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Arabshahi V, Togha M, Khorsha F. The association between dietary glycemic index and disease severity among the women with episodic migraine. Nutr Neurosci 2024:1-11. [PMID: 38593064 DOI: 10.1080/1028415x.2024.2338343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2024]
Abstract
PURPOSE To our knowledge, no studies have evaluated the association between dietary glycemic index (GI) and glycemic load (GL) with migraine-related clinical symptoms. METHODS This cross-sectional study was conducted among 266 women with episodic migraine. The migraine disability assessment (MIDAS) was used to evaluate migraine-related disability in the recent three months. Visual analogue scales (VAS) were also employed to examine migraine-related pains. Glycemic index and glycemic load indices were calculated using the nutritional information obtained from the food frequency questionnaire. RESULTS The study participants had a mean age of 34.32 ± 7.86 years. It was observed that individuals in the quartile 4 of GI and GL reported significantly higher consumption of calories, carbohydrates, proteins, and fats (P < 0.05). In the unadjusted models, those in the quartile 4 of GI and GL had significantly increased odds of experiencing severe pain (based on VAS score) (OR = 2.09, 95% CI = 1.37-2.70, P < 0.001 for dietary GI, and OR = 1.75, 95% CI = 1.16-2.79, P = 0.005 for dietary GL). Additionally, compared to participants in the quartile 1 of GI and GL, those in the quartile 4 of GI and GL were more likely to suffer from severe disability (P < 0.05). CONCLUSION We found a significant positive correlation between the consumption of foods with higher GI and GL and the clinical conditions related to migraine disease. However, due to the cross-sectional nature of the study, it is not possible to establish a cause-and-effect relationship for the observed results.
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Affiliation(s)
- Vajiheh Arabshahi
- Department of Nutrition, School of Public Health, Iran University of Medical Sciences, Tehran, Iran
| | - Mansoureh Togha
- Department of Neurology, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
- Headache Department, Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Faezeh Khorsha
- Department of Community Nutrition, School of Nutritional Sciences and Dietetics, Tehran University of Medical Sciences (TUMS), Tehran, Iran
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Islam MR, Nyholt DR. Cross-trait analyses identify shared genetics between migraine, headache, and glycemic traits, and a causal relationship with fasting proinsulin. Hum Genet 2023; 142:1149-1172. [PMID: 36808568 PMCID: PMC10449981 DOI: 10.1007/s00439-023-02532-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 02/08/2023] [Indexed: 02/23/2023]
Abstract
The co-occurrence of migraine and glycemic traits has long been reported in observational epidemiological studies, but it has remained unknown how they are linked genetically. We used large-scale GWAS summary statistics on migraine, headache, and nine glycemic traits in European populations to perform cross-trait analyses to estimate genetic correlation, identify shared genomic regions, loci, genes, and pathways, and test for causal relationships. Out of the nine glycemic traits, significant genetic correlation was observed for fasting insulin (FI) and glycated haemoglobin (HbA1c) with both migraine and headache, while 2-h glucose was genetically correlated only with migraine. Among 1703 linkage disequilibrium (LD) independent regions of the genome, we found pleiotropic regions between migraine and FI, fasting glucose (FG), and HbA1c, and pleiotropic regions between headache and glucose, FI, HbA1c, and fasting proinsulin. Cross-trait GWAS meta-analysis with glycemic traits, identified six novel genome-wide significant lead SNPs with migraine, and six novel lead SNPs with headache (Pmeta < 5.0 × 10-8 and Psingle-trait < 1 × 10-4), all of which were LD-independent. Genes with a nominal gene-based association (Pgene ≤ 0.05) were significantly enriched (overlapping) across the migraine, headache, and glycemic traits. Mendelian randomisation analyses produced intriguing, but inconsistent, evidence for a causal relationship between migraine and headache with multiple glycemic traits; and consistent evidence suggesting increased fasting proinsulin levels may causally decrease the risk of headache. Our findings indicate that migraine, headache, and glycemic traits share a common genetic etiology and provide genetic insights into the molecular mechanisms contributing to their comorbid relationship.
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Affiliation(s)
- Md Rafiqul Islam
- Statistical and Genomic Epidemiology Laboratory, School of Biomedical Sciences, Faculty of Health and Centre for Genomics and Personalised Health, Queensland University of Technology, Brisbane, QLD, Australia.
| | - Dale R Nyholt
- Statistical and Genomic Epidemiology Laboratory, School of Biomedical Sciences, Faculty of Health and Centre for Genomics and Personalised Health, Queensland University of Technology, Brisbane, QLD, Australia.
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The potential impact of insulin resistance and metabolic syndrome on migraine headache characteristics. BMC Neurol 2022; 22:422. [DOI: 10.1186/s12883-022-02966-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Accepted: 11/04/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background & objectives
Studying comorbidities with migraine aids in a better understanding of its pathophysiology and potential therapeutic targets. This case-control study aimed to study the impact of insulin resistance and metabolic syndrome on the characteristics of migraine headache attacks.
Methods
A case-control study was conducted on 30 migraine patients and 30 healthy controls. The following data were assessed in migraine patients: type of migraine, duration of attacks, Migraine Severity Scale (MIGSEV), and Headache Impact Test-6 (HIT-6). Both groups were assessed for waist circumference and underwent the following tests: fasting blood glucose, fasting insulin, high-density lipoprotein cholesterol level, and triglycerides, and homeostasis model assessment–insulin resistance (HOMA-IR) was applied.
