there are specific clinical features that can distinguish between migraine patients with and without RLS is unclear. This study aims to explore whether there are specific clinical features that can distinguish between migraine patients with and without RLS, and to investigate the relationship between the degree of shunt and clinical parameters of headache.

METHODS

In this study, we enrolled consecutive migraineurs who underwent a structured, standardized questionnaire for family and personal history and for detailed migraine features. RLS was diagnosed based on a contrast enhancement transcranial Doppler (c-TCD) examination.

RESULTS

Overall, 113 migraine with aura (MA) and 192 migraine without aura (MO) patients were included. Patients with MA and RLS (MARLS+) had a higher frequency for sensory aura symptoms than those with MA without RLS (MARLS-) (27.4% vs. 10.0%, p = .03). Patients with MO and RLS (MORLS+) presented with significantly younger initial age of migraine onset and experienced more severe pain intensity than those with MO without RLS (MORLS-) (mean ± SD, 25.6 ± 8.9 vs. 29.8 ± 12.7 years, p = .008 and 5.9 ± 1.4 vs. 5.3 ± 1.3, p = .006, respectively). There was no relationship between the degree of shunt and the clinical parameters of headache.

CONCLUSIONS

Our results indicate that MO patients presented with a younger initial age of migraine onset and that sensory aura symptoms in MA patients may predict the presence of RLS. However, we did not find support for relationship between the degree of shunt and clinical parameters of headache.

A Possible Role of Amyloidogenic Blood Clotting in the Evolving Haemodynamics of Female Migraine-With-Aura: Results From a Pilot Study

Introduction: Migraine is a debilitating primary headache disorder with a poorly understood aetiology. An extensive body of literature supports the theory of migraine as a systemic vascular inflammatory disorder characterised by endothelial dysfunction. It is also well-known that chronic inflammation results in an excessive burden of oxidative stress and therefore cellular dysfunction. In this study the effects of excessive oxidative stress through the phases of female migraine-with-aura (FMA) were evaluated by examining the health of the systems of haemostasis.

Methods: Blood was obtained from 11 FMA patients at baseline and during the headache phase of migraine, as well as from 8 healthy age-matched female controls. Samples were analysed using thromboelastography (TEG) to evaluate viscoelastic profiles, light microscopy for erythrocyte morphology, Scanning Electron Microscopy (SEM) for erythrocyte and fibrin clot structure, confocal microscopy for β-amyloid detection in fibrin clots.

Results: Viscoelastic profiles from platelet poor plasma showed decreased clot reaction times in FMA at baseline (95% CI [5.56, 8.41]) vs. control (95% CI [7.22, 11.68]); as well as decreased time to maximum thrombus generation for the same comparison (95% CI [6.78, 10.20] vs. [8.90, 12.96]). Morphological analysis of erythrocytes indicated widespread macrocytosis, poikilocytosis and eryptosis in the migraineurs. Analysis of fibrin networks indicated that this hypercoagulability may be a result of aberrant fibrin polymerisation kinetics caused by the adoption of a β-amyloid conformation of fibrin(ogen).

Conclusion: The results reaffirm the hypercoagulable state in migraine, and would suggest that this state is most likely a result of a systemic inflammatory state which induces oxidative damage to both erythrocytes and fibrin(ogen) in female episodic migraine-with-aura. Furthermore, if the amylodogenic changes to fibrin(ogen) were observed in a larger cohort, this would support theories of micro-embolisation in migraine-with-aura.

The Anti-Serotonin Effect of Parthenolide Derivatives and Standardised Extract from the Leaves of Stizolophus balsamita

The presence of dominant active compounds in standardised methanol extract from the leaves of Stizolophus balsamita (S. balsamita) was examined using HPLC with a diode-array detector. The extract and three dominant parthenolide derivatives were tested with Serotonin Research ELISA for their ability to inhibit the serotonin release from platelets. The antiserotonin effect of the extract was compared with that of parthenolide, a compound with proven antiserotonin and antimigraine effects. This study aimed to evaluate the ability of natural parthenolide derivatives to inhibit serotonin release from platelets. Izospiciformin, stizolin and stizolicin were analysed along with the standardised alcohol extract of S. balsamita leaves, which also contained four other parthenolide derivatives. All the analysed substances were found to inhibit serotonin release from platelets as compared with the control sample, which had 100% of serotonin released. Izospiciformin had the most significant impact (97.98% serotonin release inhibition). The effect of the methanol extract of S. balsamita on the serotonin release inhibition was also statistically significant.

