Differences in treatment response between migraine with aura and migraine without aura: lessons from clinical practice and RCTs

Stroke Risk Reduction in Migraine Patients Using Propranolol: Evidence from Two Large-Scale Real-World Data Analyses

Background

Propranolol, a non-selective beta-blocker, is commonly used for migraine prevention, but its impact on stroke risk among migraine patients remains controversial. Using two large electronic health records-based datasets, we examined stroke risk differences between migraine patients with- and without- documented use of propranolol.

Methods

This retrospective case-control study utilized EHR data from the Vanderbilt University Medical Center (VUMC) and the All of Us Research Program. Migraine patients were first identified based on the International Classification of Headache Disorders, 3rd edition (ICHD-3) criteria using diagnosis codes. Among these patients, cases were defined as those with a primary diagnosis of stroke following the first diagnosis of migraine, while controls had no stroke after their first migraine diagnosis. Logistic regression models, adjusted for potential factors associated with stroke risk, assessed the association between propranolol use and stroke risk, stratified by sex and migraine subtype. A Cox proportional hazards regression model was used to estimate the hazard ratio (HR) for stroke risk at 1, 2, 5, and 10 years from baseline.

Results

In the VUMC database, 378 cases and 15,209 controls were identified, while the All of Us database included 267 cases and 6,579 controls. Propranolol significantly reduced stroke risk in female migraine patients (VUMC: OR=0.52, p=0.006; All of Us: OR=0.39, p=0.007), but not in males. The effect was more pronounced for ischemic stroke and in females with migraines without aura (MO) (VUMC: OR=0.60, p=0.014; All of Us: OR=0.28, p=0.006). The Cox model showed lower stroke rates in propranolol-treated female migraine patients at 1, 2, 5, and 10 years (VUMC: HR=0.06-0.55, p=0.0018-0.085; All of Us: HR=0.23, p=0.045 at 10 years).

Conclusions

Propranolol is associated with a significant reduction in stroke risk, particularly ischemic stroke, among female migraine without aura patients. These findings suggest that propranolol may benefit stroke prevention in high-risk populations.

Migraine headache (MH) classification using machine learning methods with data augmentation

Migraine headache, a prevalent and intricate neurovascular disease, presents significant challenges in its clinical identification. Existing techniques that use subjective pain intensity measures are insufficiently accurate to make a reliable diagnosis. Even though headaches are a common condition with poor diagnostic specificity, they have a significant negative influence on the brain, body, and general human function. In this era of deeply intertwined health and technology, machine learning (ML) has emerged as a crucial force in transforming every aspect of healthcare, utilizing advanced facilities ML has shown groundbreaking achievements related to developing classification and automatic predictors. With this, deep learning models, in particular, have proven effective in solving complex problems spanning computer vision and data analytics. Consequently, the integration of ML in healthcare has become vital, especially in developing countries where limited medical resources and lack of awareness prevail, the urgent need to forecast and categorize migraines using artificial intelligence (AI) becomes even more crucial. By training these models on a publicly available dataset, with and without data augmentation. This study focuses on leveraging state-of-the-art ML algorithms, including support vector machine (SVM), K-nearest neighbors (KNN), random forest (RF), decision tree (DST), and deep neural networks (DNN), to predict and classify various types of migraines. The proposed models with data augmentations were trained to classify seven various types of migraine. The proposed models with data augmentations were trained to classify seven various types of migraine. The revealed results show that DNN, SVM, KNN, DST, and RF achieved an accuracy of 99.66%, 94.60%, 97.10%, 88.20%, and 98.50% respectively with data augmentation highlighting the transformative potential of AI in enhancing migraine diagnosis.

Real-world observations and impacts of Chinese herbal medicine for migraine: results of a registry-based cohort study

Background: Migraine is a prevalent, recurrent condition with substantial disease burden. Chinese herbal medicine (CHM) has been used frequently for migraine in controlled clinical settings. This study is to summarise the characteristics of patients who seek clinical care in a tertiary Chinese medicine hospital in China; to gather their preferences and values of using CHM; to explore the effect of CHM for migraine and its comorbidities in a real-world setting, and to collect first-hand expertise of clinicians' practice pattern in prescribing CHM for migraine. Methods: This registry-based cohort study was prospectively conducted at Guangdong Provincial Hospital of Chinese Medicine from December 2020 to May 2022. Adult migraine patients seeking their initial anti-migraine clinical care at the hospital were consecutively recruited and followed up for 12 weeks. Practitioners specialised in headache management prescribed individualised treatments without research interference. Standardised case report forms were employed to gather information on patients' preferences and perspective of seeking clinical care, as well as to assess participants' migraine severity, comorbidities, and quality of life, at 4-weeks intervals. Various analytical methods were utilised based on the computed data. Results: In this study, we observed 248 participants. Of these, 73 received CHM treatment for 28 days or longer. Notably, these participants exhibited a greater disease severity, compared to those treated with CHM for less than 28 days. Of the 248 participants, 83.47% of them expected CHM would effectively reduce the severity of their migraine, around 50% expected effects for migraine-associated comorbidities, while 51.61% expressing concerns about potential side effects. CHM appeared to be effective in reducing monthly migraine days and pain intensity, improving patients' quality of life, and potentially reducing comorbid anxiety, with a minimum of 28 days CHM treatment. Herbs such as gan cao, gui zhi, chuan xiong, fu ling, bai zhu, yan hu suo, etc. were frequently prescribed for migraine, based on patients' specific symptoms. Conclusion: CHM appeared to be beneficial for migraine and comorbid anxiety in real-world clinical practice when used continuously for 28 days or more. Clinical Trial Registration: clinicaltrials.gov, identifier ChiCTR2000041003.

Different Aspects of Aging in Migraine

Migraine is a common neurological disease displaying an unusual dependence on age. For most patients, the peak intensity of migraine headaches occurs in 20s and lasts until 40s, but then headache attacks become less intense, occur less frequently and the disease is more responsive to therapy. This relationship is valid in both females and males, although the prevalence of migraine in the former is 2-4 times greater than the latter. Recent concepts present migraine not only as a pathological event, but rather as a part of evolutionary adaptive response to protect organism against consequences of stress-induced brain energy deficit. However, these concepts do not fully explain that unusual dependence of migraine prevalence on age. Many aspects of aging, both molecular/cellular and social/cognitive, are interwound in migraine pathogenesis, but they neither explain why only some persons are affected by migraine, nor suggest any causal relationship. In this narrative/hypothesis review we present information on associations of migraine with chronological aging, brain aging, cellular senescence, stem cell exhaustion as well as social, cognitive, epigenetic, and metabolic aging. We also underline the role of oxidative stress in these associations. We hypothesize that migraine affects only individuals who have inborn, genetic/epigenetic, or acquired (traumas, shocks or complexes) migraine predispositions. These predispositions weakly depend on age and affected individuals are more prone to migraine triggers than others. Although the triggers can be related to many aspects of aging, social aging may play a particularly important role as the prevalence of its associated stress has a similar age-dependence as the prevalence of migraine. Moreover, social aging was shown to be associated with oxidative stress, important in many aspects of aging. In perspective, molecular mechanisms underlying social aging should be further explored and related to migraine with a closer association with migraine predisposition and difference in prevalence by sex.