Results
This study included age and sex-matched patients and controls. Migraine patients had significantly higher waist circumference, higher mean values of serum insulin, HOMA-IR and higher frequency of insulin resistance and metabolic syndrome than the control group (P-value = 0.005, 0.049, 0.01, 0.012, 0.024, respectively). Migraine patients with insulin resistance had significantly higher intensity and tolerability scores, MIGSEV total score, and HIT-6 total score compared to those without (P-value = 0.005, 0.005, 0.002, 0.018, respectively). There was a significantly positive correlation between the MIGSEV and HIT-6 scores and fasting insulin levels, and HOMA-IR value (P-value = 0.006, ≤ 0.001, 0.017, ≤ 0.001, respectively).
Conclusion
Insulin resistance and metabolic syndrome are more common in migraine patients than in healthy controls. The severity and impact of migraine attacks are higher in patients with insulin resistance than in those without.
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Genetic Overlap Analysis Identifies a Shared Etiology between Migraine and Headache with Type 2 Diabetes. Genes (Basel) 2022; 13:genes13101845. [PMID: 36292730 PMCID: PMC9601333 DOI: 10.3390/genes13101845] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 09/26/2022] [Accepted: 10/11/2022] [Indexed: 11/17/2022] Open
Abstract
Migraine and headache frequently co-occur with type 2 diabetes (T2D), suggesting a shared aetiology between the two conditions. We used genome-wide association study (GWAS) data to investigate the genetic overlap and causal relationship between migraine and headache with T2D. Using linkage disequilibrium score regression (LDSC), we found a significant genetic correlation between migraine and T2D (rg = 0.06, p = 1.37 × 10−5) and between headache and T2D (rg = 0.07, p = 3.0 × 10−4). Using pairwise GWAS (GWAS-PW) analysis, we identified 11 pleiotropic regions between migraine and T2D and 5 pleiotropic regions between headache and T2D. Cross-trait SNP meta-analysis identified 23 novel SNP loci (Pmeta < 5 × 10−8) associated with migraine and T2D, and three novel SNP loci associated with headache and T2D. Cross-trait gene-based overlap analysis identified 33 genes significantly associated (Pgene-based < 3.85 × 10−6) with migraine and T2D, and 11 genes associated with headache and T2D, with 7 genes (EHMT2, SLC44A4, PLEKHA1, CFDP1, TMEM170A, CHST6, and BCAR1) common between them. There was also a significant overlap of genes nominally associated (Pgene-based < 0.05) with both migraine and T2D (Pbinomial-test = 2.83 × 10−46) and headache and T2D (Pbinomial-test = 4.08 × 10−29). Mendelian randomisation (MR) analyses did not provide consistent evidence for a causal relationship between migraine and T2D. However, we found headache was causally associated (inverse-variance weighted, ORIVW = 0.90, Pivw = 7 × 10−3) with T2D. Our findings robustly confirm the comorbidity of migraine and headache with T2D, with shared genetically controlled biological mechanisms contributing to their co-occurrence, and evidence for a causal relationship between headache and T2D.
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Glucose-Related Traits and Risk of Migraine—A Potential Mechanism and Treatment Consideration. Genes (Basel) 2022; 13:genes13050730. [PMID: 35627115 PMCID: PMC9141901 DOI: 10.3390/genes13050730] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/19/2022] [Accepted: 04/19/2022] [Indexed: 12/16/2022] Open
Abstract
Migraine and glucose-related (glycaemic) traits (fasting glucose, fasting insulin, and type 2 diabetes) are common and complex comorbid disorders that cause major economic and social burdens on patients and their families. Studies on the relationship between migraine and glucose-related traits have yielded inconsistent results. The purpose of this review is to synthesise and discuss the information from the available literature on the relationship between fasting glucose, fasting insulin, and type 2 diabetes (T2D) with migraine. Publications on migraine and fasting glucose, migraine and fasting insulin, and migraine and T2D were identified from a PubMed and Google Scholar database search and reviewed for this article. Multiple publications have suggested that the comorbidity of migraine and glucose-related traits may have a similar complex pathogenic mechanism, including impaired glucose homeostasis, insulin resistance, reduced cerebrovascular reactivity, abnormal brain metabolism, shared genetic factors, neurotransmitters, and sex hormones. Furthermore, several studies have found a bi-directional link between migraine with insulin resistance and T2D. There is strong evidence for a biological association between migraine headache and glucose-related traits, and burgeoning evidence for shared genetic influences. Therefore, genetic research into these comorbid traits has the potential to identify new biomarkers and therapeutic targets and provide biological insight into their relationships. We encourage healthcare professionals to consider the co-occurrence of migraine with glucose-related traits in the evaluation and treatment of their patients.
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Del Moro L, Rota E, Pirovano E, Rainero I. Migraine, Brain Glucose Metabolism and the "Neuroenergetic" Hypothesis: A Scoping Review. THE JOURNAL OF PAIN 2022; 23:1294-1317. [PMID: 35296423 DOI: 10.1016/j.jpain.2022.02.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 02/04/2022] [Accepted: 02/14/2022] [Indexed: 02/06/2023]
Abstract
Increasing evidence suggests that migraine may be the result of an impaired brain glucose metabolism. Several studies have reported brain mitochondrial dysfunction, impaired brain glucose metabolism and gray matter volume reduction in specific brain areas of migraineurs. Furthermore, peripheral insulin resistance, a condition demonstrated in several studies, may extend to the brain, leading to brain insulin resistance. This condition has been proven to downregulate insulin receptors, both in astrocytes and neurons, triggering a reduction in glucose uptake and glycogen synthesis, mainly during high metabolic demand. This scoping review examines the clinical, epidemiologic and pathophysiologic data supporting the hypothesis that abnormalities in brain glucose metabolism may generate a mismatch between the brain's energy reserve and metabolic expenditure, triggering migraine attacks. Moreover, alteration in glucose homeostasis could generate a chronic brain energy deficit promoting migraine chronification. Lastly, insulin resistance may link migraine with its comorbidities, like obesity, depression, cognitive impairment and cerebrovascular diseases. PERSPECTIVE: Although additional experimental studies are needed to support this novel "neuroenergetic" hypothesis, brain insulin resistance in migraineurs may unravel the pathophysiological mechanisms of the disease, explaining the migraine chronification and connecting migraine with comorbidities. Therefore, this hypothesis could elucidate novel potential approaches for migraine treatment.