Association of diet and headache

The global prevalence of migraine as a primary headache has been estimated as 14.4% in both sexes. Migraine headache has been ranked as the highest contributor to disability in under 50 years old population in the world. Extensive research has been conducted in order to clarify the pathological mechanisms of migraine. Although uncertainties remains, it has been indicated that vascular dysfunction, cortical spreading depression (CSD), activation of the trigeminovascular pathway, pro-inflammatory and oxidative state may play a putative role in migraine pain generation. Knowledge about pathophysiological mechanisms of migraine should be integrated into a multimodal treatment approach to increase quality of life in patients. With respect to this, within the integrative health studies growing interest pertains to dietary interventions. Although the number of studies concerning effects of diet on headache/migraine is not yet very large, the current article will review the available evidence in this area. All publications on headache/migraine and dietary interventions up to May 2019 were included in the present review through a PubMed/MEDLINE and ScienceDirect database search. According to the current findings, Ketogenic diet and modified Atkins diet are thought to play a role in neuroprotection, improving mitochondrial function and energy metabolism, compensating serotoninergic dysfunction, decreasing calcitonin gene-related peptide (CGRP) level and suppressing neuro-inflammation. It can also be speculated that prescription of low glycemic diet may be promising in headache/migraine control through attenuating the inflammatory state. Moreover, obesity and headaches including migraine could be attributed to each other through mechanisms like inflammation, and irregular hypothalamic function. Thereby, applying dietary strategies for weight loss may also ameliorate headache/migraine. Another important dietary intervention that might be effective in headache/migraine improvement is related to balance between the intake of essential fatty acids, omega-6 and omega-3 which also affect inflammatory responses, platelet function and regulation of vascular tone. Regarding elimination diets, it appears that targeted these diets in migraine patients with food sensitivities could be effective in headache/migraine prevention. Taken together, dietary approaches that could be considered as effective strategies in headache/migraine prophylaxis include weight loss diets in obese headache patients, ketogenic and low-calorie diets, reducing omega-6 and increasing omega-3 fatty acid intakes.

Episodic primary migraine headache: supplementary prophylaxis with Pycnogenol® prevents attacks and controls oxidative stress

BACKGROUND

This registry study investigated the supplement Pycnogenol® on migraine headache attacks and oxidative stress in otherwise healthy subjects with migraine and moderate headache (MH).

METHODS

To manage MH, these subjects used only a few drugs (antiemetics, analgesics on demand) and lifestyle changes; only very occasionally they used other, more specific products such as triptans. Study groups: one group used only standard management (SM), basically, management on demand. Oral magnesium and riboflavin (vitamin B2) were used with lipoic acid as they are considered useful to improve MH. Another group used the supplement Pycnogenol® (150 mg/day for 8 weeks) in addition to SM. These two groups were compared to a third (non-parallel, observational) group using topiramate (50 mg/day). If needed, subjects were allowed to use rescue medications.

RESULTS

Forty-six subjects were included in the study. Twenty-two used the standard management and 24 were supplemented with Pycnogenol® in association with SM. In addition, 21 subjects were treated with topiramate. Safety with Pycnogenol® was very good. The two main management groups and the third non-parallel group had comparable baseline characteristics. The number of migraine attacks were significantly reduced during the observation period with Pycnogenol® (P<0.05) in comparison with SM. Supplementation was more effective in reducing the use of rescue medications (P<0.05) including analgesics compared to SM. At 8 weeks, the pain score was lower with Pycnogenol in comparison with SM (P<0.05). The working incapacity was significantly lower with Pycnogenol® than in the SM group (P<0.05). The number of migraine attacks was lower with topiramate compared to SM. Pain score, working incapacity and use of rescue medication were lower with topiramate than in SM. However, adverse effects with topiramate, included paresthesia, fatigue, dizziness and nausea even at low dosages complicated management. Some 50% of these side effects require a form of further treatment including medications. Oxidative stress: all included subjects had high oxidative stress at baseline. At 8 weeks, the level of plasma free radicals was significantly lowered with Pycnogenol® (P<0.05), but not in the SM or topiramate group.

CONCLUSIONS

Pycnogenol® used as prophylaxis appears to reduce pain and the number and severity of symptoms in MH in parallel with a reduction of oxidative stress.

A Chinese Prescription Chuanxiong Chatiao San for Migraine: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Backgrounds

Chuanxiong Chatiao san (CXCT) is a famous Chinese classical prescription. It has a favorable effect in treating migraine. It is reported that CXCT combined with Western conventional medicine (WCM) could increase the therapeutic efficacy on migraine. The purpose of this paper is to systematically assess the clinical efficacy, safety, and some indexes of CXCT for migraine.

Methods

PubMed, Embase Database, China National Knowledge Infrastructure (CNKI), Wanfang Database, the Cochrane Library, and the CBM were searched from January 2000 to February 2019. We made a detailed record of outcome measurements. Meta-analysis was performed using RevMan 5.3 software.

Results

A total of 3307 patients were included in the 37 articles. Meta-analysis showed that CXCT significantly increased the total efficiency rate (TER), compared with Western medicine treatment (WMC) (P < 0.00001). When CXCT is combined with WMC, the result showed that P < 0.00001. CXCT was significantly reduced the adverse events (AEs) compared with WMC (P < 0.00001). The levels of VAS, number of migraine episodes (NE), and time of headache duration (TD) were significantly reduced (P < 0.00001). Platelet function and blood rheology level were improved via a significantly decrease in 5-HT and β-EP (P < 0.00001). Other indicators such as substance P, CGRP high-cut viscosity, low-cut viscosity, plasma viscosity, and fibrinogen were significantly reduced (P < 0.00001).