Efficacy and safety of transesophageal ultrasound-guided patent foramen ovale closure for migraine in adolescents

Objective

This retrospective analysis aims to assess the efficacy of transesophageal ultrasound-guided patent foramen ovale (PFO) closure in treating migraine in adolescents and compare the therapeutic outcomes of PFO closure for migraine with and without aura.

Methods

We conducted a retrospective analysis of 86 cases of adolescents (12-20 years old) who underwent PFO closure for migraine at our institution over the past 3 years. The efficacy was evaluated using the visual analogue scale (VAS), headache impact test (HIT)-6, and pediatric migraine disability assessment (PedMIDAS) scores, as well as by assessing the monthly frequency of migraine attacks, duration of each attack, and overall migraine burden. The patients were divided into two groups: an aura group (55 cases) and a non-aura group (31 cases) to investigate difference in therapeutic efficacy between the groups. The effect of residual shunt on migraine burden was assessed.

Results

Among the 86 patients, 46 (54%) experienced complete remission of migraine, while 71 (83%) achieved a >50% reduction in migraine burden during the one-year follow-up period. Patients in the aura group showed more significant improvements in VAS, HIT-6, and PedMIDAS scores, as well as in monthly migraine attack frequency, duration of each attack, and overall migraine burden, than patients in the non-aura group. Moreover, patients with residual shunt did not exhibit statistically significant differences in therapeutic efficacy compared to patients with complete closure.

Conclusion

PFO closure can effectively alleviate migraine symptoms in adolescents with migraine with concomitant PFO. The therapeutic efficacy is particularly pronounced for migraine with aura. Furthermore, minor levels of residual shunt have no effect on the improvement in migraine symptoms.

Towards precision medicine in migraine: Recent therapeutic advances and potential biomarkers to understand heterogeneity and treatment response

After 35 years since the introduction of the International Classification of Headache Disorders (ICHD), we are living in the era of the second great revolution in migraine therapies. First, discoveries of triptans provided a breakthrough in acute migraine treatment utilizing bench-to-bedside research results on the role of serotonin in migraine. Next, the discovery of the role of neuropeptides, more specifically calcitonin gene-related peptide (CGRP) in migraine attack led to the development of anti-CGRP therapies that are effective both in acute and preventive treatment, and are also able to reduce migraine-related burden. Here, we reviewed the most recent clinical studies and real-world data on available migraine-specific medications, including triptans, ditants, gepants and anti-CGRP monoclonal antibodies. Novel drug targets, such as PACAP and amylins were also discussed. To address the main challenges of migraine therapy, the high heterogeneity of people with migraine, the prevalent presence of various comorbid disorders, and the insufficient medical care of migraine patients were covered. Promising novel approaches from the fields of omics, blood and saliva biomarker, imaging and provocation studies might bring solutions for these challenges with the potential to identify further drug targets, distinguish more homogeneous patient subgroups, contribute to more optimal drug selection strategies, and detect biomarkers in association with headache features or predicting treatment efficacy. In the future, the combined analysis of data of different biomarker modalities with machine learning algorithms may serve precision medicine in migraine treatment.

Approach to headache disorders and the management of migraine: consensus guidelines from the Headache Society of Singapore, first edition (2023)

Headache disorders, particularly migraine, are one of the most common and disabling neurological disorders. There is a need for high-quality, accessible care for patients with headache disorders across all levels of the healthcare system in Singapore. The role of the Headache Society of Singapore is to increase awareness and advance the understanding of these disorders and to advocate for the needs of affected patients. In this first edition of local consensus guidelines, we focus on treatment approaches for headaches and provide consensus recommendations for the management of migraine in adults. The recommendations in these guidelines can be used as a practical tool in routine clinical practice by primary care physicians, neurologists and other healthcare professionals who have a common interest in headache disorders.

Aura phenomena do not initiate migraine attacks-Findings from neuroimaging

OBJECTIVES/BACKGROUND

As cortical spreading depolarization (CSD) has been suggested to be the cause of migraine aura and as CSD can activate trigeminal nociceptive neurons in animals, it has been suggested that CSD may be the cause of migraine attacks. This raises the question of how migraine pain is generated in migraine attacks without aura and has led to the hypothesis that CSD may also occur in subcortical regions in the form of "silent" CSDs, and accordingly "silent auras".

METHODS

In this case study, we provide evidence for common neuronal alterations preceding headache attacks with and without aura in a male patient with migraine, who underwent daily event-correlated functional magnetic resonance imaging of trigeminal nociception for a period of 30 days. During these days the man experienced migraine attacks with and without aura.

RESULTS

Comparing the preictal phases between both attack types revealed a common hyperactivation of the hypothalamus (p < 0.01), which was already present 2 days before the actual attack.

CONCLUSION

The time frame of the central pathophysiological orchestration of migraine attacks, irrelevant of the presence of later aura, strongly suggests that the aura is an epiphenomenon that is unrelated and does not initiate headache attacks.

Migrainous infarction: A serious complication of a common condition

ABSTRACT

Migrainous infarction is a rare neurologic condition that stems from an ordinary migraine with aura, and can cause ischemic stroke in young women. The pathophysiology of migrainous infarction is not entirely understood. An aura that is similar to previous auras but lasts longer than 60 minutes, along with evidence of acute ischemia on MRI, are diagnostic of migrainous infarction. Treatment aimed at minimizing migraine with aura is the most important preventive measure clinicians can take to help patients avoid this complication of migraine.

Migraine with aura detection and subtype classification using machine learning algorithms and morphometric magnetic resonance imaging data

Introduction

Migraine with aura (MwA) is a neurological condition manifested in moderate to severe headaches associated with transient visual and somatosensory symptoms, as well as higher cortical dysfunctions. Considering that about 5% of the world's population suffers from this condition and manifestation could be abundant and characterized by various symptoms, it is of great importance to focus on finding new and advanced techniques for the detection of different phenotypes, which in turn, can allow better diagnosis, classification, and biomarker validation, resulting in tailored treatments of MwA patients.

Methods

This research aimed to test different machine learning techniques to distinguish healthy people from those suffering from MwA, as well as people with simple MwA and those experiencing complex MwA. Magnetic resonance imaging (MRI) post-processed data (cortical thickness, cortical surface area, cortical volume, cortical mean Gaussian curvature, and cortical folding index) was collected from 78 subjects [46 MwA patients (22 simple MwA and 24 complex MwA) and 32 healthy controls] with 340 different features used for the algorithm training.

Results

The results show that an algorithm based on post-processed MRI data yields a high classification accuracy (97%) of MwA patients and precise distinction between simple MwA and complex MwA with an accuracy of 98%. Additionally, the sets of features relevant to the classification were identified. The feature importance ranking indicates the thickness of the left temporal pole, right lingual gyrus, and left pars opercularis as the most prominent markers for MwA classification, while the thickness of left pericalcarine gyrus and left pars opercularis are proposed as the two most important features for the simple and complex MwA classification.

