White matter hyperintensities in migraine: Clinical significance and central pulsatile hemodynamic correlates

Association between vertebral artery dominance and basilar artery curvature in migraineurs: an anatomical magnetic resonance imaging study

BACKGROUND AND PURPOSES

Numerous studies demonstrate a link between cerebrovascular alterations and migraine pathogenesis. We investigated the association between migraine and vertebral artery dominance (VAD), basilar artery (BA) curvature, and elongation.

MATERIALS AND METHODS

This cross-sectional MRI study included 74 migraine patients and 74 control subjects aged between 18 and 55 years. Diameters of the intracranial part of the vertebral artery (VA) and BA, height of the BA bifurcation, and total lateral displacement of the BA were measured. In addition, we investigated the directional relationship between VAD and BA curvature.

RESULTS

There were no statistically significant differences between the groups regarding VA and BA diameters and total lateral displacement of the BA. The height of the BA bifurcation was found to be significantly higher in migraine patients compared to controls (p = 0.002). The left-side VAD was more frequent in migraine patients compared to control subjects (60.8% (45/74) vs 41.9% (31/74), p = 0.001). In migraine patients, particularly those with aura (MwA) patients, with left-side VAD, the rate of BA displacement to the right side is significantly higher than those with right-side VAD or non-VAD (p = 0.022). Also, we found that total lateral displacement of the BA is correlated with VA asymmetry in patients with MwA (r = 0.538, p = 0.007).

CONCLUSION

VAD and its opposite-directional relationship with the lateral displacement of the BA may be associated with migraine pathophysiology. Together with aging, this association may contribute to changes in the vertebrobasilar system (VBS) geometry which may result in increased risk for posterior circulation infarction (PCI) in migraineurs.

A retrospective review of sex differences of white matter hyperintensities in brain MRI of patients with migraine

OBJECTIVES

The primary objective of this study was to evaluate the prevalence of white matter hyperintensities (WMHs) in patients who experience migraine and compare findings between adult male and female patients. Specific symptoms and comorbidities also were analyzed to determine whether they were associated with WMH prevalence or the sex of patients with migraine. We hypothesized that females would have a higher prevalence of WMHs, experience more frequent and more severe migraine headaches, and be more likely to have certain comorbidities associated with migraine than males.

BACKGROUND

An increased prevalence of WMHs in patients with migraine has been proposed, although this relation is not well-supported by data from population-based MRI studies. The difference in brain morphology between males and females is of research interest, and females in the general population appear to have a higher prevalence of WMHs. Sex differences and various comorbidities in patients with migraine relative to the number of WMHs on brain imaging have not been fully investigated.

METHODS

This was a cross-sectional study of 177 patients aged 18 years and older with a diagnosis of migraine who were seen in the Lehigh Valley Fleming Neuroscience Institute's Headache Center between January 1, 2000, and January 1, 2017. Patients' baseline characteristics were extracted from electronic medical records, including demographics, review of systems documentation, and brain imaging from MRI. Variables including headache severity, frequency of head pain, insomnia, and comorbidities (anxiety, depression, diabetes, hyperlipidemia, hypertension, and neck pain) also were analyzed for associations with the presence of WMHs.

RESULTS

Females were found to have a significantly higher number of WMHs than males (median 3 [IQR: 0-7] vs. 0 [IQR: 0-3], p = 0.023). Patients with WMHs were significantly more likely than those without WMHs to have hypertension (39.8% of patients with WMHs vs. 20.3% without WMHs, p = 0.011), constipation (20.9% vs. 8.3%, p = 0.034), and sleep disorder (55.7% vs. 37.3%, p = 0.022). Females with migraine were significantly more likely to experience constipation than males (20.0% vs. 2.9%, p = 0.015). None of the migraine characteristics studied (frequency, severity, presence of aura) were different between sexes, nor were they significantly associated with the presence of WMHs.

CONCLUSION

This study suggests that females with migraine may be more likely to have WMHs and experience constipation than males with migraine. Migraine frequency and severity were not different between sexes, nor were they significantly associated with the presence of WMHs. The findings of this study do not support a specific etiology of WMH development in individuals with migraine that differs from findings in the general population. Further studies are warranted.

Association between migraine and the risk of vascular dementia: A nationwide longitudinal study in South Korea

OBJECTIVE

We aimed to examine the potential association between migraine and vascular dementia (VaD) using a nationwide population database.

BACKGROUND

Migraine and VaD showed similar structural and functional changes in pathophysiology process and shared common risk factors, However, whether migraine prevalence increases VaD incidence remains controversial.

METHODS

This retrospective population-based cohort study used the medical records from the Korean National Health Insurance System database. Migraine (G43) was defined by using the Tenth Revision of the International Classification of Diseases code. More than two migraine diagnoses at least 3 months apart were defined as "chronic migraine". Cox proportional hazards model estimated hazard ratios (HRs) of VaD for group comparisons.

RESULTS

We included 212,836 patients with migraine and 5,863,348 individuals without migraine. During 10 years of follow-up, 3,914 (1.8%) and 60,258 (1.0%) patients with and without migraine, respectively, were newly diagnosed with VaD. After adjustment, patients with migraine showed a 1.21-fold higher risk of VaD than those without migraine (HR = 1.21; 95% confidence interval (CI): 1.17-1.25). Patients with chronic migraine showed a higher cumulative incidence of VaD than those with episodic migraine. The adjusted HR for the VaD incidence with migraine was higher in: (1) patients aged <65 years; (2) women; (3) patients without hypertension, diabetes, or atrial fibrillation; and (4) non-smokers.

CONCLUSION

Migraine is associated with an increased risk of VaD, particularly in chronic migraine patients. Incidence of VaD in the setting of migraine may have distinct pathophysiology from that of VaD with traditional cardiovascular risks.