Conclusion

Our findings provide evidence that CXCT and CXCT combined with WMC have higher efficacy in the treatment of migraine compared with WCM alone. Methodological quality was generally low, so the conclusion of this paper has some limitations and it has to be carefully evaluated.

Liposomal Curcumin Enhances the Effect of Naproxen in a Rat Model of Migraine

BACKGROUND Curcumin is an antioxidant that reduces inflammation and pain. This study aimed to assess the effect of pretreatment with naproxen and liposomal curcumin compared with naproxen and curcumin solution on oxidative stress parameters and pain in a rat model of migraine. MATERIAL AND METHODS Sixty-three male Wistar rats included a control group (n=9) and a rat model of migraine (n=54) induced by intraperitoneal injection of nitroglycerin (1 mg/0.1 kg). The rat model group was divided into an untreated control group (n=9), a group pretreated with naproxen alone (2.8 mg/kg) (n=9), a group pretreated with naproxen (2.8 mg/kg) combined with curcumin solution (1 mg/0.1 kg) (n=9), a group pretreated with naproxen (2.8 mg/kg) combined with curcumin solution (2 mg/0.1 kg) (n=9), a group pretreated with naproxen (2.8 mg/kg) combined with liposomal curcumin solution (1 mg/0.1 kg) (n=9) a group pretreated with naproxen (2.8 mg/kg) combined with liposomal curcumin solution (2 mg/0.1 kg) (n=9). Spectroscopy measured biomarkers of total oxidative status and nociception was tested using an injection of 1% of formalin into the rat paw. RESULTS Expression of biomarkers of oxidative stress and enhanced nociception were significantly increased following pretreatment with combined naproxen and liposomal curcumin compared with curcumin solution or naproxen alone (P<0.001). Combined curcumin solution and naproxen were more effective at a concentration of 2 mg/0.1kg for the first nociceptive phase (P<0.005). CONCLUSIONS In a rat model of migraine, combined therapy with liposomal curcumin and naproxen showed an improved antioxidant effect and anti-nociceptive effect.

The Burden of Migraine in Adults with Atrial Septal Defect: A Nationwide Cohort Study

We aimed to investigate migraine diagnoses in a hospital setting, use of prescription migraine medicine and levels of serotonin in patients with atrial septal defect. Using Danish national registries to identify all patients born before 1994 diagnosed with atrial septal defect between 1959 and 2013, thus including 2277 patients and a gender and age matched comparison cohort of 22756. Plasma serotonin was measured in 136 patients with a small, unclosed, atrial septal defects and 18 controls. Patients with atrial septal defect had an increased risk of receiving a migraine diagnosis (HR 3.4 (95% CI: 2.6–4.6)) and receiving migraine medicine (HR 1.8 (95% CI: 1.2–2.5)). Ten years after closure, 93% of those using migraine medicine pre-closure, were still receiving this. The risk of having very high plasma serotonin levels was increased in patients with atrial septal defect compared with the control group, but there was no difference in the median values between the two groups. Migraine and use of migraine medicine were increased in atrial septal defect patients. The use of medicine was not diminished by closure of the defect. Plasma serotonin was severely elevated in 18% of the patients with atrial septal defect.

Mitochondrial Migraine: Disentangling the angiopathy paradigm in m.3243A>G patients

Migraine, characterized by recurrent attacks of predominantly unilateral throbbing headache, affects approximately 15% of the adult population and is an important cause of disability worldwide. Knowledge required for the development of new classes of antimigraine drugs might come from studying rare metabolic diseases associated with migraine. An illustrative example of a monogenetic disorder associated with migraine is the spectrum of disorders caused by the m.3243A>G mutation in the mitochondrial transfer RNA Leucine. Reported migraine prevalence figures in patients with this particular mutation vary considerably, but compared to the general population, m.3243A>G patients have a higher migraine prevalence. This burdensome symptom might sometimes even be the only clinical feature in maternal relatives carrying the m.3243A>G mutation. Although the exact sequence of events and the relative importance of factors underlying migraine in m.3243A>G MELAS spectrum disorders are still enigmatic, substantial evidence in man exist that dysfunctional mitochondria in both the vascular, the smooth muscle cells and the neuronal system and the interaction between these are at the starting point of the migraine developing pathophysiological cascade. Exclusively based on results of studies performed in patients harboring the m.3243A>G mutation, either in vivo or ex vivo, we here summarize our current understanding of mitochondrial angiopathy associated migraine in m.3243A>G patients which knowledge might lead to potential new avenues for migraine drug development.

A New Perspective of Migraine Symptoms in Patients With Congenital Heart Defect

OBJECTIVE

To investigate the association between congenital heart defects (CHDs) and migraine and evaluate the efficacy of transcatheter defect closure from a new perspective.