Discussion

This method shows significant potential in the validation of MwA diagnosis and subtype classification, which can tackle and challenge the current treatments of MwA.

Excitation-Inhibition Imbalance in Migraine: From Neurotransmitters to Brain Oscillations

Migraine is among the most common and debilitating neurological disorders typically affecting people of working age. It is characterised by a unilateral, pulsating headache often associated with severe pain. Despite the intensive research, there is still little understanding of the pathophysiology of migraine. At the electrophysiological level, altered oscillatory parameters have been reported within the alpha and gamma bands. At the molecular level, altered glutamate and GABA concentrations have been reported. However, there has been little cross-talk between these lines of research. Thus, the relationship between oscillatory activity and neurotransmitter concentrations remains to be empirically traced. Importantly, how these indices link back to altered sensory processing has to be clearly established as yet. Accordingly, pharmacologic treatments have been mostly symptom-based, and yet sometimes proving ineffective in resolving pain or related issues. This review provides an integrative theoretical framework of excitation-inhibition imbalance for the understanding of current evidence and to address outstanding questions concerning the pathophysiology of migraine. We propose the use of computational modelling for the rigorous formulation of testable hypotheses on mechanisms of homeostatic imbalance and for the development of mechanism-based pharmacological treatments and neurostimulation interventions.

Migraine with aura: less control over pain and fragrances?

BACKGROUND

Accumulating data emphasizes the importance of olfaction in migraine pathophysiology. However, there are only a few studies evaluating how the migraine brain processes olfactory stimulation, and virtually no studies comparing patients with and without aura in this context.

METHODS

This cross-sectional study recorded event-related potentials from 64 electrodes during a pure olfactory or pure trigeminal stimulus in females with episodic migraine with aura (n = 13) and without aura (n = 15), to characterize the central nervous processing of these intranasal stimuli. Patients were tested in interictal state only. Data were analyzed in the time domain and in the time-frequency domain. Source reconstruction analysis was also performed.

RESULTS

Patients with aura had higher event-related potentials amplitudes for left-sided trigeminal and left-sided olfactory stimulations, and higher neural activity for right-sided trigeminal stimulation in brain areas related to trigeminal and visual processing. Following olfactory stimulations patients with aura displayed decreased neural activity in secondary olfactory structures compared to patients without aura. Oscillations in the low frequency bands (< 8 Hz) differed between patient groups.

CONCLUSIONS

Altogether this may reflect hypersensitivity to nociceptive stimuli in patients with aura relative to patients without aura. Patients with aura have a bigger deficit in engaging secondary olfactory-related structures, possibly leading to distorted attention and judgements towards odors. The cerebral overlap between trigeminal nociception and olfaction might explain these deficits.

The holistic approach to the CHRNA7 gene, hsa-miR-3158-5p, and 15q13.3 hotspot CNVs in migraineurs

Migraine is a neurological disease characterized by severe headache attacks. Combinations of different genetic variations such as copy number variation (CNV) in a gene and microRNA (miRNA) expression can provide a holistic approach to the disease as a pathophysiological, diagnostic, and therapeutic target. CNVs, the Cholinergic Receptor Nicotinic Alpha 7 Subunit (CHRNA7) gene, and expression of gene-targeting miRNAs (hsa-miR-548e-5p and hsa-miR-3158-5p) in migraineurs (n = 102; with aura, n = 43; without aura, n = 59) and non-migraines (n = 120) aged 15-60 years, comparative, case-control study was conducted. Genetic markers were compared with biochemical parameters (BMI, WBC, Urea, GFR, ESR, CRP, HBG). All analyzes were performed by quantitative Real-Time PCR (q-PCR) and fold change was calculated with the 2^-ΔΔCT method. The diagnostic power of the CHRNA7 gene, CNV, and miRNAs were analyzed with the receiver operating curve (ROC). CHRNA7 gene and hsa-miR-3158-5p are down-regulated in migraineurs and the gene is controlled by this miRNA via CNVs (p < .05). Both deletion and duplication were detected in patients with migraine for CVN numbers (p = .05). The number of CNV deletions was higher than duplications. When CHRNA7-CNV-hsa-miR-3158-5p was modeled together in the ROC analysis, the area under the curve (AUC) was 0.805, and the diagnostic power was "good". In migraineurs, the CHRNA7 gene can be controlled by hsa-miR-3158-5p via CNVs to modulate the mechanism of pain. These three genetic markers have diagnostic potential and may be used in antimigraine treatments.

Differential Diagnosis of Visual Phenomena Associated with Migraine: Spotlight on Aura and Visual Snow Syndrome

Migraine is a severe and common primary headache disorder, characterized by pain as well as a plethora of non-painful symptoms. Among these, visual phenomena have long been known to be associated with migraine, to the point where they can constitute a hallmark of the disease itself. In this review we focus on two key visual disorders that are directly or indirectly connected to migraine: visual aura and visual snow syndrome (VSS). Visual aura is characterized by the transient presence of positive and negative visual symptoms, before, during or outside of a migraine attack. VSS is a novel stand-alone phenomenon which has been shown to be comorbid with migraine. We discuss key clinical features of the two disorders, including pathophysiological mechanisms, their differential diagnoses and best treatment practices. Our aim is to provide an aid for clinicians and researchers in recognizing these common visual phenomena, which can even appear simultaneously in patients with an underlying migraine biology.

Preventive treatment response associated with migraine aura subtypes in a Thai population

Introduction

Some studies indicate a different response to treatment between migraine patients with and without aura.

Objectives

To determine whether aura, or simple or complex aura subtypes, are clinical markers predicting response to preventive treatment.

Methods

Conducted a retrospective cohort study at a headache clinic in a tertiary referral hospital. We included data from patients registered from 1 November 2014, to 30 June 2022, having migraine with or without aura, or with simple or complex aura, and who had received migraine preventive treatments with at least 3 months follow-up. The primary outcome was a response to preventive treatment defined as at least a 50% reduction from a baseline of monthly migraine or headache days (MMDs/MHDs). Secondary outcomes were improvement in quality of life and disability scores.

Results

For migraine patients with (45) and without (123) aura who took a migraine preventive with at least 3 months follow-up; except for median age, which was older for patients without aura, baseline sex, comorbidity, and migraine data were without significant difference including median history of migraine, chronic migraine subtype, chronic migraine with medication-overuse headache, median or mean MMDs/MHDs, number of preventive medications used, or migraine preventive medication inhibiting spreading depolarizations. Treatment outcomes at 3 and 6 months follow-up were not significantly different between migraine patients with and without aura, or with simple and complex aura, but tended to be greater in those with aura and those with complex aura. After adjustment for baseline comorbidity, migraine subtypes, aura subtypes, the number of preventives used, history of migraine, and MMDs/MHDs, we found no significant differences in 30% and 50% reduction from baseline of MMDs/MHDs in 3 or 6 months or most recent follow-up.