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Affiliation(s)
- Lorenzo Del Moro
- Foundation Allineare Sanità and Salute, Scientific Committee, Milan, Italy; LUMEN APS, European Salus Network, Scientific Committee, San Pietro in Cerro (PC), Italy.
| | - Eugenia Rota
- Neurology Unit, ASL AL, San Giacomo Hospital, Novi Ligure, Italy
| | - Elenamaria Pirovano
- Foundation Allineare Sanità and Salute, Scientific Committee, Milan, Italy; LUMEN APS, European Salus Network, Scientific Committee, San Pietro in Cerro (PC), Italy
| | - Innocenzo Rainero
- Headache Center, Department of Neuroscience "Rita Levi Montalcini", University of Torino, Italy
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Is there any association between migraine headache and polycystic ovary syndrome (PCOS)? A review article. Mol Biol Rep 2021; 49:595-603. [PMID: 34651295 DOI: 10.1007/s11033-021-06799-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 10/01/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Polycystic ovary syndrome (PCOS) and migraine headaches are considered to be common health problems that may share some risk factors. This study aimed to discuss the possible association between migraine headache and polycystic ovary syndrome. METHODS AND RESULTS In this narrative review, PubMed, Scopus, Web of Science, and Google Scholar were systematically searched for retrieving and summarizing published studies up to January 2021 to explore the possible interplay between migraine headache and PCOS. We discuss the possible pathways that may explain the association between migraine headaches and PCOS signs/symptoms and complications. While genetic factors have profound effects on the pathogenesis of migraine headaches, sex hormones, including estrogen and progesterone may also play an important role in inducing migraine headaches. Some disorders, such as sleep apnea, amenorrhea, and vascular disease that are more likely to occur in women with PCOS, may cause or exacerbate migraine headaches in women with PCOS. CONCLUSIONS Future comprehensive studies are needed to investigate the exact underlining mechanisms related to the association between PCOS and migraine headaches.
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Rivera-Mancilla E, Al-Hassany L, Villalón CM, MaassenVanDenBrink A. Metabolic Aspects of Migraine: Association With Obesity and Diabetes Mellitus. Front Neurol 2021; 12:686398. [PMID: 34177788 PMCID: PMC8219973 DOI: 10.3389/fneur.2021.686398] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 04/29/2021] [Indexed: 12/24/2022] Open
Abstract
Migraine is a disabling neurovascular disorder, characterized by moderate to severe unilateral headaches, nausea, photophobia, and/or phonophobia, with a higher prevalence in women than in men, which can drastically affect the quality of life of migraine patients. In addition, this chronic disorder is related with metabolic comorbidities associated with the patient's lifestyle, including obesity and diabetes mellitus (DM). Beyond the personal and socioeconomic impact caused by migraine, obesity and DM, it has been suggested that these metabolic disorders seem to be related to migraine since: (i) they are a risk factor for developing cardiovascular disorders or chronic diseases; (ii) they can be influenced by genetic and environmental risk factors; and (iii) while clinical and epidemiological studies suggest that obesity is a risk factor for migraine, DM (i.e., type 1 and type 2 DM) have been reported to be either a protective or a risk factor in migraine. On this basis, and given the high worldwide prevalence of migraine, obesity, and DM, this article provides a narrative review of the current literature related to the association between the etiology and pathophysiology of migraine and these metabolic disorders, considering lifestyle aspects, as well as the possible involvement of neurotransmitters, neuropeptides, and/or sex hormones. While a link between migraine and metabolic disorders has been suggested, many studies are contradictory and the mechanisms involved in this association are not yet sufficiently established. Therefore, further research should be focused on understanding the possible mechanisms involved.
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Affiliation(s)
- Eduardo Rivera-Mancilla
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Linda Al-Hassany
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, Netherlands
| | | | - Antoinette MaassenVanDenBrink
- Division of Vascular Medicine and Pharmacology, Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, Netherlands
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Tekgol Uzuner G, Yalın OO, Uluduz D, Ozge A, Uzuner N. Migraine and cardiovascular risk factors: A clinic-based study. Clin Neurol Neurosurg 2020; 200:106375. [PMID: 33260087 DOI: 10.1016/j.clineuro.2020.106375] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 10/29/2020] [Accepted: 11/14/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The relation between migraine and vascular risk factors is an unclear issue. Furthermore, the reasons for chronification are still unknown. Probably, the age-related risk and other factors leading to migraine progression will also change in the future. Under these questions, we aimed to investigate whether or not there is a specific association with vascular risk factors between several age groups and subtypes of migraine and also in their families. METHODS A dataset (the Turkish Headache Database) from four tertiary headache centres in Turkey was used. This database included headache-defining features according to ICHD criteria based on face-to-face interviews and examinations by a Neurologist. Vascular risk factors of migraine without aura (MwoA), migraine with aura (MwA) and chronic migraine (CM) were compared between three age groups (under 30 years, 30-50 years and over 50 years) and in first-degree relatives of the patients. Our study included 2712 patients comprising 1868 (68.9 %), 246 (9.1 %) and 598 (22.1 %) subjects with MwoA, MwA and CH, respectively. RESULTS This study showed that both the patients and the first-degree relatives were more frequently associated with vascular risk factors in CM than episodic MwA and MwoA. MwoA showed a weaker association with vascular risk factors than MwA and CM. CONCLUSION Chronic migraine was associated with vascular risk factors at all ages and first-degree relatives as well. Vascular risk factors should be investigated with greater focus on chronic migraine.