METHODS

The patients with CHDs who underwent transcatheter defect closure were screened in the medical database of Chinese PLA General Hospital from January 2006 to January 2017. The assessment included basic admission information, the 3-item ID Migraine Screener, and a detailed questionnaire administered by telephone or in an outpatient clinic. Patients were divided into ventricular septal defect (VSD) group and AP group (ie, patients with ASD or PFO) based on the type of defects. The latter group could be further divided into right-to-left shunt (RLS) group and left-to-right (LRS) shunt group. Each group contained 4 subgroups according to their migraine diagnosis before and after defect closure: persistent migraine (PM), relieved migraine (RM), without migraine (WM), and new-onset migraine (NM).

RESULTS

The study recruited total 441 CHDs patients. Most patients in RLS group had migraine before and/or after surgery (76.4%, 42/55) and the proportion of them in NM group was higher than that of in LRS group (23.5%, 4/17 vs 6.8%, 18/266, P = .0418). Although the size of closure device or defect did not show significant differences, the ratios (R = size of closure/size of defect) were significantly higher in NM group than those in WM group (1.40 [1.26, 1.80] vs 1.22 [1.13, 1.38] in AP group, P = .00238; 1.38 [1.23, 1.50] vs 1.22 [1.13, 1.37] in LRS group, P = .024934, respectively). Further logistic regression analysis illustrated that larger R value was a risk factor for NM in AP group (OR 1.48, 95% CI 1.07-2.05, P = .0188). Besides, migraine symptoms decreased significantly after defect closure in PM group among patients with ASD and PFO.

CONCLUSION

This study revealed several associations between migraine and CHDs, especially the large ratio of closure device size to defect size. High-quality randomized controlled trials and animal studies are needed to further investigate and clarify the underlying association between CHDs and migraine.

Patent Foramen Ovale in Cryptogenic Stroke and Migraine with Aura: Does Size Matter?

Introduction: There is an association between cryptogenic strokes and patent foramen ovale (PFO), as well as between migraines with aura and PFO. The purpose of the current study was to compare shunt characteristics in the stroke and migraine populations.

Methods: We retrospectively evaluated the degree of the shunt in 68 consecutive patients with cryptogenic stroke (n=33) or migraines with aura (n=35) evaluated in a single transcranial Doppler laboratory. All patients underwent an intravenous injection of agitated saline, followed by the insonation of the middle cerebral artery to determine the degree of the right-to-left shunt. We graded the shunt size according to the number of emboli: Grade I, none; Grade II, 1-10; Grade III, 11-100; and Grade IV, >100. Grades I and II were considered low-grade shunts, and Grades III and IV were considered high-grade.

Results: In the 14-month study period, we found 31 high-grade shunts and 37 low-grade shunts. Among migraines with aura patients, 27 (77%) had high-grade shunts, whereas only 4 patients (12%) with cryptogenic stroke had high-grade shunts. These percentages were significantly different between groups (Fisher’s exact test, p<0.0001).

Conclusions: In a standardized laboratory using uniform methods, we found a significant difference in shunt size associated with PFO between cryptogenic stroke and migraine with aura patients. We hypothesize that in migraines with aura, venous admixture with arterial blood is the main mechanism by which PFO contributes to the condition. In contrast, cryptogenic strokes associated with PFO are more likely to arise from an atrial septal clot within the PFO space.

Frequency of Patent Foramen Ovale and Migraine in Patients With Cryptogenic Stroke

BACKGROUND AND PURPOSE

Individuals with migraine are at higher risk for stroke, but the mechanism has not been established. On the basis of the association between migraine and intracardiac right-to-left shunt, it has been proposed that stroke in migraineurs could be caused by a paradoxical embolus passing through a patent foramen ovale (PFO) or pulmonary arteriovenous malformation. The aim of this study was to determine the prevalence of PFO with right-to-left shunt in patients who presented with cryptogenic stroke and had a history of migraine.

METHODS

Patients between 18 and 60 years old who presented with an ischemic stroke were characterized based on ASCOD phenotyping (atherosclerosis; small-vessel disease; cardiac pathology; other causes; dissection). A migraine diagnosis was identified by reviewing physician notes, and frequent aura was defined if present in at least 50% of attacks. A PFO with right-to-left shunt diagnosis was identified by the presence of a positive bubble contrast study with either transcranial Doppler, transthoracic, or transesophageal echocardiography.

RESULTS

Of the 712 patients who presented with ischemic stroke, 127 (18%) were diagnosed as cryptogenic; 68 patients had adequate testing for PFO and a documented migraine history. The prevalence of PFO in patients with cryptogenic stroke without migraine was elevated (59%) compared with the general population (18%). Patients with both cryptogenic stroke and migraine had a higher prevalence of PFO (79%). In patients with cryptogenic stroke who had migraine with frequent aura, the prevalence of PFO was 93%. Only 5 patients (4%) had a history compatible with migrainous infarction.

CONCLUSIONS

In patients with cryptogenic stroke who have migraine, there is a high prevalence (79%) of PFO with right-to-left shunt. The timing of the stroke in migraineurs is usually not related to a migraine attack. These observations are consistent with the hypothesis that the mechanism of stroke in migraineurs is most likely because of a paradoxical embolus. Future cryptogenic stroke classification schemes should consider including PFO as a separate etiologic category.