Conclusions

Preventive treatment response tended to be associated with migraine aura subtypes. We found preventive treatment response tended to have more favorable outcomes in those with aura, especially those with complex aura.

Evaluating migraine with typical aura with neuroimaging

Objective

To provide an up-to-date narrative literature review of imaging in migraine with typical aura, as a means to understand better migraine subtypes and aura biology.

Background

Characterizing subtypes of migraine with typical aura and appreciating possible biological differences between migraine with and without aura, are important to understanding the neurobiology of aura and trying to advance personalized therapeutics in this area through imaging biomarkers. One means of doing this over recent years has been the use of increasingly advanced neuroimaging techniques.

Methods

We conducted a literature review of neuroimaging studies in migraine with aura, using a PubMed search for terms 'imaging migraine', 'aura imaging', 'migraine with aura imaging', 'migraine functional imaging' and 'migraine structural imaging'. We collated the findings of the main studies, excluding small case reports and series with n < 6, and have summarized these and their implications for better understanding of aura mechanisms.

Results

Aura is likely mediated by widespread brain dysfunction in areas involving, but not limited to, visual cortex, somatosensory and insular cortex, and thalamus. Higher brain excitability in response to sensory stimulation and altered resting-state functional connectivity in migraine sufferers with aura could have a genetic component. Pure visual aura compared to visual aura with other sensory or speech symptoms as well, may involve different functional reorganization of brain networks and additional mitochondrial dysfunction mediating more aura symptoms.

Conclusion

There is a suggestion of at least some distinct neurobiological differences between migraine with and without aura, despite the shared phenotypic similarity in headache and other migraine-associated symptoms. It is clear from the vast majority of aura phenotypes being visual that there is a particular predisposition of the occipital cortex to aura mechanisms. Why this is the case, along with the relationships between cortical spreading depression and headache, and the reasons why aura does not consistently present in affected individuals, are all important research questions for the future.

Migraine with aura

This chapter describes the different types of aura including rare aura subtypes such as retinal aura. In addition, aura manifestations not classified in the International Classification of Headache Disorders and auras in headache disorders others than migraine are also described. The differential diagnosis of migraine aura comprises several neurological disorders which should be known to specialists. Migraine aura also has impact on the choice of migraine treatment; recommendations for the treatment of the migraine aura itself are also presented in this chapter.

Explainable AI (XAI) Applied in Machine Learning for Pain Modeling: A Review

Pain is a complex term that describes various sensations that create discomfort in various ways or types inside the human body. Generally, pain has consequences that range from mild to severe in different organs of the body and will depend on the way it is caused, which could be an injury, illness or medical procedures including testing, surgeries or therapies, etc. With recent advances in artificial-intelligence (AI) systems associated in biomedical and healthcare settings, the contiguity of physician, clinician and patient has shortened. AI, however, has more scope to interpret the pain associated in patients with various conditions by using any physiological or behavioral changes. Facial expressions are considered to give much information that relates with emotions and pain, so clinicians consider these changes with high importance for assessing pain. This has been achieved in recent times with different machine-learning and deep-learning models. To accentuate the future scope and importance of AI in medical field, this study reviews the explainable AI (XAI) as increased attention is given to an automatic assessment of pain. This review discusses how these approaches are applied for different pain types.

Efficacy and quality-of-life improvements with fremanezumab treatment in patients with difficult-to-treat migraine with associated neurological dysfunction

BACKGROUND

Fremanezumab, a fully humanised monoclonal antibody (IgG2Δa) that selectively targets calcitonin gene-related peptide (CGRP), has demonstrated efficacy as a preventive treatment for adults with episodic migraine (EM) or chronic migraine (CM) and inadequate response to 2-4 prior preventive treatment classes in the phase 3b FOCUS study. In this post-hoc analysis, we evaluated efficacy and effects on quality-of-life outcomes for fremanezumab in subgroups of patients with and without aura or similar neurological symptoms, here referred to as migraine with or without associated neurological dysfunction.

METHODS

In the FOCUS study, 838 patients were randomised (1:1:1) to quarterly fremanezumab, monthly fremanezumab, or matched placebo for 12 weeks of double-blind treatment. For this post-hoc analysis, subgroups of patients with migraine with and without associated neurological dysfunction at baseline were identified based on patient response to questions about symptoms.

RESULTS

In patients with migraine with associated neurological dysfunction at baseline, fremanezumab significantly reduced monthly average days with neurological symptoms (quarterly, -1.7 days; monthly, -1.8 days) compared to placebo (-0.5 days; both P ≤0.01). In comparison with placebo, both dosing regimens of fremanezumab yielded greater reductions in monthly migraine days over 12 weeks (P <0.0001) and improvements in Headache Impact Test-6 and Migraine-specific Quality of Life scores over the last 4 weeks (P <0.05), regardless of neurological dysfunction at baseline.

CONCLUSIONS

Fremanezumab reduced days with neurological symptoms, effectively prevented migraine, and improved quality of life in patients with migraine with associated neurological dysfunction, including those with previous inadequate response to 2-4 migraine preventive medication classes.

Could the New Anti-CGRP Monoclonal Antibodies Be Effective in Migraine Aura? Case Reports and Literature Review

Recently, monoclonal antibodies (mAbs) directed against calcitonin gene-related peptide (CGRP) (Eptinezumab, Fremanezumab, and Galcanezumab) or its receptor (Erenumab) have been approved for clinical use as prophylactic drugs for high-frequency episodic and chronic migraine. While their therapeutic effects on headache pain is well documented, there is scarce information on the usefulness of these medications in preventing migraine aura, which is believed to be associated with cortical spreading depression (CSD). Because of their large size, mAbs cannot easily cross the blood-brain barrier in high quantities, rendering the peripheral trigeminovascular system to likely be a major site of their action. In this paper, we report two cases of patients suffering from migraine with and without aura, who reported a complete disappearance of aura or reduced aura duration and intensity while taking Galcanezumab or Erenumab, respectively. Then, we present a brief overview of the literature about the controversial relationship between CSD and CGRP and about the potential "additional central" role of these mAbs in the pathophysiology of migraine aura.