Correlation between migraine and cerebral small vessel disease: A case-control study

BACKGROUND

Microcirculatory pathology is one of the pathophysiological theories of migraine, which may present as visually subclinical lesions. Image markers of cerebral small vessel disease (CSVD) have been investigated in elderly migraineurs. However, past studies looked at only part of image features, and the conclusions may have been hindered by confounding factors. The relationship between migraine and CSVD signs needs reliable demonstrations.

METHODS

We conducted a case-control study by recruiting episodic young migraineurs from a tertiary headache centre, with tension-type headache (TTH) and healthy controls. Distinct image features of microvascular damage and baseline characteristics across groups were assessed, and multivariate linear regression was performed to evaluate the risk factors for image abnormalities in migraineurs.

RESULTS

Forty-eight migraineurs, 32 TTHs and 49 healthy controls were included. The median age was 32 year-old. 58.7% of the participants were female. The Scheltens score and volume of white matter hyperintensities (WMHs) in migraineurs, and the number of Virchow-Robin spaces (VRSs) in both migraineurs and TTHs were different from those in normal controls. No lacunar infarct-like lesions (ILLs) or cerebral microbleeds (CMBs) were found. Age, education level (high level: β = -2.23, lobar WMHs), attack duration (long duration: β = 3.81, lobar WMHs) and attack frequency were independent risk factors for Scheltens score and volume of WMH in migraineurs. Migraine aura (β = -2.389), attack frequency and education level were correlated with the number of VRSs.

CONCLUSIONS

Migraine was associated with WMHs and VRSs. Aura, attack duration, attack frequency, age and education level were risk factors for image abnormalities of CVSD in migraineurs.

SIGNIFICANCE

This study provides a novel and comprehensive landscape of CSVD MRI features in young migraineurs, and it fills the blank of CMBs and VRSs which received less attention, with more persuasive, more reliable and stronger evidence of the association between CSVD and migraine. Our results also imply some new feature of TTH and the possible pathophysiology of the migraine course as well as new clues for the early management of migraine in terms of visual brain damage.

Associations of Cerebrovascular Regulation and Arterial Stiffness With Cerebral Small Vessel Disease: A Systematic Review and Meta-Analysis

BACKGROUND

Cerebral small vessel disease (cSVD) is a major contributing factor to ischemic stroke and dementia. However, the vascular pathologies of cSVD remain inconclusive. The aim of this systematic review and meta-analysis was to characterize the associations between cSVD and cerebrovascular reactivity (CVR), cerebral autoregulation, and arterial stiffness (AS).

METHODS AND RESULTS

MEDLINE, Web of Science, and Embase were searched from inception to September 2023 for studies reporting CVR, cerebral autoregulation, or AS in relation to radiological markers of cSVD. Data were extracted in predefined tables, reviewed, and meta-analyses performed using inverse-variance random effects models to determine pooled odds ratios (ORs). A total of 1611 studies were identified; 142 were included in the systematic review, of which 60 had data available for meta-analyses. Systematic review revealed that CVR, cerebral autoregulation, and AS were consistently associated with cSVD (80.4%, 78.6%, and 85.4% of studies, respectively). Meta-analysis in 7 studies (536 participants, 32.9% women) revealed a borderline association between impaired CVR and cSVD (OR, 2.26 [95% CI, 0.99-5.14]; P=0.05). In 37 studies (27 952 participants, 53.0% women) increased AS, per SD, was associated with cSVD (OR, 1.24 [95% CI, 1.15-1.33]; P<0.01). Meta-regression adjusted for comorbidities accounted for one-third of the AS model variance (R2=29.4%, Pmoderators=0.02). Subgroup analysis of AS studies demonstrated an association with white matter hyperintensities (OR, 1.42 [95% CI, 1.18-1.70]; P<0.01).

CONCLUSIONS

The collective findings of the present systematic review and meta-analyses suggest an association between cSVD and impaired CVR and elevated AS. However, longitudinal investigations into vascular stiffness and regulatory function as possible risk factors for cSVD remain warranted.

Migraine and white matter lesions: a mendelian randomization study

Previous studies have found that migraine patients are associated with white matter lesions (WMLs), but the causal relationship between the two remains unclear. We intend to explore the bidirectional causal relationship between migraine and WMLs using a two-sample mendelian randomization (MR) method. We employed summary-level data from a recent large-scale genome-wide association study (GWAS) that characterized three white matter (WM) phenotypes: white matter hyperintensities (WMH, N = 18,381), fractional anisotropy (FA, N = 17,673), and mean diffusivity (MD, N = 17,467), as well as migraine (N = 589,356). The inverse variance-weighted (IVW) method was used as the main approach for analyzing causality. Weighted median analysis, simple median analysis, and MR-Egger regression served as complementary methods. The bidirectional MR study affords no support for causality between WMLs and migraine. In all MR methods, there was no obvious causal evidence between them. In our bidirectional MR study, we didn't reach this conclusion that WMLs can cause migraine, migraine wouldn't increase the risk of WMLs, either.

Mechanical loading of the ventricular wall as a spatial indicator for periventricular white matter degeneration

Progressive white matter degeneration in periventricular and deep white matter regions appears as white matter hyperintensities (WMH) on MRI scans. To date, periventricular WMHs are often associated with vascular dysfunction. Here, we demonstrate that ventricular inflation resulting from cerebral atrophy and hemodynamic pulsation with every heartbeat leads to a mechanical loading state of periventricular tissues that significantly affects the ventricular wall. Specifically, we present a physics-based modeling approach that provides a rationale for ependymal cell involvement in periventricular WMH formation. Building on eight previously created 2D finite element brain models, we introduce novel mechanomarkers for ependymal cell loading and geometric measures that characterize lateral ventricular shape. We show that our novel mechanomarkers, such as maximum ependymal cell deformations and maximum curvature of the ventricular wall, spatially overlap with periventricular WMH locations and are sensitive predictors for WMH formation. We also explore the role of the septum pellucidum in mitigating mechanical loading of the ventricular wall by constraining the radial expansion of the lateral ventricles during loading. Our models consistently show that ependymal cells are stretched thin only in the horns of the ventricles irrespective of ventricular shape. We therefore pose that periventricular WMH etiology is strongly linked to the deterioration of the over-stretched ventricular wall resulting in CSF leakage into periventricular white matter. Subsequent secondary damage mechanisms, including vascular degeneration, exacerbate lesion formation and lead to progressive growth into deep white matter regions.