Arguments against the role of cortical spreading depression in migraine

Cortical spreading depression (CSD) is a wave of increased electrocortical activity and vasodilation, followed by sustained decreased activity and prolonged vasoconstriction. Although the discovery of CSD has been ascribed to Leão, rather than vasoconstriction, he only observed a depression of neural activity combined with vasodilation, with much weaker stimulation than used by his followers. There is a longstanding belief that CSD underlies migraine aura, with its positive symptoms such as mosaic patterns and its negative symptoms such as scotoma, and a similar propagation speed and vasoreaction pattern. However, there are many arguments against this theory. CSD is difficult to evoke in man, and electroencephalography (EEG) readings are not flattened during migraine (as opposed to EEG during CSD). Moreover, in contrast to CSD, migraine can occur bilaterally, and is not accompanied by a disrupted blood-brain barrier, increased cerebral metabolism, or cerebral cell swelling. Calcitonin gene-related peptide, which is thought to be characteristic of migraine pain, is increased in the blood from the external jugular vein during migraine in humans, but not during CSD in cats or rats. Moreover, CSD does not explain the appearance of premonitory symptoms or allodynia, long before the actual onset of aura. In addition, there is a variation in the pain mechanisms of migraine and CSD, and in their reaction to transcranial magnetic stimulation and several pharmacologic interventions. Finally, the origin of putative CSD in migraine is currently unknown.

Patent Foramen Ovale and Migraine Headache

Migraine headache is a common and debilitating disease that has a demonstrable association with the presence of patent foramen ovale (PFO) in multiple case series. Closure of PFO has been performed to try to treat migraine with aura, with variable results. Although early trials suggested benefit to PFO closure, these were of poor quality, and subsequent randomized trials have failed to yield positive results. This article discusses the evidence of an association with PFO and migraine headache, and the trials that have so far been performed to assess the benefits of closure.

The Use of Cannabis for Headache Disorders

Headache disorders are common, debilitating, and, in many cases, inadequately managed by existing treatments. Although clinical trials of cannabis for neuropathic pain have shown promising results, there has been limited research on its use, specifically for headache disorders. This review considers historical prescription practices, summarizes the existing reports on the use of cannabis for headache, and examines the preclinical literature exploring the role of exogenous and endogenous cannabinoids to alter headache pathophysiology. Currently, there is not enough evidence from well-designed clinical trials to support the use of cannabis for headache, but there are sufficient anecdotal and preliminary results, as well as plausible neurobiological mechanisms, to warrant properly designed clinical trials. Such trials are needed to determine short- and long-term efficacy for specific headache types, compatibility with existing treatments, optimal administration practices, as well as potential risks.

Migraine Modulation and Debut after Percutaneous Atrial Septal Defect Closure: A Review

INTRODUCTION

Change in migraine headache (MH)-preexisting MH change or development of de novo MH-are known potential complications following percutaneous closure of atrial septal defect (ASD), but consensus on a causal trigger remains elusive.

OBJECTIVES

To expose potential MH triggers linked, mainly by timing and occurrence, to the emergence of de novo MH or change in preexisting MH subsequent to percutaneous ASD closure (pASDC).

METHODS

The literature was systematically searched for studies available in English reporting MH status after pASDC published between January 1, 1990 and November 15, 2015. We determined the number and percentage of patients experiencing MH status change within 7 days post procedure and the cumulative total by final follow-up (Mdn = 12 months).

RESULTS

Twenty-five studies met the inclusion criteria, which accounted for a total of 1,646 pASDC patients. Pre-procedure MH prevalence was 8% (126/1,646). Change in preexisting MH occurred in a total of 72% (91/126), 12% (11/91) within 7-days after pASDC; within follow-up MH improved in 14% (18/126), resolved in 37% (47/126), but persisted in 63% (79/126). De novo MH incidence ranged between 10 (153/1,520) and 18.3% (153/836); 34% incipience (52/153) was within 7-days of pASDC; females accounted for 80% (63/79) of gender differentiated cases; of type distinguished cases, 42% (51/122) were MH without aura (MO) and 58% (71/122) were MH with aura (MA); MH improved in 10% (16/153), resolved in 24% (37/153) but persisted beyond final follow-up in 76% (116/153). Antiplatelet agents were effective modulators of MH in 44% (11/25) studies. Possible adverse MH-predisposing traits were scarce: larger ASD size reported in ~2% (39/1,646) of patients experiencing de novo MH or preexisting MH exacerbation; short aortic rim reported in three de novo MH patients; allergic response to occluder nickel alloy in four patients with MH status change from baseline (de novo or preexisting MH change not specified).

INTERPRETATION

Early intensification of MH status change but later amelioration (virtually paralleling stages of endothelialization), relatively high efficacy of antiplatelet agents, and the emergence of MA as the dominant de novo MH type favor proinflammatory triggers of MH status change after pASDC.

The relationship between right-to-left shunt and brain white matter lesions in Japanese patients with migraine: a single center study

BACKGROUND

There may be a link between right-to-left shunt (RLs) and brain white matter lesions (WMLs) in patients with migraine. In this study, we assessed the relationship between WMLs and RLs in Japanese migraine patients.