Evaluating Plasma and Brain TRPV1 Channels in the Animal Model of Episodic and Chronic Migraine: The Possible Role of Somatosensory Cortex TRPV1 in Migraine Transformation

Background: Despite extensive research, the exact molecular mechanisms underlying migraine development and especially its progression and transformation from episodic into chronic is still unknown. Objectives: This study aimed to assess the role of somatosensory cortex and hippocampal transient receptor potential vanilloid 1 (TRPV1) in migraine in a rat model. Methods: This study was an intervention study. Adult male Wistar rats were divided into three groups, including sham, episodic migraine (EM), and chronic migraine (CM). The sham group received normal intraperitoneal (IP) saline injections every two days for 11 days, and the EM group received a single dose of trinitroglycerin (TNG) injection (IP; 10 mg/kg). For the CM group, TNG was administrated every two days (on days 3, 5, 7, 9, and 11; IP; 10 mg/kg). TRPV1 levels in plasma, somatosensory cortex, and hippocampus were detected with an enzyme-linked immunosorbent assay (ELISA) kit. Results: The findings showed that in both CM and EM groups the TRPV1 levels in plasma (P < 0.001 in both groups), somatosensory cortex (P < 0.05 and P < 0.001, respectively), and hippocampus (P < 0.01 in both groups) increased after migraine induction. Interestingly, in the somatosensory cortex, this TRPV1 elevation in the CM group was much greater than the EM group, and a significant difference was observed between the two groups (P < 0.05). Conclusions: Our results suggested that headache severity and frequency may enhance concomitant with the upregulation of somatosensory cortex TRPV1. This new achievement can help to develop new drug approaches to prevent CM.

Harnessing Intranasal Delivery Systems of Sumatriptan for the Treatment of Migraine

Sumatriptan (ST) is a commonly prescribed drug for treating migraine. The efficiency of several routes of ST administration has been investigated. Recently, the intranasal route with different delivery systems has gained interest owing to its fast-acting and effectiveness. The present study is aimed at reviewing the available studies on novel delivery systems for intranasal ST administration. The oral route of ST administration is common but complicated with some problems. Gastroparesis in patients with migraine may reduce the absorption and effectiveness of ST upon oral use. Furthermore, the gastrointestinal (GI) system and hepatic metabolism can alter the pharmacokinetics and clinical effects of ST. The bioavailability of conventional nasal liquids is low due to the deposition of a large fraction of the delivered dose of a drug in the nasal cavity. Several delivery systems have been utilized in a wide range of preclinical and clinical studies to enhance the bioavailability of ST. The beneficial effects of the dry nasal powder of ST (AVP-825) have been proven in clinical studies. Moreover, other delivery systems based on microemulsions, microspheres, and nanoparticles have been introduced, and their higher bioavailability and efficacy were demonstrated in preclinical studies. Based on the extant findings, harnessing novel delivery systems can improve the bioavailability of ST and enhance its effectiveness against migraine attacks. However, further clinical studies are needed to approve the safety and efficacy of employing such systems in humans.

Prevalence and impact of visual aura in migraine and probable migraine: a population study

Visual aura (VA) presents in 98% of cases of migraine with aura. However, data on its prevalence and impact in individuals with migraine and probable migraine (PM) are limited. Data from the nation-wide, population-based Circannual Change in Headache and Sleep Study were collected. Participants with VA rating scale scores ≥ 3 were classified as having VA. Of 3,030 participants, 170 (5.6%) and 337 (11.1%) had migraine and PM, respectively; VA prevalence did not differ between these cohorts (29.4% [50/170] vs. 24.3% [82/337], p = 0.219). Participants with migraine with VA had a higher headache frequency per month (4.0 [2.0–10.0] vs. 2.0 [1.0–4.8], p = 0.014) and more severe cutaneous allodynia (12-item Allodynia Symptom Checklist score; 3.0 [1.0–8.0] vs. 2.0 [0.0–4.8], p = 0.046) than those without VA. Participants with PM with VA had a higher headache frequency per month (2.0 [2.0–8.0] vs. 2.0 [0.6–4.0], p = 0.001), greater disability (Migraine Disability Assessment score; 10.0 [5.0–26.3] vs. 5.0 [2.0–12.0], p < 0.001), and more severe cutaneous allodynia (12-item Allodynia Symptom Checklist score, 2.5 [0.0–6.0] vs. 0.0 [0.0–3.0], p < 0.001) than those without VA. VA prevalence was similar between migraine and PM. Some symptoms were more severe in the presence of VA.

Status Migrainosus and Endometriosis: A Case Report and Review of the Literature

Status migrainosus is a migraine complication describing an attack lasting longer than 72 hours. In this paper, we present a case of a 34-year-old female with a history of severe endometriosis and hypercoagulable factor type II disease who presented to the emergency department (ED) with a three-week history of new-onset intractable migraine with aura. Imaging findings revealed a frontal T2/FLAIR hyperintensity, venous anomaly, and bilateral optic nerve thickening. The patient was admitted for three days of inpatient treatment with improvement of her symptoms.

Assessment of Erenumab Safety and Efficacy in Patients With Migraine With and Without Aura: A Secondary Analysis of Randomized Clinical Trials

Question

Is erenumab therapy effective for patients with migraine and a history of aura?

Findings

In this post hoc secondary analysis of 4 randomized clinical trials involving 2682 patients, erenumab treatment was associated with reduced migraine frequency and fewer days of acute migraine-specific medication use in patients with migraine with and without history of aura. No differences were observed in the safety profiles of patients in either group.

Meaning

Findings of this analysis suggest that erenumab may be safe and effective for patients with migraine with and without history of aura.

Importance

Migraine with aura may respond differently to therapies than migraine without aura. Individuals with migraine with aura have an elevated vascular risk, necessitating a safety assessment of migraine preventive treatments in this patient subgroup.

Objective

To assess the efficacy and safety profiles of erenumab in patients with migraine with aura.

Design, Setting, and Participants

This post hoc secondary analysis evaluated 4 double-blind, placebo-controlled randomized clinical trials that were conducted in treatment centers in North America, Europe, Russia, and Turkey between August 6, 2013, and November 12, 2019. Participants were adults aged 18 to 65 years with episodic migraine or chronic migraine and were randomized to receive either erenumab or placebo.

Interventions

One or more dose of erenumab (70 mg or 140 mg once per month) or placebo was administered by subcutaneous injection in the double-blind treatment phase and open-label or dose-blinded active treatment, and erenumab, 70 mg or 140 mg, was administered once per month by subcutaneous injection during extension phases.

Main Outcomes and Measures

Efficacy assessments included change from baseline monthly migraine days (MMDs) and monthly acute migraine–specific medication (AMSM) days. Safety end points included patient incidences of adverse events. Subgroups of patients were categorized according to their history of aura.

Results

Of the 2682 patients who were randomized in the 4 trials, 1400 (52.2%) received 1 or more dose of erenumab, 70 mg or 140 mg, and 1043 (38.9%) received placebo. Patients had a mean (SD) age of 41.7 (11.2) years and were predominantly women (n = 2055 [84.1%]). Reductions from baseline MMDs and AMSM days were greater in the erenumab than placebo groups in patients with and without a history of aura during the double-blind treatment phase, and these reductions were maintained throughout the extension phases. In patients with episodic migraine and a history of aura, least-squares mean differences in change from baseline MMDs at week 12 were –1.1 (95% CI, –1.7 to –0.6) in those who received erenumab, 70 mg, and –0.9 (95% CI, –1.6 to –0.2) in those who received erenumab, 140 mg, compared with placebo. In patients with chronic migraine with a history of aura, the least-squares mean differences from placebo treatment were –2.1 (95% CI, –3.8 to –0.5) in those who received erenumab, 70 mg, and –3.1 (95% CI, –4.8 to –1.4) in those who received erenumab, 140 mg. Overall safety profiles were similar across treatment groups regardless of aura history and were comparable to that of placebo over 12 weeks, with no increased emergence of adverse events over time.