Do Mean Platelet Volume and Platelet Distribution Width Have An Association with White Matter Hyperintensities in Migraine Patients?

Objective

Increased prevalence of white matter hyperintensities (WMH) is reported in migraine patients; however, the pathophysiology and the progression of these lesions are not definitely clear. Mean platelet volume (MPV) and platelet distribution width (PDW) are easily obtained markers for platelet activity. The aim of this study is to evaluate the relationship between the presence of WMH and MPV and PDW in patients with migraine in order to determine the role of platelet activity in the pathophysiology of WMH.

Methods

Patients who were admitted to the neurology outpatient clinics of Baskent University Hospital from January 2011 to December 2015 with migraine and between 18 and 55 years of age were evaluated retrospectively. The blood samples were taken and total blood count parameters including MPV and PDW were analyzed. Brain magnetic resonance images were evaluated.

Results

Totally, 218 patients were evaluated in this study. Forty-eight (22.0%) patients had WMH in the brain magnetic resonance imaging. In patients with WMH, the median of age was higher than the patients without WMH and the difference was statistically significant (P < 0.05). There was no statistically significant difference between MPV, PDW values, and the presence of WMH.

Conclusions

There are multiple theories suggested for the mechanism of WMH, but the major cause and pathophysiology are still undetermined. Our data suggested that increased platelet activity is insufficient by itself to explain the pathophysiology of WMH in migraine patients and to improve the knowledge on this issue further large longitudinal studies should be performed.

Cardiovascular profiles associated with white matter hyperintensities in healthy young women

Women who experience hypertension in pregnancy have increased risk of both chronic hypertension and dementia. High blood pressure is associated with increased evidence of white matter hyperintensities (WMH) in brain imaging. WMH are disruptions of the white matter of the brain that occur with demyelination and axonal degeneration, are associated with vascular disease, occur more frequently in people with hypertension, and are associated with cognitive impairment. We evaluated the relationship between WMH and subclinical cardiovascular function in healthy young nulliparous women and women with a history of early-onset preeclampsia. Sixty-two reproductive-aged women were assessed during the follicular phase of the menstrual cycle after a 3-day sodium/potassium-controlled diet. Half of participants had a history of early-onset preeclampsia, and half were nulliparous. Blood was drawn to assess inflammatory markers. Cardiovascular assessments included tonometric blood pressure monitoring, volume loading to assess vascular compliance, echocardiography to assess cardiac ejection time, brachial pulse wave velocity of the brachial artery, assessing cardiovascular stiffness, and brachial artery flow mediated vasodilation to assess endothelial mediated dilatory response. T2 fluid-attenuated inversion recovery (FLAIR) MRI imaging was obtained. Two raters, blinded to cardiovascular assessments and pregnancy history, reviewed MRI scans for evidence of WMH using the Fazekas rating scale. WMHs were detected in 17 women; 45 had normal white matter structure. Participants with Fazekas score>0 had exaggerated response to volume loading compared to women with a Fazekas score of 0 and longer cardiac ejection times. Fazekas scores >0 had lower brachial flow-mediated vasodilation and increased white blood count compared to those with no evidence of WMH. Women with WMH had reduced cardiovascular compliance, and a trend towards decreased endothelial responsiveness compared to those without WMH. These data demonstrated that the relationship between cardiovascular and brain health was detectable in young, healthy, reproductive-aged women, and may play a role in later development of clinical disease. These findings may help identify women who are at risk for cognitive decline and pathological aging.

Structural MRI in Migraine: A Review of Migraine Vascular and Structural Changes in Brain Parenchyma

Migraine is a complex and common disorder that affects patients around the world. Despite recent advances in this field, the exact pathophysiology of migraine is still not completely understood. Structural MRI sequences have revealed a variety of changes to brain parenchyma associated with migraine, including white matter lesions, volume changes, and iron deposition. This Review highlights different structural imaging findings in various types of migraine and their relationship to migraine characteristics and subtypes in order to improve our understanding of migraine, its pathophysiologic mechanisms, and how to better diagnose and treat it.

Multiple sclerosis and migraine: Links, management and implications

Multiple sclerosis (MS) is a chronic inflammatory disease leading to multifocal neuronal demyelination and axonal damage in the central nervous system (CNS). MS symptoms vary widely but typically do not include headaches. A large spectrum of headaches manifestations was reported as comorbidities in MS and results in additional disability. Migraine, tension-type headache and cluster headache are the most frequently reported primary headache syndromes in patients with MS (pwMS). Secondary causes of headache should be excluded (cerebral vein thrombosis, CNS or systemic infection, cervical and/or cranial trauma, headaches associated with psychiatric disorders, medication overuse headache, etc.) in this particular population. A careful medical history and general and neurological examinations and sometimes further investigations may be needed to rule out secondary headache syndromes. In pwMS, the headache could be an adverse effect of the disease-modifying therapies or a complication of pain medication overuse prescribed to relieve other causes of pain related to MS (neuropathic pain, mechanical pain, pain associated with spasticity, etc.). Migraine-type headache occurs in pwMS more frequently than in the general population. It can precede the disease onset, be associated with relapses, or appear during the MS course. A predominance of brainstem inflammatory lesions is described on magnetic resonance imaging (MRI) in MS patients with migraine. The relationship between both conditions remains unclear. Migraine and MS occur in the same demographic groups with similar background factors, including gender, hormonal status, and psychological features (anxiety, depression, stress). An early diagnosis and adequate treatment of migraine in MS patients are important to improve their quality of life. In this review, we focus on the relationship between MS and Migraine, discuss the differential diagnoses of migraine in pwMS, and describe its management in this particular context.