METHODS

A total of 107 consecutive patients with migraine with (MA) and without aura (MWOA) were included in this study. Contrast transcranial Doppler ultrasound was used to detect RLs. WMLs were graded using brain magnetic resonance imaging based on well-established criteria.

FINDINGS

The prevalence of RLs was significantly increased in the WMLs positive group (n = 24) compared with the WMLs negative group (n = 83) (75.0% vs. 47.0%, p = 0.015). In prevalence of WMLs between MA and MWOA patients, there were no statistical differences (p = 0.410). Logistic regression analysis adjusted by age and disease duration of migraine identified an RLs-positive status as the sole determinant for the presence of WMLs (OR = 6.15; 95% CI 1.82-20.8; p = 0.003) CONCLUSION: Our study suggests a possible link between RLs and WMLs in Japanese patients with migraine.

Prevalence of Right to Left Shunts in Japanese Patients with Migraine: A Single-center Study

Objective Several studies have shown an increased prevalence of right-to-left shunt (RLs) in migraine patients, particularly those with aura. However, the prevalence of RLs and its relation to Japanese patients with migraine are unknown. We investigated the prevalence of RLs in Japanese patients with migraine. Methods In total, 112 consecutive patients with migraine were recruited from our headache outpatient clinic. Migraine with aura (MA) and migraine without aura (MWOA) were diagnosed according to the International Classification of Headache Disorders, 3rd edition (beta-version). Contrast transcranial Doppler ultrasound was used to detect RLs, including patent foramen ovale (PFO). Then, the associations between RLs and patients' backgrounds and presence of aura were assessed. Results The overall prevalence of RLs and PFO in migraine patients was 54.5% and 43.8%, respectively. The prevalence of RLs and PFO in the MA group were significantly higher than in the MWOA group (RLs, 62.9% vs. 44.0%, p=0.046; PFO, 54.8% vs. 30.0%, p=0.008). There were no marked differences in the prevalence of large, middle and small shunts between MA and MWOA patients. Compared with the MWOA patients, the MA patients were younger (p=0.013) and had early onset age (p=0.013) and increased prevalence of photophobia (p=0.008). Conclusion RLs were found in over half of the Japanese patients with migraine. Our study suggests a possible link between RLs and MA.

Serotonergic mechanisms of trigeminal meningeal nociception: Implications for migraine pain

Serotonergic mechanisms play a central role in migraine pathology. However, the region-specific effects of serotonin (5-HT) mediated via multiple types of receptors in the nociceptive system are poorly understood. Using extracellular and patch-clamp recordings, we studied the action of 5-HT on the excitability of peripheral and central terminals of trigeminal afferents. 5-HT evoked long-lasting TTX-sensitive firing in the peripheral terminals of meningeal afferents, the origin site of migraine pain. Cluster analysis revealed that in majority of nociceptive fibers 5-HT induced either transient or persistent spiking activity with prevailing delta and theta rhythms. The 5-HT3-receptor antagonist MDL-72222 or 5-HT1B/D-receptor antagonist GR127935 largely reduced, but their combination completely prevented the excitatory pro-nociceptive action of 5-HT. The 5-HT3 agonist mCPBG activated spikes in MDL-72222-dependent manner but the 5HT-1 receptor agonist sumatriptan did not affect the nociceptive firing. 5-HT also triggered peripheral CGRP release in meninges, which was blocked by MDL-72222.5-HT evoked fast membrane currents and Ca²⁺ transients in a fraction of trigeminal neurons. Immunohistochemistry showed expression of 5-HT3A receptors in fibers innervating meninges. Endogenous release of 5-HT from degranulated mast cells increased nociceptive firing. Low pH but not histamine strongly activated firing. 5-HT reduced monosynaptic inputs from trigeminal Aδ- and C-afferents to the upper cervical lamina I neurons and this effect was blocked by MDL-72222. Consistent with central inhibitory effect, 5-HT reduced CGRP release in the brainstem slices. In conclusion, 5-HT evokes powerful pro-nociceptive peripheral and anti-nociceptive central effects in trigeminal system transmitting migraine pain.

Antiplatelet and antithrombotic effects of cordycepin-enriched WIB-801CE from Cordyceps militaris ex vivo, in vivo, and in vitro

BACKGROUND

A species of the fungal genus Cordyceps has been used as a complementary and alternative medicine of traditional Chinese medicine, and its major component cordycepin and cordycepin-enriched WIB-801CE are known to have antiplatelet effects in vitro. However, it is unknown whether they have also endogenous antiplatelet and antithrombotic effects. In this study, to resolve these doubts, we prepared cordycepin-enriched WIB-801CE, an ethanol extract from Cordyceps militaris-hypha, then evaluated its ex vivo, in vivo, and in vitro antiplatelet and antithrombotic effects.