Conclusions and Relevance

Results of this secondary analysis of 4 randomized clinical trials showed reduced migraine frequency and AMSM days with erenumab treatment in patients with migraine with and without a history of aura. The findings support the efficacy and safety of using erenumab in this patient population.

Trial Registration

ClinicalTrials.gov Identifiers: NCT01952574, NCT02456740, NCT02483585, NTCT02066415, and NCT02174861

Which is the best transcranial direct current stimulation protocol for migraine prevention? A systematic review and critical appraisal of randomized controlled trials

BACKGROUND

Transcranial direct current stimulation (tDCS) could counteract the pathophysiological triggers of migraine attacks by modulating cortical excitability. Several pilot randomized controlled trials (RCTs) assessed the efficacy of tDCS for migraine prevention. We reviewed and summarized the state of the art of tDCS protocols for migraine prevention, discussing study results according to the stimulations parameters and patients' populations.

MAIN BODY

We combined the keywords 'migraine', 'headache', 'transcranial direct current stimulation', and 'tDCS' and searched Pubmed, Scopus, and Web of Science, from the beginning of indexing to June 22, 2021. We only included RCTs comparing the efficacy of active tDCS with sham tDCS to decrease migraine frequency, intensity, and/or acute drug utilization. The risk of bias of each RCT was assessed by using the RoB-2 tool (Cochrane Collaboration). Thirteen RCTs (from 2011 to 2021) were included in the review. The included patients ranged from 13 to 135. RCTs included patients with any migraine (n=3), chronic migraine (n=6), episodic migraine (n=3) or menstrual migraine (n=1). Six RCTs used cathodal and five anodal tDCS, while two RCTs compared the efficacy of both cathodal and anodal tDCS with that of sham. In most of the cathodal stimulation trials, the target areas were the occipital regions, with reference on central or supraorbital areas. In anodal RCTs, the anode was usually placed above the motor cortical areas and the cathode on supraorbital areas. All RCTs adopted repeated sessions (from 5 to 28) at variable intervals, while the follow-up length spanned from 1 day up to 12 months. Efficacy results were variable but overall positive. According to the RoB-2 tool, only four of the 13 RCTs had a low risk of bias, while the others presented some concerns.

CONCLUSIONS

Both anodal and cathodal tDCS are promising for migraine prevention. However, there is a need for larger and rigorous RCTs and standardized procedures. Additionally, the potential benefits and targeted neurostimulation protocols should be assessed for specific subgroups of patients.

Role of herbal medicine for prevention and treatment of migraine

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

Reflexive Eye Closure in Response to Cone and Melanopsin Stimulation: A Study of Implicit Measures of Light Sensitivity in Migraine

BACKGROUND AND OBJECTIVES

To quantify interictal photophobia in migraine with and without aura using reflexive eye closure as an implicit measure of light sensitivity and to assess the contribution of melanopsin and cone signals to these responses.

METHODS

Participants were screened to meet criteria for 1 of 3 groups: headache-free (HF) controls, migraine without aura (MO), and migraine with visual aura (MA). MO and MA participants were included if they endorsed ictal and interictal photophobia. Exclusion criteria included impaired vision, inability to collect usable pupillometry, and history of either head trauma or seizure. Participants viewed light pulses that selectively targeted melanopsin, the cones, or their combination during recording of orbicularis oculi EMG (OO-EMG) and blinking activity.

RESULTS

We studied 20 participants in each group. MA and MO groups reported increased visual discomfort to light stimuli (discomfort rating, 400% contrast, MA: 4.84 [95% confidence interval 0.33, 9.35]; MO: 5.23 [0.96, 9.50]) as compared to HF controls (2.71 [0, 6.47]). Time course analysis of OO-EMG and blinking activity demonstrated that reflexive eye closure was tightly coupled to the light pulses. The MA group had greater OO-EMG and blinking activity in response to these stimuli (EMG activity, 400% contrast: 42.9%Δ [28.4, 57.4]; blink activity, 400% contrast: 11.2% [8.8, 13.6]) as compared to the MO (EMG activity, 400% contrast: 9.9%Δ [5.8, 14.0]; blink activity, 400% contrast: 4.7% [3.5, 5.9]) and HF control (EMG activity, 400% contrast: 13.2%Δ [7.1, 19.3]; blink activity, 400% contrast: 4.5% [3.1, 5.9]) groups.

DISCUSSION

Our findings suggest that the intrinsically photosensitive retinal ganglion cells (ipRGCs), which integrate melanopsin and cone signals, provide the afferent input for light-induced reflexive eye closure in a photophobic state. Moreover, we find a dissociation between implicit and explicit measures of interictal photophobia depending on a history of visual aura in migraine. This implies distinct pathophysiology in forms of migraine, interacting with separate neural pathways by which the amplification of ipRGC signals elicits implicit and explicit signs of visual discomfort.

Increased migraine-free intervals with multifocal repetitive transcranial magnetic stimulation

INTRODUCTION

Episodic migraine is a debilitating condition associated with vast impairments of health, daily living, and life quality. Several prophylactic treatments exist, having a moderate ratio of action related to side effects and therapy costs. Repetitive transcranial magnetic stimulation (rTMS) is an evidence based therapy in several neuropsychiatric conditions, showing robust efficacy in alleviating specific symptoms. However, its efficacy in migraine disorders is unequivocal and might be tightly linked to the applied rTMS protocol. We hypothesized that multifocal rTMS paradigm could improve clinical outcomes in patients with episodic migraine by reducing the number of migraine days, frequency and intensity of migraine attacks, and improve the quality of life.

METHODS

We conducted an experimental, double-blind, randomized controlled study by applying a multifocal rTMS paradigm. Patients with episodic migraine with or without aura were enrolled in two centers from August 2018, to December 2019, and randomized to receive either real (n = 37) or sham (sham coil stimulation, n = 28) multifocal rTMS for six sessions over two weeks. Patients, physicians, and raters were blinded to the applied protocol. The experimental multifocal rTMS protocol included two components; first, swipe stimulation of 13 trains of 140 pulses/train, 67 Hz, 60% of RMT, and 2s intertrain interval and second, spot burst stimulation of 33 trains of 15 pulses/train, 67 Hz, 85% of RMT, and 8s intertrain interval. Reduction >50% from the baseline in migraine days (as primary outcome) and frequency and intensity of migraine attacks (as key secondary outcomes) over a 12-week period were assessed. To balance the baseline variables between the treatment arms, we applied the propensity score matching through the logistic regression.