Cerebrovascular reactivity and deep white matter hyperintensities in migraine: A prospective CO2 targeting study

Several studies suggested the association of migraine with deep white matter hyperintensities (WMHs). We aimed to explore the cerebrovascular reactivity (CVR), deep WMH burden, and their association in patients with migraine using a state-of-the-art methodology. A total of 31 patients with migraine without aura and 31 age/sex-matched controls underwent 3T MRI with prospective end-tidal carbon dioxide (CO₂) targeting. We quantified deep WMH clusters using an automated segmentation tool and measured voxel-wise CVR by changes in blood oxygen level-dependent signal fitted to subjects' end-tidal CO₂. The association of migraine and CVR with the presence of WMH in each voxel and interaction of migraine and CVR on WMH were analysed. Patients had a higher number of deep WMHs than controls (p = 0.015). Migraine and reduced CVR were associated with increased probability of having WMHs in each voxel (adjusted OR 30.78 [95% CI 1.89-500.53], p = 0.016 and adjusted OR 0.30 [0.29-0.32], p < 0.001, respectively). Migraine had an effect modification on CVR on deep WMHs (p for interaction <0.001): i.e. the association between CVR and WMH was greater in patients than in controls. We suggest that the migraine-WMH association can be explained by the effect modification on the CVR.

Neurological soft signs are increased in migraine without aura: relationship with the affective status

Introduction

Neurological soft signs (NSS) are subtle non-localizing sensorimotor abnormalities initially reported as increased in primary headache patients. The aims of this study were confirming with full power NSS increased expression in migraine and, collaterally, determining if psychiatric traits or white matter lesions at brain imaging could influence this result.

Methods

Forty drug-free episodic migraine outpatients (MH) were recruited with 40 matched controls. NSS were determined by the 16-item Heidelberg scale; depression, anxiety and QoL by the HAM-D; the STAI-X1/X2; and the SF36, respectively. The Fazekas scale on brain MR studies was applied in n = 32 MH, unravelling deep white matter signal alterations (DWM). MH characteristics, including the headache disability inventory (HDI), were recorded.

Results

NSS were 46% increased in MH vs. controls (p = 0.0001). HAM-D and STAI-X1/X2 were increased in MH, while SF36 was unchanged, but they all failed to influence NSS, just as MH characteristics. NSS scores were increased in MH-DWM + (n = 11, + 85%) vs. MH-DWM − (n = 21, + 27%) vs. controls (p < 0.0001). NSS increased expression in MH was influenced by DWM, while psychiatric traits and headache characteristics failed to do so.

Discussion/conclusions

NSS are increased in MH and probably not influenced by the affective status, possibly marking a dysfunction within the cerebellar-thalamic-prefrontal circuit that may deserve further attention from the prognostic point of view.

The putative role of trigemino-vascular system in brain perfusion homeostasis and the significance of the migraine attack

Besides representing the place where a migraine attack generates, what is the physiological role of peptidergic control of arteriolar caliber within the trigemino-vascular system? Considering that the shared goal of most human CGRP-based neurosensory systems is the protection from an acute threat, especially if hypoxic, what is the end meaning of a migraine attack? In this paper, we have reviewed available evidence on the possible role of the trigemino-vascular system in maintaining cerebral perfusion pressure homeostasis, despite the large physiological fluctuations in intracranial pressure occurring in daily life activities. In this perspective, the migraine attack is presented as the response to a cerebral hypoxic threat consequent to a deranged intracranial pressure control aimed at generating a temporary withdrawal from the environment with limitation of physical activity, a condition required to promote the restoration of cerebral fluids dynamic balance.

Evaluating the relationship between right-to-left shunt and white matter hyperintensities in migraine patients: A systematic review and meta-analysis

Introduction

White matter hyperintensities (WMHs) have been observed with greater frequency in patients with migraine and are thought to be associated with impaired cognition and function. The relationship between WMHs and right-to-left shunt (RLS) in migraine patients is unknown. We performed a systematic review to determine if there is an association between RLS and WMHs in patients with migraine.

Methods

A systematic search of the literature was performed in PubMed and Embase using a suitable keyword search strategy from inception up to 16th June 2021. All studies that included patients with migraine and studied RLS and WMHs were included.

Results

A total of 8 non-randomized observational studies comprising 1125 patients with migraine were included; 576 had an RLS, compared to 549 patients with no RLS. The mean age of the study populations ranged from 28.4 to 43 years, while the average duration from migraine diagnosis ranged from 5.1 to 19 years. The proportion of female to male patients was consistently higher in all studies (60.0–94.4%). Amongst migraine patients with RLS, 338 patients (58.7%) had WMHs. In contrast, 256 (46.6%) of migraine patients without RLS had WMHs. RLS was significantly associated with the presence of WMHs in migraine patients (OR: 1.56, 95% CI: 1.05–2.34, p = 0.03).

Conclusion

In migraine patients, RLS was significantly associated with the presence of WMHs. Longitudinal studies are warranted to establish RLS as a risk factor for WMHs in patients with migraine, and to establish the significance of these changes.

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.

The Characteristics of White Matter Hyperintensities in Patients With Migraine

Background

The presence of white matter hyperintensities (WMHs) in migraine is well-documented, but the location of WMH in patients with migraine is insufficiently researched. This study assessed WMH in patients with migraine using a modified version of the Scheltens visual rating scale, a semiquantitative scale for categorizing WMH in periventricular, lobar, basal ganglia, and infratentorial regions.