METHODS

Ex vivo effects of WIB-801CE on collagen- and ADP-induced platelet aggregation, serotonin release, thromboxane A2 (TXA2) production and its associated activities of enzymes [cyclooxygenase-1 (COX-1), TXA2 synthase (TXAS)], arachidonic acid (AA) release and its associated phosphorylation of phospholipase Cβ3, phospholipase Cγ2 or cytosolic phospholipase A2, mitogen-activated protein kinase (MAPK) [p38 MAPK, extracellular signal-regulated kinase (ERK)], and blood coagulation time in rats were investigated. In vivo effects of WIB-801CE on collagen plus epinephrine-induced acute pulmonary thromboembolism, and tail bleeding time in mice were also inquired. In vitro effects of WIB-801CE on cytotoxicity, and fibrin clot retraction in human platelets, and nitric oxide (NO) production in RAW264.7 cells or free radical scavenging activity were studied.

RESULTS

Cordycepin-enriched WIB-801CE inhibited ex vivo platelet aggregation, TXA2 production, AA release, TXAS activity, serotonin release, and p38 MAPK and ERK2 phosphorylation in collagen- and ADP-activated rat platelets without affecting blood coagulation. Furthermore, WIB-801CE manifested in vivo inhibitory effect on collagen plus epinephrine-induced pulmonary thromboembolism mice model. WIB-801CE inhibited in vitro NO production and fibrin clot retraction, but elevated free radical scavenging activity without affecting cytotoxicity against human platelets.

CONCLUSION

WIB-801CE inhibited collagen- and ADP-induced platelet activation and its associated thrombus formation ex vivo and in vivo. These were resulted from down-regulation of TXA2 production and its related AA release and TXAS activity, and p38MAPK and ERK2 activation. These results suggest that WIB-801CE has therapeutic potential to treat platelet activation-mediated thrombotic diseases in vivo.

Migraine and the risk of stroke: an updated meta-analysis of prospective cohort studies

Dozens of observational studies and two meta-analyses have investigated the association of migraine with the risk of stroke, but their results are inconsistent. We aimed to quantitatively evaluate the relationship between migraine and stroke risk by performing a meta-analysis of prospective cohort studies. PubMed and Embase were searched through July 2016 to identify studies that met pre-stated inclusion criterion and reference lists of retrieved articles were also reviewed. Information on the characteristics of the included study, risk estimates, and control for possible confounding factors were extracted independently by two authors. The random-effects model was used to calculate the pooled risk estimates. Eleven prospective cohort studies involving 3371 patients with stroke and 2,221,888 participants were included in this systematic review. Compared with non-migraineurs, the pooled relative risks of total stroke, hemorrhagic stroke, and ischemic stroke for migraineurs were 1.55 [95% confidence interval (CI) 1.38-1.75], 1.15 (95% CI 0.85-1.56), and 1.64 (95% CI 1.22-2.20), respectively. Exception of any single study did not materially alter the combined risk estimate. Integrated epidemiological evidence supports that migraine should be associated with the increased risk of total stroke and ischemic stroke, but the relationship between migraine and the risk of hemorrhagic stroke is not of certainty.

Migraine with aura and patent foramen ovale: myth or reality?

Several observational studies report that subjects with migraine with aura have a higher prevalence of right-to left shunt, commonly due to patent foramen ovale, and that patent foramen ovale is more prevalent in subjects with migraine with aura. Although migraine without aura has been less extensively studied, it does not seem to be associated with an increased prevalence of right-to left shunt. The mechanism that underlies the possible relationship between patent foramen ovale and migraine with aura remains speculative. The proposed mechanisms are migraine-triggering vasoactive chemicals bypassing the pulmonary filter and reaching the cerebral circulation and paradoxical microembolization. However, it is unclear, at this time, if there is a causal or comorbid association between the two conditions. In some families atrial shunts show a dominant inheritance that seems to be linked to inheritance of migraine with aura. Migraine with aura is an independent risk factor for ischemic stroke, and patent foramen ovale is present more frequently in patients with cryptogenic stroke than in controls. At this moment, there is no convincing evidence that excess stroke risk of migraine is simply mediated by patent foramen ovale through paradoxical embolism. Several non-controlled studies suggest that closure of the foramen ovale significantly reduces attack frequency in migraine patient, but the only prospective placebo-controlled trial does not support these results. Patent foramen ovale closure, at present, is not indicated as a treatment for migraine in clinical practice.

Headache in the presentation of noncephalic acute illness

Background:

Headache is a frequent symptom of many systemic diseases that do not involve cranial structures. In this observational study, we assessed factors associated with headache in the acute presentation of systemic conditions in a nonsurgical emergency department (ED).

Methods:

Consecutive patients, admitted to Soroka University Medical Center ED due to noncephalic illness, were prospectively surveyed using a structured questionnaire focused on the prevalence and characteristics of headache symptoms. Medical data were extracted from the patient's charts.

Results:

Between 1 and 6/2012, 194 patients aged 64.69 ± 19.52 years, were evaluated. Headache was reported by 83 (42.7%) patients and was more common among patients with febrile illness (77.5% vs. 22.5%, P < 0.001). Respiratory illness and level of O₂ saturation were not associated with headache. Headache in the presentation of a noncephalic illness was associated with younger age (58 vs. 69, P < 0.001) and with suffering from a primary headache disorder (48.2% vs. 10.8%, P < 0.001). Headache was also associated with higher body temperature and lower platelets count.