RESULTS

Among 65 randomized patients, sixty (age 39.7 ± 11.6; 52 females; real rTMS n = 33 and sham rTMS n = 27) completed the trial and five patients dropped out. Over 12 weeks, the responder's rate in the number of migraine days was significantly higher in the real rTMS compared to the sham group (42% vs. 26%, p < 0.05). The mean migraine days per month decreased from 7.6 to 4.3 days in the real rTMS group and from 6.2 to 4.3 days in the sham rTMS group, resulting in a difference with real vs. sham rTMS of -3.2 days (p < 0.05). Similarly, over the 12-week period, the responder's rate in the reduction of migraine attacks frequency was higher in the real rTMS compared to the sham group (42% vs 33%, p < 0.05). No serious adverse events were observed.

CONCLUSION

Our pilot study shows compelling evidence in a double placebo-controlled trial that multifocal rTMS is an effective and well-tolerated preventive treatment in patients with episodic migraine.

Mid- and Late-Life Migraine Is Associated with an Increased Risk of All-Cause Dementia and Alzheimer's Disease, but Not Vascular Dementia: A Nationwide Retrospective Cohort Study

We used a nationwide cohort sample of data from 2002 to 2013, representing approximately 1 million patients to investigate the prospective association between migraine and dementia. The migraine group (n = 1472) included patients diagnosed between 2002 and 2004, aged over 55 years; the comparison group was selected using propensity score matching (n = 5888). Cox proportional hazards regression analyses was used to calculate the hazard ratios (HRs). The incidence of dementia was 13.5 per 1000 person-years in the migraine group. Following adjustment for sociodemographic and comorbidities variables, patients with migraine developed dementia more frequently than those in the comparison group (adjusted HR = 1.37, 95% confidence interval [CI], 1.16–1.61). In the subgroup analysis, we found a higher HR of dementia events in male, the presence of comorbidities, and older age (≥65) patients with migraine, compared to those without migraine. Moreover, patients with migraine had a significantly higher incidence of Alzheimer’s disease (adjusted HR = 1.31, 95% CI, 1.08–1.58), but not vascular dementia, than those without migraine. Therefore, our findings suggest that mid- and late-life migraines may be associated with an increased incidence of all-cause dementia and Alzheimer’s disease, but not vascular dementia.

Revised guidelines of the French headache society for the diagnosis and management of migraine in adults. Part 2: Pharmacological treatment

The French Headache Society proposes updated French guidelines for the management of migraine. This article presents the second part of the guidelines, which is focused on the pharmacological treatment of migraine, including both the acute treatment of attacks and the prophylaxis of episodic migraine as well as chronic migraine with and without medication overuse. The specific situations that can be encountered in women with migraine are also discussed, including pregnancy, menstrual migraine, contraception and hormonal replacement therapy.

Validity and reliability of the self-administered Visual Aura Rating Scale questionnaire for migraine with aura diagnosis: A prospective clinic-based study

OBJECTIVE

To assess the validity and reliability of the self-administered Visual Aura Rating Scale (VARS) questionnaire using a hospital-based sample in a cross-sectional setting.

BACKGROUND

Visual aura is the most common type of aura manifesting in 98%-99% of migraine with aura (MA). The VARS is a diagnostic rating scale used to quantify the cardinal characteristics of MA and has shown high sensitivity and specificity in the diagnosis of visual aura.

METHODS

We translated the VARS into Korean and constructed a five-item self-administered questionnaire based on the VARS. We consecutively recruited first-visit patients with migraine at the neurology clinics of two university hospitals. The scoring of the self-administered VARS questionnaire was the same as that for the original VARS. We assessed criterion validity and internal consistency reliability. The diagnosis of migraine and aura was assigned by two headache neurologists based on a comprehensive clinical assessment using the International Classification of Headache Disorders, 3rd edition.

RESULTS

A total of 240 participants with migraine were enrolled. Of these, 55 (22.9%) had MA. All participants with MA had visual aura. Receiver operating characteristic curve analysis revealed that a cutoff score of 3 provided the highest rate of correct identification of patients ([200/240], 83.3%), with a sensitivity of 96.4% (95% confidence interval [CI], 84.5%-99.6%) and specificity of 79.5% (95% CI, 72.9%-85.0%). Cronbach's alpha coefficient was 0.852.

CONCLUSION

The self-administered VARS questionnaire is a valid and reliable instrument for the screening of visual aura in patients with migraine in neurology outpatient clinics.

Pediatric Episodic Migraine with Aura: A Unique Entity?

Migraine headache is a common cause of pain and disability in children and adolescents and is a major contributor to frequently missed school days and limitations in activities. Of children and adolescents with migraine headache, approximately one-third have migraine with aura (MA). MA is often considered to be similar to migraine without aura (MO), and thus, many studies do not stratify patients based on the presence of aura. Because of this, treatment recommendations are often analogous between MA and MO, with a few notable exceptions. The purpose of this review is to highlight the current evidence demonstrating the unique pathophysiology, clinical characteristics, differential diagnosis, co-morbidities, and treatment recommendations and responses for pediatric MA.

A Nomogram for the Prediction of Cessation of Migraine Among Patients With Patent Foramen Ovale After Percutaneous Closure

Objective: This study aimed to develop and validate a nomogram to predict cessation of patent foramen ovale (PFO) patients with migraine headache after percutaneous closure.

Methods: A total of 247 eligible patients with PFO and migraine after percutaneous closure between May, 2016 and May, 2018 were divided into a development cohort (n = 149) and a validation cohort (n = 98). The primary end point was cessation of migraine at follow-up of 1 year after the procedure measured by the Migraine Disability Assessment Score (MIDAS). In the development cohort, the LASSO regression was used data dimension reduction. A multivariable logistic regression analysis was used to develop the predicting nomogram. The performance of the nomogram was assessed by concordance index (C-index), calibration and clinical usefulness. The results were validated in the validation cohort.

Results: Migraine with aura, history of antiplatelet, and the right-to-left shunt (RLS) at rest were identified as significant predictors based on the analysis of multivariate logistic regression. The nomogram incorporating these variables showed good calibration and discrimination in the development cohort with C-index of 0.906 (95% CI: 0.847–0.965), which was confirmed using the validation cohort with C-index of 0.827 (95% CI: 0.751–0.903). The nomogram showed good agreement between prediction by nomogram and actual observation. Furthermore, the decision curve indicated that the novel nomogram was clinically useful.

Conclusion: The novel nomogram showed favorable predictive accuracy for cessation of migraine among patients with PFO after percutaneous closure and might provide constructive guidance in clinical decision making.

Response inhibition alterations in migraine: evidence from event-related potentials and evoked oscillations

BACKGROUND

Migraine is characterized by a hypersensitivity to environmental stimulation which climaxes during headache attacks but persists during attack-free period. Despite ongoing debates about the nature of the mechanisms giving rise to this abnormality, the presence of deficient inhibitory cortical processes has been proposed to be one possible mechanism underlying its pathogenesis. Empirical evidence supporting this claim is mainly based on previous accounts showing functional cortical disexcitability in the sensory domain. Considering that a general inhibitory control process can play an important role across early to later stage of information processing, this may indicate the important role other dimensions of inhibitory control can play in migraine disability. The present study examined the pathophysiological features of inhibitory control that takes place during suppression of prepotent responses in migraineurs.