Methods

In total, 263 patients with migraine (31 men and232 women) enrolled in the American Registry for Migraine Research (ARMR) from Mayo Clinic Arizona and who had clinical brain magnetic resonance imaging (MRI) were included in this study. Those with imaging evidence for gross anatomical abnormalities other than WMHs were excluded. A board-certified neuroradiologist identified WMHs on axial T2 and fluid-attenuated inversion recovery (FLAIR) sequences. WMHs were characterized via manual inspection and categorized according to the scale's criteria.

Results

Results showed that 95 patients (36.1%, mean age: 41.8 years) had no WMHs on axial T2 and FLAIR imaging and 168 patients (63.9%, mean age: 51.4 year) had WMHs. Of those with WMHs, 94.1% (n = 158) had lobar hyperintensities (frontal: 148/158, 93.7%; parietal: 57/158, 36.1%; temporal: 35/158, 22.1%; and occipital: 9/158, 5.7%), 13/168, 7.7% had basal ganglia WMHs, 49/168, 29.1% had periventricular WMHs, and 17/168, 10.1% had infratentorial WMHs. In addition, 101/168 patients (60.1%) had bilateral WMHs and 67/168 (39.9%) had unilateral WMHs (34 right hemisphere/33 left hemisphere).

Discussion

Among ARMR participants who were enrolled by Mayo Clinic Arizona and who had clinical brain MRIs, nearly two-thirds had WMHs. The WMHs were the most common in the frontal lobes. Describing the features of WMHs in those with migraine, and comparing them with WMHs attributable to other etiologies, might be useful for developing classifiers that differentiate between migraine-specific WMH and other causes of WMH.

Relationship between Helicobacter pylori infection and white matter lesions in patients with migraine

Background/aim

White matter lesions (WML) are more frequently observed in migraine patients than in the average population. Associations between Helicobacter pylori (H. pylori) infection and different extraintestinal pathologies have been identified. Here, we aimed to investigate the association between H. pylori infection and WML in patients diagnosed with episodic migraine.

Materials and methods

A retrospective study was conducted with 526 subjects with a diagnosis of episodic migraine. Hyperintensity of WML had been previously evaluated in these patients with brain magnetic resonance imaging (MRI) examinations. Previous endoscopic gastric biopsy histopathological examination of the same patients and reports on H. pylori findings were recorded. The demographic characteristics of the patients, such as age, gender and chronic systemic diseases such as hypertension and diabetes mellitus (DM) were recorded. Statistical evaluation was made.

Results

Evaluation was made among 526 migraine patients who met the inclusion criteria, comprising 397 (75.5%) females and 129 (24.5%) males with a mean age of 45.57 ± 13.46 years (range, 18–69 years). WML was detected on brain MRI in 178 (33.8%) patients who were also positive for H. pylori (p <  0.05). Subjects who are H. pylori-positive with migraine, WML were observed at a 2.5-fold higher incidence on brain MRI (odds ratio: 2.562, 95% CI 1.784–3.680). WML was found to be more significant in patients with hypertension and migraine than those without (p <  0.001). Older age was also found to be associated with WML (OR = 1.07, 95% CI: 0.01–0.04, p <  0.001). The age (p <  0.001), H. pylori (p <  0.001), hypertension (p <  0.001), and hypertension + DM (p <  0.05), had significant associations in predicting WML according to the multivariate logistic regression analysis. The presence of hypertension had a higher odds ratio value than the other variables.

Conclusion

It was concluded that H. pylori infection, as a chronic infection, can be considered a risk factor in developing WML in subjects with migraine.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-022-02715-0.

Elevated Aortic Pulse Wave Velocity Relates to Longitudinal Gray and White Matter Changes

OBJECTIVE

To determine whether baseline aortic stiffness, measured by aortic pulse wave velocity (PWV), relates to longitudinal cerebral gray or white matter changes among older adults. Baseline cardiac magnetic resonance imaging will be used to assess aortic PWV while brain magnetic resonance imaging will be used to assess gray matter and white matter hyperintensity (WMH) volumes at baseline, 18 months, 3 years, 5 years, and 7 years. Approach and Results: Aortic PWV (m/s) was quantified from cardiac magnetic resonance. Multimodal 3T brain magnetic resonance imaging included T₁-weighted imaging for quantifying gray matter volumes and T₂-weighted fluid-attenuated inversion recovery imaging for quantifying WMHs. Mixed-effects regression models related baseline aortic PWV to longitudinal gray matter volumes (total, frontal, parietal, temporal, occipital, hippocampal, and inferior lateral ventricle) and WMH volumes (total, frontal, parietal, temporal, and occipital) adjusting for age, sex, race/ethnicity, education, cognitive diagnosis, Framingham stroke risk profile, APOE (apolipoprotein E)-ε4 carrier status, and intracranial volume. Two hundred seventy-eight participants (73±7 years, 58% male, 87% self-identified as non-Hispanic White, 159 with normal cognition, and 119 with mild cognitive impairment) from the Vanderbilt Memory & Aging Project (n=335) were followed on average for 4.9±1.6 years with PWV measurements occurring from September 2012 to November 2014 and longitudinal brain magnetic resonance imaging measurements occurring from September 2012 to June 2021. Higher baseline aortic PWV was related to greater decrease in hippocampal (β=-3.6 [mm³/y]/[m/s]; [95% CI, -7.2 to -0.02] P=0.049) and occipital lobe (β=-34.2 [mm³/y]/[m/s]; [95% CI, -67.8 to -0.55] P=0.046) gray matter volume over time. Higher baseline aortic PWV was related to greater increase in WMH volume over time in the temporal lobe (β=17.0 [mm³/y]/[m/s]; [95% CI, 7.2-26.9] P<0.001). All associations may be driven by outliers.