Conclusions:

Headache is a common symptom in acute noncephalic conditions and was found to be associated with younger age and febrile disease on presentation. Patients who present with primary headache disorders are more prone to have headache during acute illness. Acute obstructive respiratory disease, hypercarbia or hypoxemia were not associated with headache.

Sleep Deprivation-Induced Blood-Brain Barrier Breakdown and Brain Dysfunction are Exacerbated by Size-Related Exposure to Ag and Cu Nanoparticles. Neuroprotective Effects of a 5-HT3 Receptor Antagonist Ondansetron

Military personnel are often subjected to sleep deprivation (SD) during combat operations. Since SD is a severe stress and alters neurochemical metabolism in the brain, a possibility exists that acute or long-term SD will influence blood-brain barrier (BBB) function and brain pathology. This hypothesis was examined in young adult rats (age 12 to 14 weeks) using an inverted flowerpot model. Rats were placed over an inverted flowerpot platform (6.5 cm diameter) in a water pool where the water levels are just 3 cm below the surface. In this model, animals can go to sleep for brief periods but cannot achieve deep sleep as they would fall into water and thus experience sleep interruption. These animals showed leakage of Evans blue in the cerebellum, hippocampus, caudate nucleus, parietal, temporal, occipital, cingulate cerebral cortices, and brain stem. The ventricular walls of the lateral and fourth ventricles were also stained blue, indicating disruption of the BBB and the blood-cerebrospinal fluid barrier (BCSFB). Breakdown of the BBB or the BCSFB fluid barrier was progressive in nature from 12 to 48 h but no apparent differences in BBB leakage were seen between 48 and 72 h of SD. Interestingly, rats treated with metal nanoparticles, e.g., Cu or Ag, showed profound exacerbation of BBB disruption by 1.5- to 4-fold, depending on the duration of SD. Measurement of plasma and brain serotonin showed a close correlation between BBB disruption and the amine level. Repeated treatment with the serotonin 5-HT3 receptor antagonist ondansetron (1 mg/kg, s.c.) 4 and 8 h after SD markedly reduced BBB disruption and brain pathology after 12 to 24 h SD but not following 48 or 72 h after SD. However, TiO2-nanowired ondansetron (1 mg/kg, s.c) in an identical manner induced neuroprotection in rats following 48 or 72 h SD. However, plasma and serotonin levels were not affected by ondansetron treatment. Taken together, our observations are the first to show that (i) SD could induce BBB disruption and brain pathology, (ii) nanoparticles exacerbate SD-induced brain damage, and (iii) serotonin 5-HT3 receptor antagonist ondansetron is neuroprotective in SD that is further potentiated byTiO2-nanowired delivery, not reported earlier.

Inhibitory effects of total saponin from Korean Red Ginseng on [Ca(2+)]i mobilization through phosphorylation of cyclic adenosine monophosphate-dependent protein kinase catalytic subunit and inositol 1,4,5-trisphosphate receptor type I in human platelets

Background

Intracellular Ca²⁺([Ca²⁺]_i) is a platelet aggregation-inducing molecule. Therefore, understanding the inhibitory mechanism of [Ca²⁺]_i mobilization is very important to evaluate the antiplatelet effect of a substance. This study was carried out to understand the Ca²⁺-antagonistic effect of total saponin from Korean Red Ginseng (KRG-TS).

Methods

We investigated the Ca²⁺-antagonistic effect of KRG-TS on cyclic nucleotides-associated phosphorylation of inositol 1,4,5-trisphosphate receptor type I (IP₃RI) and cyclic adenosine monophosphate (cAMP)-dependent protein kinase (PKA) in thrombin (0.05 U/mL)-stimulated human platelet aggregation.

Results

The inhibition of [Ca²⁺]_i mobilization by KRG-TS was increased by a PKA inhibitor (Rp-8-Br-cAMPS), which was more stronger than the inhibition by a cyclic guanosine monophosphate (cGMP)-dependent protein kinase (PKG) inhibitor (Rp-8-Br-cGMPS). In addition, Rp-8-Br-cAMPS inhibited phosphorylation of PKA catalytic subunit (PKAc) (Thr¹⁹⁷) by KRG-TS. The phosphorylation of IP₃RI (Ser¹⁷⁵⁶) by KRG-TS was very strongly inhibited by Rp-8-Br-cAMPS compared with that by Rp-8-Br-cGMPS. These results suggest that the inhibitory effect of [Ca²⁺]_i mobilization by KRG-TS is more strongly dependent on a cAMP/PKA pathway than a cGMP/PKG pathway. KRG-TS also inhibited the release of adenosine triphosphate and serotonin. In addition, only G-Rg3 of protopanaxadiol in KRG-TS inhibited thrombin-induced platelet aggregation.

Conclusion

These results strongly indicate that KRG-TS is a potent beneficial compound that inhibits [Ca²⁺]_i mobilization in thrombin–platelet interactions, which may result in the prevention of platelet aggregation-mediated thrombotic disease.