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Affiliation(s)
- Gulnur Tekgol Uzuner
- Department of Neurology and Algology, Eskisehir Osmangazi University, Eskisehir, Turkey.
| | - Osman Ozgur Yalın
- Neurology Clinic, Istanbul Education and Research Hospital, Istanbul, Turkey.
| | - Derya Uluduz
- Department of Neurology and Algology, Istanbul University, Istanbul, Turkey.
| | - Aynur Ozge
- Department of Neurology and Algology, Mersin University, Mersin, Turkey.
| | - Nevzat Uzuner
- Department of Neurology and Cerebrovascular Disease, Eskisehir Osmangazi University, Eskisehir, Turkey.
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Gur-Ozmen S, Karahan-Ozcan R. Factors Associated with Insulin Resistance in Women with Migraine: A Cross-Sectional Study. PAIN MEDICINE 2020; 20:2043-2050. [PMID: 30938814 DOI: 10.1093/pm/pnz055] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Studies have shown a relationship between insulin resistance (IR) and migraine that is more evident in some migraineurs. Long-term use of various drugs and increased risk of diverse side effects is an unavoidable reality in this population of patients. Thus, in this study, we aimed to investigate factors associated with IR in migraine and the impact of chronic usage of various drugs, which might play a part in development of IR. DESIGN Cross-sectional study. SETTING Gebze Fatih General Hospital, Kocaeli, Turkey. SUBJECTS Migraine patients (N = 150) were investigated. METHODS Weight, height, waist circumference, and blood pressure were measured. Fasting glucose, fasting insulin, glycated hemoglobin, and lipid profile were also measured. IR was selected as a dependent variable. The independent variables included age, cigarette smoking, alcohol consumption, family history of migraine, diabetes mellitus and hypertension, characteristics of pain, migraine triggers and subgroups, medication used during attack treatment, medication used as prophylactic treatment, and oral contraceptive treatment. Descriptive analysis and multivariate logistic regression were performed. RESULTS Central obesity (odds ratio [OR] = 7.131, 95% confidence interval [CI] = 2.451-20.741, P < 0.0001), metoclopramide treatment during an attack (OR = 3.645, 95% CI = 0.996-13.346, P = 0.041), family history of DM (OR = 3.109, 95% CI = 1.189-8.132, P = 0.035), nonsteroidal anti-inflammatory drug (NSAID) usage during an attack (OR = 2.578, 95% CI = 1.053-6.311, P = 0.043), and negative family history of hypertension (OR = 0.226, 95% CI = 0.085-0.602, P = 0.002) were significant factors for exhibiting IR in migraine. CONCLUSIONS Our study demonstrates an association between metoclopramide and NSAID treatments and IR in migraine.
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Affiliation(s)
- Selen Gur-Ozmen
- Department of Neuroscience, Graduate School of Health Sciences, Bahcesehir University, Istanbul, Turkey
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Hassan SA, Farooque U, Choudhry AS, Pillai B, Sheikh FN. Therapeutic Implications of Altered Energy Metabolism in Migraine: A State-of-the-Art Review. Cureus 2020; 12:e8571. [PMID: 32670707 PMCID: PMC7358961 DOI: 10.7759/cureus.8571] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Currently, the management strategies aimed at the resolution of migraine are pharmacological. Most of these therapies are known to alter the serotonin balance of the brain. Furthermore, therapies blocking the calcitonin gene-related peptide (CGRP) have also proven to be quite effective in their treatments. However, apart from being expensive, these therapies do not influence premonitory and aura symptoms. This suggests an incomplete approach and an inadequate understanding of the migraine pathophysiology. Recent metabolic studies have indicated that migraine should be considered as an adaptive response to the mismatch between the cerebral energy reserves and expenditure. Therefore, understanding the underlying metabolism helps derive possible novel therapeutic modalities for migraines. In this review, we highlight the underlying metabolic abnormalities found in migraine patients. This will form the basis of our evidence-based discussion on metabolic therapeutic options for migraines.
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Affiliation(s)
- Syed Adeel Hassan
- Neurology, Dow University of Health Sciences, Karachi, PAK.,Internal Medicine, Dow University of Health Sciences, Karachi, PAK
| | - Umar Farooque
- Neurology, Dow University of Health Sciences, Karachi, PAK
| | - Ali S Choudhry
- Internal Medicine, Lahore Medical and Dental College, Lahore, PAK
| | - Bharat Pillai
- Neurology, Amrita Institute of Medical Sciences, Kochi, IND
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Abstract
Introduction: Most preventive migraine treatments modify the brain's excitation/inhibition balance and/or serotonin metabolism, which likely accounts for their unfavorable adverse effect profile. Novel biological therapies blocking CGRP transmission are effective and better tolerated, but they are expensive and may not influence brain dysfunctions upstream in the pathophysiological cascade of migraine, including premonitory and aura symptoms. Biochemical and clinical studies suggest that there may be another complimentary treatment strategy, the one that targets the underestimated metabolic facet of migraine pathophysiology.Areas covered: After a brief description of the metabolic abnormalities found in migraine patients, we will review and discuss published data on metabolic treatments of migraine. There is evidence that riboflavin and co-enzyme Q10 are effective for the prevention of migraine and quasi devoid of adverse effects. Response rates are close to those of topiramate, propranolol, and CGRP/CGRPrec mAbs. The evidence is weaker for thioctic acid. Dietary and pharmacological strategies inducing ketosis are novel promising approaches for which preliminary trials with favorable outcomes have been published.Expert opinion: Metabolic treatments of migraine constitute an effective, well-tolerated, inexpensive, and evidence-supported therapeutic option for migraine prophylaxis, and may be considered as first treatment line in many patients, including in children and adolescents.