CONCLUSIONS

In older adults, higher baseline aortic PWV related to greater decrease in gray matter volume and greater increase in WMHs over time. Because of unmet cerebral metabolic demands and microvascular remodeling, arterial stiffening may preferentially affect certain highly active brain regions like the temporal lobes. These same regions are affected early in the course of Alzheimer disease.

Peak ependymal cell stretch overlaps with the onset locations of periventricular white matter lesions

Deep and periventricular white matter hyperintensities (dWMH/pvWMH) are bright appearing white matter tissue lesions in T2-weighted fluid attenuated inversion recovery magnetic resonance images and are frequent observations in the aging human brain. While early stages of these white matter lesions are only weakly associated with cognitive impairment, their progressive growth is a strong indicator for long-term functional decline. DWMHs are typically associated with vascular degeneration in diffuse white matter locations; for pvWMHs, however, no unifying theory exists to explain their consistent onset around the horns of the lateral ventricles. We use patient imaging data to create anatomically accurate finite element models of the lateral ventricles, white and gray matter, and cerebrospinal fluid, as well as to reconstruct their WMH volumes. We simulated the mechanical loading of the ependymal cells forming the primary brain-fluid interface, the ventricular wall, and its surrounding tissues at peak ventricular pressure during the hemodynamic cycle. We observe that both the maximum principal tissue strain and the largest ependymal cell stretch consistently localize in the anterior and posterior horns. Our simulations show that ependymal cells experience a loading state that causes the ventricular wall to be stretched thin. Moreover, we show that maximum wall loading coincides with the pvWMH locations observed in our patient scans. These results warrant further analysis of white matter pathology in the periventricular zone that includes a mechanics-driven deterioration model for the ventricular wall.

Migraine with Visual aura and the Risk of Stroke- a Narrative Review

OBJECTIVES

Patients with migraine with visual aura (MwvA) often present to eye care providers for evaluation. A thorough ophthalmological history and examination is needed to exclude ophthalmologic disorders. Additionally, it has been increasingly recognized that MwvA is associated with ischemic stroke (IS). The aim of this narrative review is to provide a comprehensive overview of the differential diagnosis of MwvA and its association with IS.

MATERIALS AND METHODS

We conducted a PubMed search using key words including "migraine aura", "visual aura without headache", "late onset migraine accompaniment", "migraine and stroke", "migraine and atrial fibrillation", and "migraine and patent foramen ovale (PFO)". We narratively summarized the main findings of the identified studies in sections including age of onset and frequency of migraine with aura, stroke subtypes, and the role of cardioembolism in the migraine-stroke association.

RESULTS AND CONCLUSION

For women younger than 50 years, MwvA is associated with an increased risk of IS, and the risk further increases in patients who also smoke and use oral contraceptives. Age of onset of MwvA 50 years or greater is associated with IS that occurs in late life. Studies reported that increased frequency of aura is associated with an increased risk of IS in women. MwvA is associated with an increased risk of cardioembolic stroke and a higher incidence of atrial fibrillation compared to migraine without aura. Most studies that assessed the migraine-stroke association were based on patients with MwvA. The risks of stroke associated with other types of migraine aura or aura without headache, as well as such association in men require further investigation. More data is needed to determine the absolute risk of stroke when evaluating MwvA in situations including smoking and low dose estrogen use, new or late onset (>50 years) MwvA, to facilitate the development of practice guidelines for stroke prevention in specific clinical scenarios.

Structural aberrations of the brain associated with migraine: A narrative review

OBJECTIVE

To summarize major results from imaging studies investigating brain structure in migraine.

BACKGROUND

Neuroimaging studies, using several different imaging and analysis techniques, have demonstrated aberrations in brain structure associated with migraine. This narrative review summarizes key imaging findings and relates imaging findings with clinical features of migraine.

METHODS

We searched PubMed for English language articles using the key words "neuroimaging" AND/OR "MRI" combined with "migraine" through August 20, 2020. The titles and abstracts of resulting articles were reviewed for their possible inclusion in this manuscript, followed by examination of the full texts and reference lists of relevant articles.

RESULTS

Migraine is associated with structural brain aberrations within regions that participate in pain processing, the processing of other sensory stimuli, multisensory integration, and in white matter fiber tracts. Furthermore, migraine is associated with magnetic resonance imaging T2/fluid-attenuated inversion recovery white matter hyperintensities. Some structural aberrations are correlated with the severity and clinical features of migraine, whereas others are not. These findings suggest that some structural abnormalities are associated with or amplified by recurrent migraine attacks, whereas others are intrinsic to the migraine brain.

CONCLUSIONS

Migraine is associated with aberrant brain structure. Structural neuroimaging studies contribute to understanding migraine pathophysiology and identification of brain regions associated with migraine and its individual symptoms. Additional work is needed to determine the extent to which structural aberrations are a result of recurrent migraine attacks, and perhaps reversible with effective treatment or migraine resolution, versus being intrinsic traits of the migraine brain.

Genome-wide association study reveals susceptibility loci for self-reported headache in a large community-based Asian population

BACKGROUND

The genetic substrate for headache in the general population has not been identified in Asians. We investigated susceptible genetic variants for self-reported headache in a large community-based Asian population.

METHODS

We conducted a genome-wide association study in participants recruited from a community-based cohort to identify the genetic variants associated with headache in Taiwanese. All participants received a structured questionnaire for self-reported headache. A total of 2084 patients with "self-reported headache" and 11,822 age- and sex-matched controls were enrolled. Gene enrichment analysis using the Genotype-Tissue Expression version 6 database was performed to explore the potential function of the identified variants.

RESULTS

We identified two novel loci, rs10493859 in TGFBR3 and rs13312779 in FGF23, that are functionally relevant to vascular function and migraine to be significantly associated with self-reported headache after adjusting age, sex and top 10 principal components (p = 8.53 × 10^-11 and p = 1.07 × 10^-8, respectively). Gene enrichment analysis for genes with GWAS suggestive significance (p < 10^-6) demonstrated that the expression of these genes was significantly enriched in the artery (p = 8.18 × 10^-4) and adipose tissue (p = 8.95 × 10^-4).

