Plasma Calcitonin Gene-Related Peptide: A Potential Biomarker for Diagnosis and Therapeutic Responses in Pediatric Migraine

Management of calcified cysticerci in the brain parenchyma: treating the dead parasite

INTRODUCTION

Calcifications are the end stage of many parenchymal brain cysticerci and may occur either spontaneously or as the result of treatment with cysticidal drugs. These lesions, traditionally considered inert and asymptomatic, have been associated with several complications that seem to be mostly related to brain damage and inflammation ensuing as the result of the exposure of the host's immune system to parasitic antigens trapped within calcifications.

AREAS COVERED

This review, based on the search of different electronic databases up to May 2024, focuses on the reported correlates and complications of calcified cysticerci (chronic headaches, seizures/epilepsy, hippocampal atrophy/sclerosis, gliomas), and the different interventions developed for their prevention and treatment. Common analgesics, non-steroidal anti-inflammatory drugs, corticosteroids, and antiseizure medications have been used with success but, with the exception of the latter, these drugs offer temporary relief of symptoms and support for their use is based on level 3 evidence.

EXPERT OPINION

Several strategies may reduce the severity of clinical consequences of calcified cysticerci. Probably, the most relevant intervention would be the prevention of their occurrence or reduction in their size. In this view, the use of bisphosphonates appears as a potential option that needs to be tested in humans.

Effectiveness and Tolerability of Anti-Calcitonin Gene-Related Peptide Therapy for Migraine and Other Chronic Headaches in Adolescents and Young Adults: A Retrospective Study in the USA

This retrospective study assesses the efficacy and tolerability of anti-calcitonin gene-related peptide (anti-CGRP) therapy in adolescents and young adults (ages 12-21) with migraine and chronic daily headaches unresponsive to standard treatments. Migraines in this demographic significantly impair school performance, self-esteem, psychological well-being, and cognitive health. These young patients are also particularly sensitive to the side effects of conventional medications, which are often prescribed off-label and come with high insurance denial rates. Medication overuse, including analgesics, triptans, and NSAIDs, is prevalent due to treatment failures. Elevated plasma CGRP levels observed during migraines suggest that anti-CGRP therapies, successful in adult populations, may also benefit this younger age group. Over a three-year period, patients at a specialized pediatric headache center were evaluated for the impact of anti-CGRP treatments, including monoclonal antibodies (erenumab, fremanezumab, and galcanezumab) and small-molecule CGRP receptor antagonists (ubrogepant, rimegepant, and atogepant), administered either alone or in combination with OnabotulinumtoxinA. Data were extracted from the hospital's electronic medical records, and patient progress was consistently documented using a structured template for each clinic visit. Additional patient satisfaction data were collected via telephone follow-ups and patient message reviews. The study included 23 patients, primarily treated for chronic migraine (CM) (78.3%), with a smaller subset addressing episodic migraine (EM), new daily persistent headaches (NDPHs), and post-traumatic headaches (PTHs). Comprehensive demographic and clinical data, including age, treatment duration, history of preventive treatment failures, and comorbidities like psychiatric conditions and sleep disorders, were collected. Anti-CGRP therapies, particularly when combined with traditional treatments or OnabotulinumtoxinA, resulted in significant improvements: 91.3% of patients experienced reduced migraine duration and intensity, 82.6% reported improvements in other bothersome symptoms, and 73.9% saw an improved response to rescue medications. Additionally, 78.3% of patients reported a reduction in their use of rescue medications per week by more than 50%, and emergency room visits were reduced for 56.5% of patients. Significant reductions in headache days were observed in 82.6% of patients after one month and 87% after three months, with nearly 40% experiencing more than a 50% reduction in both periods. The greatest benefits were observed in patients treated for more than six months. Adverse effects were minimal, with 95.7% of patients reporting no side effects, and patient satisfaction was high, with 69.6% opting to continue treatment. Overall, this study highlights the substantial potential of anti-CGRP therapy in improving outcomes for adolescents and young adults with CM and EM, offering a promising approach for a demographic that faces considerable challenges with conventional treatment options. However, further research is needed to confirm these findings and expand clinical applications in this age group.

Calcitonin Gene-Related Peptide Inhibitors in the Treatment of Migraine in the Pediatric and Adolescent Populations: A Review

There are limited well-studied treatments for migraine in the pediatric population. Calcitonin gene-related peptide (CGRP) inhibitors are an established safe and effective treatment in adults, and use may be appropriate for pediatric patients in certain clinical situations. We describe migraine pathophysiology as it relates to CGRP, provide an overview of available medications, and discuss clinical usage in this population.