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Affiliation(s)
- Marco Lisicki
- Headache Department, Neuroscience Unit, Conci∙Carpinella Institute, Córdoba, Argentina.,Department of Neurology-Citadelle Hospital, Headache Research Unit, University of Liège, Liège, Belgium
| | - Jean Schoenen
- Department of Neurology-Citadelle Hospital, Headache Research Unit, University of Liège, Liège, Belgium
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The Association Between Migraine, Metabolic Syndrome, Insulin Resistance, and Obesity in Women: A Case-Control Study. MEDICAL BULLETIN OF SISLI ETFAL HOSPITAL 2019; 53:395-402. [PMID: 32377115 PMCID: PMC7192290 DOI: 10.14744/semb.2018.09582] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/29/2018] [Accepted: 11/26/2019] [Indexed: 01/03/2023]
Abstract
Objectives: The aim of this study was to examine the relationship between migraines and obesity, insulin resistance (IR), and metabolic syndrome in female migraineurs. Methods: A total of 141 female patients who experience migraines and a control group of 141 sex- and age-matched individuals who do not were enrolled in this case-control study. The migraine group was composed of patients from the Gebze Fatih Community Hospital (Kocaeli, Turkey) neurology outpatient service and the control group included hospital staff and friends who volunteered to participate. Descriptive statistics and multivariate logistic regression analyses were performed. Migraine was designated as a dependent variable. Family history of migraine, stroke, metabolic syndrome, cardiac disease, hypertension, hyperlipidemia, and diabetes mellitus; cigarette use; alcohol consumption; and the presence of hypertension, IR, hypertriglyceridemia, low level of high-density lipoprotein (HDL), central obesity, metabolic syndrome; as well as homeostasis model assessment and quantitative insulin sensitivity check index results were selected as independent variables. Results: The mean waist circumference, mean height, mean weight, and central obesity were greater in the control group (p=0.009, 0.004, 0.036, and 0.015, respectively). A multivariate logistic regression model of migraine presence showed that a family history of migraine (odds ratio [OR]: 1.542, 95% confidence interval [CI]: 2.451-8.905; p<0.0001), family history of stroke (OR: 1.043, 95% CI: 1.214-6.633; p=0.016), and no central obesity (OR: -0.705, 95% CI: -0.290-0.843; p=0.010) were statistically significant variables in our study. Conclusion: The results of our study indicated that IR and metabolic syndrome were not associated with migraine in women. There was an inverse relationship between central obesity and migraine. Additional research with larger participant groups should be performed to further explore the complex relationship between migraine, obesity, IR, and metabolic syndrome.
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The metabolic face of migraine - from pathophysiology to treatment. Nat Rev Neurol 2019; 15:627-643. [PMID: 31586135 DOI: 10.1038/s41582-019-0255-4] [Citation(s) in RCA: 116] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2019] [Indexed: 12/11/2022]
Abstract
Migraine can be regarded as a conserved, adaptive response that occurs in genetically predisposed individuals with a mismatch between the brain's energy reserve and workload. Given the high prevalence of migraine, genotypes associated with the condition seem likely to have conferred an evolutionary advantage. Technological advances have enabled the examination of different aspects of cerebral metabolism in patients with migraine, and complementary animal research has highlighted possible metabolic mechanisms in migraine pathophysiology. An increasing amount of evidence - much of it clinical - suggests that migraine is a response to cerebral energy deficiency or oxidative stress levels that exceed antioxidant capacity and that the attack itself helps to restore brain energy homeostasis and reduces harmful oxidative stress levels. Greater understanding of metabolism in migraine offers novel therapeutic opportunities. In this Review, we describe the evidence for abnormalities in energy metabolism and mitochondrial function in migraine, with a focus on clinical data (including neuroimaging, biochemical, genetic and therapeutic studies), and consider the relationship of these abnormalities with the abnormal sensory processing and cerebral hyper-responsivity observed in migraine. We discuss experimental data to consider potential mechanisms by which metabolic abnormalities could generate attacks. Finally, we highlight potential treatments that target cerebral metabolism, such as nutraceuticals, ketone bodies and dietary interventions.
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Gross EC, Klement RJ, Schoenen J, D'Agostino DP, Fischer D. Potential Protective Mechanisms of Ketone Bodies in Migraine Prevention. Nutrients 2019; 11:E811. [PMID: 30974836 PMCID: PMC6520671 DOI: 10.3390/nu11040811] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 04/04/2019] [Accepted: 04/08/2019] [Indexed: 12/15/2022] Open
Abstract
An increasing amount of evidence suggests that migraines are a response to a cerebral energy deficiency or oxidative stress levels that exceed antioxidant capacity. The ketogenic diet (KD), a diet mimicking fasting that leads to the elevation of ketone bodies (KBs), is a therapeutic intervention targeting cerebral metabolism that has recently shown great promise in the prevention of migraines. KBs are an alternative fuel source for the brain, and are thus likely able to circumvent some of the abnormalities in glucose metabolism and transport found in migraines. Recent research has shown that KBs-D-β-hydroxybutyrate in particular-are more than metabolites. As signalling molecules, they have the potential to positively influence other pathways commonly believed to be part of migraine pathophysiology, namely: mitochondrial functioning, oxidative stress, cerebral excitability, inflammation and the gut microbiome. This review will describe the mechanisms by which the presence of KBs, D-BHB in particular, could influence those migraine pathophysiological mechanisms. To this end, common abnormalities in migraines are summarised with a particular focus on clinical data, including phenotypic, biochemical, genetic and therapeutic studies. Experimental animal data will be discussed to elaborate on the potential therapeutic mechanisms of elevated KBs in migraine pathophysiology, with a particular focus on the actions of D-BHB. In complex diseases such as migraines, a therapy that can target multiple possible pathogenic pathways seems advantageous. Further research is needed to establish whether the absence/restriction of dietary carbohydrates, the presence of KBs, or both, are of primary importance for the migraine protective effects of the KD.