METHODS

Twenty-two patients with migraine without aura (mean age = 30.86 ± 5.69 years; 19 females) during the interictal period and 25 healthy controls (mean age = 30.24 ± 3.52 years; 18 females) were recruited. We used a stop signal task in combination with event-related potentials (ERPs) to examine participants' neural activity supporting response inhibition.

RESULTS

Behaviorally, migraineurs exhibited prolonged stop signal reaction times relative to healthy controls. At the neural level, the amplitude of the stop-N2 over fronto-central, central and centro-parietal scalp regions, a component of the ERPs related to conflict monitoring during early, non-motoric stages of inhibition, was significantly increased in migraineurs. Meanwhile, the amplitude of the stop-P3 over central and centro-parietal scalp regions, a component of the ERPs reflecting late-stage inhibition of the motor system and cognitive evaluation of motor inhibition, was also significantly increased in migraineurs. Ultimately, our time-frequency analysis further revealed increased delta activity in migraineurs.

CONCLUSIONS

Consistent with the theory that alterations in cognitive cortical processes are a key signature of migraine, our findings revealed an abnormal state of suppressing prepotent responses in migraineurs, which can be attributed to cortical disexcitability of the pre-frontal executive network and centro-parietal sensorimotor network. These novel findings extend to show the existence of dysfunctional inhibition control that occurs during suppression of prepotent responses in migraneurs.

Increased Risk of Migraine in Patients with Temporomandibular Disorder: A Longitudinal Follow-Up Study Using a National Health Screening Cohort

Background: The aim of this study was to investigate the association between temporomandibular disorder (TMD) and migraine through a longitudinal follow-up study using population data from a national health screening cohort. Methods: This cohort study used data from the Korean National Health Insurance Service-Health Screening Cohort from 2002 to 2015. Of the 514,866 participants, 3884 TMD patients were matched at a 1:4 ratio with 15,536 control participants. Crude models and models adjusted for obesity, smoking, alcohol consumption, systolic blood pressure, diastolic blood pressure, fasting blood glucose, total cholesterol, and Charlson Comorbidity Index (CCI) scores were calculated. Chi-squared test, Kaplan–Meier analysis, and two-tailed log-rank test were used for statistical analysis. Stratified Cox proportional hazard models were used to assess hazard ratios (HR) and 95% confidence intervals (CIs) for migraine in both control groups. Results: The adjusted HR for migraine was 2.10 (95% CI: 1.81–2.44) in the TMD group compared to the control group, which was consistent in subgroup analyses according to age, sex, and Kaplan–Meier analysis. Conclusions: This study demonstrated that TMD patients have a higher risk of migraine. These results suggest that dentists can decrease the risk of migraine in TMD patients by managing TMD properly.

Mid- to late-life migraine diagnoses and risk of dementia: a national register-based follow-up study

BACKGROUND

Previous studies found an association between migraine and dementia, which are two leading causes of disability. However, these studies did not differentiate between migraine types and did not investigate all prevalent dementia subtypes. The main objective of this national register-based study was to investigate whether migraine was a risk factor for dementia. Additionally, we explored potential differences in dementia risk for migraine with and without aura.

METHODS

We obtained data on birth cohorts born between 1935 and 1956 (n = 1,657,890) from Danish national registers. Individuals registered with migraine before age 59 (n = 18,135) were matched (1:5) on sex and birthdate with individuals without migraine (n = 1,378,346). Migraine was defined by International Classification of Diseases (ICD) diagnoses and dementia was defined by ICD diagnoses and anti-dementia medication. After matching, 62,578 individuals were eligible for analysis. For the statistical analyses, we used Cox regression models and adjusted for socio-demographic factors and several psychiatric and somatic morbidities.

RESULTS

During a median follow-up time of 6.9 (IQR: 3.6-11.2) years, 207 individuals with migraine developed dementia. Compared with individuals without migraine, we found a 50% higher rate of dementia among individuals with migraine (HR = 1.50; 95% CI: 1.28-1.76). Individuals without aura had a 19% higher rate of dementia (HR = 1.19; 95% CI: 0.84-1.70), and individuals with aura had a two times higher rate of dementia (HR = 2.11; 95% CI: 1.48-3.00).

CONCLUSIONS

Our findings support the hypothesis that migraine is a midlife risk factor for dementia in later life. The higher rate of dementia in individuals with a hospital-based diagnosis of migraine with aura emphasizes the need for studies on pathological mechanisms and potential preventative measures. Furthermore, given that only hospital-based migraine diagnoses were included in this study, future research should also investigate migraine cases derived from the primary healthcare system to include less severe migraine cases.

Pyridoxine, folate and cobalamin for migraine: A systematic review

There is a possible relationship between migraine and hypercoagulability inducing factors, such as hyperhomocysteinemia. In this context, homocysteine (Hcy)-lowering vitamins (B6-folate-B12) may prove beneficial in the management-prophylaxis of migraine. We performed a systematic literature search in order to retrieve studies assessing the supplementation of B6, folate and B12 (alone or as adjunctive therapies) to migraine patients, as well as patients suffering from other primary headache disorders. MEDLINE, EMBASE, CENTRAL, Google Scholar, trial registries and OpenGrey were searched. Twelve relevant articles were retrieved. The management of acute migraine attacks with Hcy-lowering vitamins has not provided promising results (one randomized controlled trial-RCT-and one prospective uncontrolled trial). On the contrary, significant benefits were registered for the use of B6 alone, in combination with folate and in combination with folate and B12 in the prophylaxis of migraine with aura (MA) in adults compared to placebo (five RCTs, only one did not obtain significant results). Folate supplementation alone was not more efficacious than placebo (one RCT). Limited data for the prophylaxis of migraine without aura (MO) in children (two prospective uncontrolled trials) and adults (two prospective uncontrolled trials involving both MA and MO participants) impede the extraction of safe conclusions. An overall attractive safety profile was exhibited with gastrointestinal adverse events being the most common. Overall, a potential beneficial effect regarding the administration of B6, folate and/or B12 in the prophylaxis of MA in adults was indicated. Additional high-quality RCTs that will investigate MO in adults as well as MO and MA in children are warranted.

Redefining migraine phases - a suggestion based on clinical, physiological, and functional imaging evidence

Migraine is defined by attacks of headache with a specific length and associated symptoms such as photophobia, phonophobia and nausea. It is long recognized that migraine is more than just the attacks and that migraine should be understood as a cycling brain disorder with at least 4 phases: interictal, preictal, ictal and postictal. However, unlike the pain phase, the other phases are less well defined, which renders studies focusing on these phases susceptible to bias. We herewith review the available clinical, electrophysiological, and neuroimaging data and propose that the preictal phase should be defined as up to 48 hours before the headache attack and the postictal phase as up to 24 hours following the ictal phase. This would allow future studies to specifically investigate these migraine phases and to make study results more comparable.