CONCLUSION

Our results suggest that vascular dysfunction might play important roles in the pathogenesis of self-reported headache in Asian populations.

White matter hyperintensity in different migraine subtypes

The diagnostic value of white matter hyperintensities (WMH) in different types of migraineare unknown. To evaluate the WMH pattern of different subtypes in migraine patients with no vascular risk factors. 92 migraine patients (73 females, mean age 34.6 ± 8.9; 61 episodic migraine, 31 chronic migraine, 36 migraine with aura, 56 migraine without aura) without vascular risk factors underwent brain MRI (3 T). We also included a matched healthy control group with no migraine (n = 24). The prevalence of WMH in different types of migraine was similar and ranged from 38.7 to 44.4%; the control group showed no WMH at all. Lesions were located within frontal, parietal and temporal lobes (in order of decreasing incidence) in juxtacortical and/or deep white matter. WMH appeared as round or slightly elongated foci with a median size of 2.5 mm [1.5; 3]. Total number, size and prevalence of WMH by lobes and white matter regions were similar between groups, and no interaction with age or sex was found. The number of lesions within the frontal lobe juxtacortical white matter correlated with the age of patients (r = 0.331, p = 0.001) and the duration since migraine onset (r = 0.264, p = 0.012). Patients with different migraine subtypes and without vascular risk factors are characterized by a similar pattern of WMH in the absence of subclinical infarctions or microbleedings. Therefore, WMH have no relevant prognostic value regarding the course of migraine and vascular complications. WMH pattern may be used to differentiate migraine as a primary disorder and other disorders with migraine-like headache and WMH.

White Matter Lesions in Migraine

Migraine, the third most common disease worldwide, is a well-known independent risk factor for subclinical focal deep white matter lesions (WMLs), even in young and otherwise healthy individuals with no cardiovascular risk factors. These WMLs are more commonly seen in migraine patients with transient neurologic symptoms preceding their headaches, the so-called aura, and those with a high attack frequency. The pathophysiology of migraine-related deep white matter hyperintensities remains poorly understood despite their prevalence. Characteristic differences in their distribution related to chronic small vessel ischemic disease compared with that of common periventricular WMLs in the elderly suggest a different underlying mechanism. Both ischemic and inflammatory mechanisms have been proposed, as there is increased cerebral vulnerability to ischemia in migraineurs, whereas there is also evidence of blood-brain barrier disruption with associated release of proinflammatory substances during migraine attacks. An enhanced susceptibility to spreading depolarization, the electrophysiological event underlying migraine, may be the mechanism that causes repetitive episodes of cerebral hypoperfusion and neuroinflammation during migraine attacks. WMLs can negatively affect both physical and cognitive function, underscoring the public health importance of migraine, and suggesting that migraine is an important contributor to neurologic deficits in the general population.

Associations of Blood Pressure and Carotid Flow Velocity with Brain Volume and Cerebral Small Vessel Disease in a Community-Based Population

Cerebral small vessel disease (CSVD) is a common finding on brain magnetic resonance imaging (MRI). We previously demonstrated that high blood pressure (BP) and low carotid flow velocity were associated with cerebrovascular disease. However, their associations with brain volume and CSVD remain to be determined. A total of 721 adults (≥ 50 years) from the community-based I-Lan Longitudinal Aging Study were included. Flow velocities at the common (CCA) and internal carotid artery (ICA), including peak systolic velocity (PSV) and end-diastolic velocity (EDV), were measured with Doppler ultrasound. We further detected the presence of CSVD including lacune, microbleed, and white matter hyperintensity (WMH) on brain MRI, which were used to construct a combined CSVD score. General linear regression and logistic regression analysis were exploited to evaluate the association between carotid flow velocity, BP, brain volume, and CSVD. The mean of white matter, gray matter, and WMH volume were 422.2 cm³, 546.9 cm³, and 2.61 cm³, respectively. The proportion of lacune and microbleed were 11.1% and 14.2%, respectively. The CSVD score were negatively associated with gray (r = - 0.121, p < .01) and white matter volume (r = 0.058, p = 0.12), but positively associated with systolic BP (beta = 1.02, p = 0.0017). EDV at common carotid artery associated positively with white matter volume (beta = 1.013, p = 0.0064) and negatively predicted the presence CSVD (odds ratio [OR] = 0.93, p = 0.0023). In the ordinal logistic regression analysis adjusting for age, sex, total intracranial volume education, low-density lipoprotein cholesterol, and fasting glucose, compared with hypertensive subjects with low EDV, normotensive subjects with low, middle, and high EDV had an odds ratio of 0.656 (0.327-1.318), 0.429 (0.261-0.705), and 0.272 (0.147-0.502) for CSVD score, respectively. High SBP and low carotid flow velocities were independently associated with brain volume and CSVD. These associations may be involved in the pathophysiology of cognitive function decline.

Migraine and risk of stroke

Migraine and stroke are two common and heterogeneous neurovascular disorders responsible for a significant burden for those affected and a great economic cost for the society. There is growing evidence that migraine increases the overall risk of cerebrovascular diseases. In this review, based on available literature through a PubMed search, we found that ischaemic stroke in people with migraine is strongly associated with migraine with aura, young age, female sex, use of oral contraceptives and smoking habits. The risk of transient ischaemic attack also seems to be increased in people with migraine, although this issue has not been extensively investigated. Although migraine appears to be associated with haemorrhagic stroke, the migraine aura status has a small influence on this relationship. Neuroimaging studies have revealed a higher prevalence of asymptomatic structural brain lesions in people with migraine. They are also more likely to have unfavourable vascular risk factors; however, the increased risk of stroke seems to be more apparent among people with migraine without traditional risk factors. The mechanism behind the migraine-stroke association is unknown. In light of the higher risk of stroke in people with migraine with aura, it is important to identify and modify any vascular risk factor. There is currently no direct evidence to support that a migraine prophylactic treatment can reduce future stroke in people with migraine.