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Affiliation(s)
- Elena C Gross
- Division of Paediatric Neurology, University Children's Hospital Basel (UKBB), University of Basel, 4056 Basel, Switzerland.
| | - Rainer J Klement
- Department of Radiation Oncology, Leopoldina Hospital Schweinfurt, 97422 Schweinfurt, Germany.
| | - Jean Schoenen
- Headache Research Unit, University of Liège, Dept of Neurology-Citadelle Hospital, 4000 Liège, Belgium.
| | - Dominic P D'Agostino
- Department of Molecular Pharmacology and Physiology, Metabolic Medicine Research Laboratory, Morsani College of Medicine, University of South Florida, Tampa, FL 33612, USA.
- Institute for Human and Machine Cognition, Ocala, FL 34471, USA.
| | - Dirk Fischer
- Division of Paediatric Neurology, University Children's Hospital Basel (UKBB), University of Basel, 4056 Basel, Switzerland.
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Macronutrient Intake in Relation to Migraine and Non-Migraine Headaches. Nutrients 2018; 10:nu10091309. [PMID: 30223543 PMCID: PMC6164759 DOI: 10.3390/nu10091309] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 09/07/2018] [Accepted: 09/12/2018] [Indexed: 12/11/2022] Open
Abstract
We investigated the association of mean daily macronutrient intake with migraine and non-migraine headaches. This cross-sectional study included 8042 men and 23,728 women from the ongoing population-based NutriNet-Santé e-cohort. Headache status was assessed via an online self-report questionnaire (2013–2016). Migraine was defined using established criteria and dietary macronutrient intake was estimated via ≥3 24 h dietary records. Mean daily intake (g/day) of carbohydrates (simple, complex, and total), protein, and fat (saturated fatty acids, monounsaturated fatty acids, polyunsaturated fatty acids, and total) were the main exposure variables. Adjusted gender-specific analysis of variance (ANOVA) models were fit. Presence of migraines was noted in 9.2% of men (mean age = 54.3 ± 13.3 years) and 25.7% of women (mean age = 49.6 ± 12.8 years). In adjusted models, we observed (1) somewhat lower protein (p < 0.02) and higher total fat (p < 0.01) intake among male migraineurs compared with males without headaches and those with non-migraine headaches; (2) somewhat higher total fat (p < 0.0001) and total carbohydrate intake (p < 0.05) among female migraineurs compared with females without headaches and those with non-migraine headaches. The findings, which provide preliminary support for modest gender-specific differences in macronutrient intake by migraine status, merit confirmation in different population-based settings, as well as longitudinally, and could help to inform future dietary interventions in headache prevention.
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Abstract
PURPOSE OF THE REVIEW The goals of this review are to evaluate recent studies regarding comorbidity between migraine and different metabolic and endocrine disorders and to discuss the role of insulin resistance as a common pathogenetic mechanism of these diseases. RECENT FINDINGS Recently, several studies showed that migraine is associated with insulin resistance, a condition in which a normal amount of insulin induces a suboptimal physiological response. All the clinical studies that used the oral glucose tolerance test to examine insulin sensitivity found that, after glucose load, there is in migraine patients a significant increase of both plasmatic insulin and glucose concentrations in comparison with controls. On the contrary, no association was found between migraine and type 2 diabetes, while type 1 diabetes seems to have a protective effect in the disease. Obesity and hypertension were shown to be risk factors for both episodic and chronic migraine. Metabolic syndrome has been recently associated mainly with migraine with aura and is now considered a risk factor also for medication overuse headache. Finally, a bidirectional association between migraine and hypothyroidism has been recently demonstrated, suggesting that common genetic or autoimmune mechanisms underlie both diseases. Recent studies showed that insulin receptor signaling and the related physiological responses are altered in migraine and may have a relevant pathogenic role in the disease. Further studies are warranted in order to better elucidate mechanisms underlying insulin resistance in migraine in order to develop new therapeutic strategies for this debilitating disease.
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Antonazzo IC, Riise T, Cortese M, Berge LI, Engeland A, Bernt Fasmer O, Lund A, Joachim Ødegaard K, Poluzzi E, Bjornevik K. Diabetes is associated with decreased migraine risk: A nationwide cohort study. Cephalalgia 2017; 38:1759-1764. [PMID: 29249165 DOI: 10.1177/0333102417748573] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Background Results from studies on diabetes and migraine risk are conflicting, which may be due to methodological limitations. Prospective studies with long follow-up could increase our understanding of the relationship between the two diseases. Method We performed a cohort study including the whole Norwegian population alive on 01.01.2004, using prescriptions registered in the Norwegian prescription database to identify individuals developing type 1 diabetes, type 2 diabetes and migraine during follow-up (10 years). We used Cox proportional hazards regression to estimate rate ratios with corresponding 95% confidence intervals for the effect of diabetes on migraine risk, adjusting for age, sex, and educational level. Result We identified 7,883 type 1 diabetes patients and 93,600 type 2 patients during the study period. Type 1 diabetes was significantly associated with a subsequent decreased migraine risk during follow-up in the age- and sex-adjusted analyses (0.74; 0.61-0.89). Type 2 diabetes was also associated with a significantly lower migraine risk (0.89; 0.83-0.95). Further adjustment for educational level yielded similar results for both diabetes. Conclusion Both type 1 and type 2 diabetes were significantly associated with a decreased risk of migraine. This suggests that diabetes or diabetes treatment may have a protective effect on the development of migraine.
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Affiliation(s)
- Ippazio Cosimo Antonazzo
- 1 Department of Global Public Health and Primary Care, University of Bergen, Norway.,2 Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Italy
| | - Trond Riise
- 1 Department of Global Public Health and Primary Care, University of Bergen, Norway.,3 The Norwegian Multiple Sclerosis Competence Center, Department of Neurology, Haukeland University Hospital, Norway
| | - Marianna Cortese
- 1 Department of Global Public Health and Primary Care, University of Bergen, Norway.,3 The Norwegian Multiple Sclerosis Competence Center, Department of Neurology, Haukeland University Hospital, Norway.,4 Department of Clinical Medicine, University of Bergen, Norway
| | - Line Iden Berge
- 5 Kronstad DPS, Division of Psychiatry, Haukeland University Hospital, Norway
| | - Anders Engeland
- 1 Department of Global Public Health and Primary Care, University of Bergen, Norway.,6 Division of Mental and Physical Health, Norwegian Institute of Public Health, Norway
| | - Ole Bernt Fasmer
- 5 Kronstad DPS, Division of Psychiatry, Haukeland University Hospital, Norway.,7 Section for Psychiatry, Department of Clinical Medicine, Faculty of Medicine and Dentistry, University of Bergen, Norway
| | - Anders Lund
- 5 Kronstad DPS, Division of Psychiatry, Haukeland University Hospital, Norway.,7 Section for Psychiatry, Department of Clinical Medicine, Faculty of Medicine and Dentistry, University of Bergen, Norway
| | - Ketil Joachim Ødegaard
- 5 Kronstad DPS, Division of Psychiatry, Haukeland University Hospital, Norway.,7 Section for Psychiatry, Department of Clinical Medicine, Faculty of Medicine and Dentistry, University of Bergen, Norway
| | - Elisabetta Poluzzi
- 2 Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, Italy
| | - Kjetil Bjornevik
- 1 Department of Global Public Health and Primary Care, University of Bergen, Norway.,3 The Norwegian Multiple Sclerosis Competence Center, Department of Neurology, Haukeland University Hospital, Norway
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Abstract
Background Metabolic syndrome (MetS) and migraine are known to be associated. This study assessed the risk of MetS and its clinical characteristics in migraine with aura (MA) and without aura (MO) based on a large-scale cross-sectional survey. Methods The study material consisted of 751 participants in the Nutrition, Environment and CardioVascular Health (NESCaV) survey. Diagnosis of migraine was based on the ef-ID migraine questionnaire and MetS was defined according to the Revised-Adult Treatment Panel III criteria. Sociodemographic and risk factors were also recorded. Weighted logistic regression was used to assess the risk of MetS. Results After adjusting for stratification (gender, age, district) and other factors (smoking status, sedentary lifestyle, family history of stroke, myocardial infarction and hypertension), MA subjects were at higher risk of MetS (OR 3.45; 95% CI: 1.63–7.29) while MO individuals were not, when compared to non-migraineurs. When considering MetS components, MA was positively associated with low HDL-cholesterol (OR 2.26; 95% CI: 1.08–4.74), hyperglycemia (OR 2.77; 95% CI: 1.30–5.88) and abdominal obesity (OR 2.03; 95% CI: 1.07–3.86). Conclusion Migraineurs with aura are at higher risk of MetS, suggesting that these subjects, already more exposed to stroke, may benefit from a systematic screening for the metabolic syndrome.
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Verrotti A, Carotenuto M, Altieri L, Parisi P, Tozzi E, Belcastro V, Esposito M, Guastaferro N, Ciuti A, Mohn A, Chiarelli F, Agostinelli S. Migraine and obesity: metabolic parameters and response to a weight loss programme. Pediatr Obes 2015; 10:220-5. [PMID: 24990114 DOI: 10.1111/ijpo.245] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 05/09/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND OBJECTIVE Weight loss can determine significant improvement of migraine in obese patients. Herein, we evaluated a clinical sample of adolescent migraineurs with obesity who participated in an interdisciplinary programme for weight loss, in order to identify possible metabolic parameters associated with good migraine control. SUBJECTS AND METHODS Using a cross-sectional design, we evaluated 112 out of 135 adolescents who previously underwent our intervention programme. Based on persistence of headache, subjects for comparison were 40 migraine-free and 72 not migraine-free adolescents. Participants underwent anthropometric evaluations and biochemical tests. RESULTS Patients with persistence of migraine had significantly higher weight (P < 0.01), body mass index (P < 0.01), waist circumference (P < 0.01), homeostasis model assessment of insulin resistance (P < 0.001), triglyceride (P < 0.05), total cholesterol (P < 0.05) and low-density lipoprotein cholesterol (P < 0.05) values when compared with those who became migraine-free. Between potential predictors, only insulin resistance (odds ratio = 3.5, 95% confidence interval = 1.4-6.1; P < 0.001) was significantly associated with persistence of migraine after intervention programme. CONCLUSIONS Among obese adolescents with migraine who underwent an intervention programme for weight loss, patients who did not become migraine-free showed higher adiposity values than those who became migraine-free. Patients with insulin resistance had 3.5 times the odds of having persistence of migraine compared with those without.