The impact of attack frequency and duration on neurocognitive processing in migraine sufferers: evidence from event-related potentials using a modified oddball paradigm

Background

Several studies have suggested that migraineurs suffer from neurocognitive abnormalities, but this phenomenon and exact mechanisms remain controversial. In this study, we aimed to reevaluate visual spatial attention via event-related potential (ERP) examinations and explore further correlations between ERP data and migraine characteristics.

Methods

Altogether, 25 migraine patients (9 males, 16 females; mean age 35.240 years) in the interictal period and 21 age-matched healthy controls (8 males, 13 females; mean age 35.286 years) were recruited. A modified visual oddball paradigm which contained standard, target and novel stimuli was used in the test, and amplitudes and latencies of corresponding original/difference ERP components were measured and analyzed independently.

Results

We found that P3 amplitude was markedly reduced in migraineurs. This phenomenon was further validated in analysis of difference P3 components (target minus standard and novel minus standard). Additionally, the N1 and N2 latencies elicited by novel stimulus were both delayed in patients compared with controls. Furthermore, these deviant cognitive ERPs were correlated with frequency and duration of migraine attacks.

Conclusions

These results indicated impaired visual spatial attention in migraine patients, which could be related to frequency and duration of attacks.

Cerebrovascular reactivity as a determinant of deep white matter hyperintensities in migraine

OBJECTIVE

To evaluate the association between the cerebrovascular reactivity to carbon dioxide (CO₂-CVR) and the deep white matter hyperintensity (WMH) burden in patients with migraine.

METHODS

A total of 86 nonelderly patients with episodic migraine without vascular risk factors and 35 headache-free controls underwent 3T MRI. Deep WMHs were quantified with a segmentation method developed for nonelderly migraineurs. The interictal CO₂-CVR was measured with transcranial Doppler with the breath-holding method. The mean breath-holding index of the bilateral middle cerebral arteries (MCA-BHI) was square root transformed and analyzed with univariate and multivariate logistic regression models to determine its association with the highest tertiles of deep WMH burden (number and volume).

RESULTS

A low MCA-BHI was independently associated with the highest tertile of deep WMH number in patients with migraine (adjusted odds ratio [OR] 0.02, 95% confidence interval [CI] 0.0007-0.63, p = 0.026). In controls, the MCA-BHI was not associated with deep WMH number. Interaction analysis revealed that migraine modified the effect of MCA-BHI on deep WMH number (p for interaction = 0.029). The MCA-BHI was not associated with increased deep WMH volume in both patients and controls. Age was independently associated with deep WMH volume in patients (adjusted OR 1.07, 95% CI 1.004-1.15, p = 0.037).

CONCLUSIONS

In this study, we found a migraine-specific association between a reduced CVR to apnea and increased number of deep WMHs in healthy, nonelderly patients with migraine. A dysfunctional vascular response to apnea may predispose migraineurs to an increased risk of WMHs.

Carotid Flow Augmentation, Arterial Aging, and Cerebral White Matter Hyperintensities

Objective—

Aortic stiffness and pressure wave reflection are associated with age-related cerebral microvascular disease, but the underlying mechanism remains obscure. We hypothesized that cerebral (carotid) flow alterations potentially mediate these associations.

Approach and Results—

Doppler waveforms were recorded in 286 patients with hypertension to measure the carotid flow augmentation index (FAIx) as the late/early-systolic velocity amplitude ratio. Tonometric waveforms were recorded to estimate the aortic pressure AIx (PAIx), aortic compliance, and carotid-femoral and carotid-radial pulse wave velocities. Additionally, white matter hyperintensities on brain magnetic resonance imaging were evaluated using the Fazekas scale. With increasing age, the carotid late systolic velocity increased, whereas the early systolic velocity decreased, although the aortic augmented pressure increased in parallel with the incident wave height ( P <0.001). Both FAIx and PAIx increased with age, but the age-dependent curves were upwardly concave and convex, respectively. FAIx increased exponentially with increasing PAIx ( r =0.71). Compared with PAIx, FAIx was more closely ( P ≤0.001) correlated with the aortic pulse wave velocity, aortic compliance, and elastic/muscular pulse wave velocity ratio. FAIx was associated with white matter hyperintensities scores independently of confounders including age, sex, diabetes mellitus, hypercholesterolemia, and aortic pulse wave velocity ( P =0.01), and was more predictive of white matter hyperintensities presence than PAIx.

Conclusions—

Carotid FAIx had closer associations with age, aortic stiffness, and cerebral white matter hyperintensities than aortic PAIx. These results indicate that carotid flow augmentation (enhanced by aortic stiffening and pressure wave reflection from the lower body) causes microcerebrovascular injury potentially through increasing cerebral flow pulsations, but this detrimental effect is greater than that estimated from PAIx.

Migraine and cluster headache - the common link

Although clinically distinguishable, migraine and cluster headache share prominent features such as unilateral pain, common pharmacological triggers such glyceryl trinitrate, histamine, calcitonin gene-related peptide (CGRP) and response to triptans and neuromodulation. Recent data also suggest efficacy of anti CGRP monoclonal antibodies in both migraine and cluster headache. While exact mechanisms behind both disorders remain to be fully understood, the trigeminovascular system represents one possible common pathophysiological pathway and network of both disorders. Here, we review past and current literature shedding light on similarities and differences in phenotype, heritability, pathophysiology, imaging findings and treatment options of migraine and cluster headache. A continued focus on their shared pathophysiological pathways may be important in paving future treatment avenues that could benefit both migraine and cluster headache patients.