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Affiliation(s)
- A Verrotti
- Department of Pediatrics, University of Perugia, Perugia, Italy
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Kokavec A. Effect of sucrose consumption on serum insulin, serum cortisol and insulin sensitivity in migraine: Evidence of sex differences. Physiol Behav 2015; 142:170-8. [DOI: 10.1016/j.physbeh.2015.02.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Revised: 02/07/2015] [Accepted: 02/13/2015] [Indexed: 02/08/2023]
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Ornello R, Ripa P, Pistoia F, Degan D, Tiseo C, Carolei A, Sacco S. Migraine and body mass index categories: a systematic review and meta-analysis of observational studies. J Headache Pain 2015; 16:27. [PMID: 25903159 PMCID: PMC4385329 DOI: 10.1186/s10194-015-0510-z] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2015] [Accepted: 03/03/2015] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Several studies have assessed the associations between migraine and underweight, pre-obesity or obesity, with conflicting results. To assess the consistency of the data on the topic, we performed a systematic review and meta-analysis of the available observational studies. METHODS Multiple electronic databases were systematically searched up to October 2014 for studies assessing the association between migraine and body mass index categories (underweight, pre-obesity, or obesity). RESULTS Out of 2,022 records, we included 15 studies. When considering the 11 studies following the World Health Organization BMI cutoffs, we found an increased risk of having migraine in underweight subjects (pooled adjusted effect estimate [PAEE] 1.21; 95% CI, 1.07-1.37; P = 0.002) and in obese women (PAEE 1.44; 95% CI, 1.05-1.97; P = 0.023) as compared with normal weight subjects; additionally, pre-obese subjects had an increased risk of having chronic migraine (PAEE 1.39; 95% CI, 1.13-1.71; P = 0.002). When considering all the 15 studies, we additionally found an increased risk of having migraine in obese as compared with normal weight subjects (PAEE 1.14; 95% CI, 1.02-1.27; P = 0.017); additionally, obese subjects had an increased risk of having chronic migraine (PAEE 1.75; 95% CI, 1.33-2.29; P < 0.001). The pooled analysis did not indicate an increased risk of having migraine in pre-obese subjects. CONCLUSIONS The meta-analysis of the available observational studies suggested an association between migraine and obesity likely mediated by gender and migraine frequency. Further studies taking into account gender, migraine type, frequency, activity, and duration could provide more robust evidence.
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Affiliation(s)
- Raffaele Ornello
- Department of Applied Clinical Sciences and Biotechnology, Institute of Neurology, University of L'Aquila, 67100, L'Aquila, Italy.
| | - Patrizia Ripa
- Department of Applied Clinical Sciences and Biotechnology, Institute of Neurology, University of L'Aquila, 67100, L'Aquila, Italy.
| | - Francesca Pistoia
- Department of Applied Clinical Sciences and Biotechnology, Institute of Neurology, University of L'Aquila, 67100, L'Aquila, Italy.
| | - Diana Degan
- Department of Applied Clinical Sciences and Biotechnology, Institute of Neurology, University of L'Aquila, 67100, L'Aquila, Italy.
| | - Cindy Tiseo
- Department of Applied Clinical Sciences and Biotechnology, Institute of Neurology, University of L'Aquila, 67100, L'Aquila, Italy.
| | - Antonio Carolei
- Department of Applied Clinical Sciences and Biotechnology, Institute of Neurology, University of L'Aquila, 67100, L'Aquila, Italy.
| | - Simona Sacco
- Department of Applied Clinical Sciences and Biotechnology, Institute of Neurology, University of L'Aquila, 67100, L'Aquila, Italy.
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Celikbilek A, Celikbilek M, Okur A, Dogan S, Borekci E, Kozan M, Gursoy S. Non-alcoholic fatty liver disease in patients with migraine. Neurol Sci 2014; 35:1573-8. [PMID: 24756192 DOI: 10.1007/s10072-014-1798-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Accepted: 04/09/2014] [Indexed: 12/13/2022]
Abstract
Evidence suggests that migraine is associated with metabolic syndrome, which is also implicated in non-alcoholic fatty liver disease (NAFLD). Reported for the first time, we aimed to investigate the relationship between migraine and NAFLD in patients with migraine. A total of 90 consecutive migraine patients were enrolled in this cross-sectional study. The diagnosis of migraine was determined according to the International Classification of Headache Disorders-II diagnostic criteria. The diagnosis of NAFLD was based on abdominal ultrasonography findings. Anthropometric indices and the homeostasis model assessment of insulin resistance (HOMA-IR) were calculated, and serum insulin level measurements and other biochemical analyses were performed for each subject. The measurements of body mass index and waist circumference were significantly higher in migraine patients with NAFLD than in those without NAFLD (p < 0.001). Regarding the laboratory results, insulin (p = 0.024), alanine aminotransferase (p = 0.027), and triglyceride levels (p = 0.001) and the HOMA-IR (p = 0.039) were higher in migraineurs with NAFLD than in those without NAFLD. Among the headache characteristics, the presence of aura was higher, and disease and attack durations were significantly longer in migraineurs with NAFLD than in those without NAFLD (p = 0.005, p = 0.024, and p = 0.023; respectively). However, the headache characteristics did not correlate with either the hepatosteatosis grade or HOMA-IR in migraine patients (p > 0.05). Our results show that NAFLD may present in migraine patients with higher frequency of auras and longer disease and attack durations.
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Affiliation(s)
- Asuman Celikbilek
- Department of Neurology, Bozok University, School of Medicine, 66200, Yozgat, Turkey,
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