Longitudinal Associations Between Persistent Post-Concussion Symptoms and Blood Biomarkers of Inflammation and CNS-Injury After Mild Traumatic Brain Injury

The aim of our study was to investigate the biological underpinnings of persistent post-concussion symptoms (PPCS) at 3 months following mild traumatic brain injury (mTBI). Patients (n = 192, age 16-60 years) with mTBI, defined as Glasgow Coma Scale (GCS) score between 13 and 15, loss of consciousness (LOC) <30 min, and post-traumatic amnesia (PTA) <24 h were included. Blood samples were collected at admission (within 72 h), 2 weeks, and 3 months. Concentrations of blood biomarkers associated with central nervous system (CNS) damage (glial fibrillary acidic protein [GFAP], neurofilament light [NFL], and tau) and inflammation (interferon gamma [IFNγ], interleukin [IL]-8, eotaxin, macrophage inflammatory protein-1-beta [MIP]-1β, monocyte chemoattractant protein [MCP]-1, interferon-gamma-inducible protein [IP]-10, IL-17A, IL-9, tumor necrosis factor [TNF], basic fibroblast growth factor [FGF]-basic platelet-derived growth factor [PDGF], and IL-1 receptor antagonist [IL-1ra]) were obtained. Demographic and injury-related factors investigated were age, sex, GCS score, LOC, PTA duration, traumatic intracranial finding on magnetic resonance imaging (MRI; within 72 h), and extracranial injuries. Delta values, that is, time-point differences in biomarker concentrations between 2 weeks minus admission and 3 months minus admission, were also calculated. PPCS was assessed with the British Columbia Post-Concussion Symptom Inventory (BC-PSI). In single variable analyses, longer PTA duration and a higher proportion of intracranial findings on MRI were found in the PPCS group, but no single biomarker differentiated those with PPCS from those without. In multi-variable models, female sex, longer PTA duration, MRI findings, and lower GCS scores were associated with increased risk of PPCS. Inflammation markers, but not GFAP, NFL, or tau, were associated with PPCS. At admission, higher concentrations of IL-8 and IL-9 and lower concentrations of TNF, IL-17a, and MCP-1 were associated with greater likelihood of PPCS; at 2 weeks, higher IL-8 and lower IFNγ were associated with PPCS; at 3 months, higher PDGF was associated with PPCS. Higher delta values of PDGF, IL-17A, and FGF-basic at 2 weeks compared with admission, MCP-1 at 3 months compared with admission, and TNF at 2 weeks and 3 months compared with admission were associated with greater likelihood of PPCS. Higher IL-9 delta values at both time-point comparisons were negatively associated with PPCS. Discriminability of individual CNS-injury and inflammation biomarkers for PPCS was around chance level, whereas the optimal combination of biomarkers yielded areas under the curve (AUCs) between 0.62 and 0.73. We demonstrate a role of biological factors on PPCS, including both positive and negative effects of inflammation biomarkers that differed based on sampling time-point after mTBI. PPCS was associated more with acute inflammatory processes, rather than ongoing inflammation or CNS-injury biomarkers. However, the modest discriminative ability of the models suggests other factors are more important in the development of PPCS.

The kynurenine pathway of tryptophan metabolism in abdominal migraine in children - A therapeutic potential?

BACKGROUND

Abdominal migraine (AM) is a clinical diagnosis specified by Rome IV and ICHD III as a functional gastrointestinal disease (FGID) and a migraine associated syndrome, respectively. Abdominal migraine in childhood and adolescence may continue with migraine headaches in adulthood. This disease is undiagnosed and undertreated, and thus far the FDA has not approved any drug for AM treatment. It was shown that changes in the kynurenine (KYN) pathway of tryptophan (TRP) metabolism played an important role in the pathogenesis and treatment of FIGDs and associated mood disorders. Changes in the KYN pathway were shown in migraine and therefore it may be involved in AM pathogenesis.

FINDINGS

Abdominal migraine reflects an impairment in the communication within the gut-brain axis. Treatment approaches in AM are based on the experience of physicians, presenting personal rather than evidence-based practice, including efficacy of some drugs in adult migraine. Non-pharmacological treatment of AM is aimed at preventing or ameliorating AM triggers and is based on the STRESS mnemonic. Metabolic treatments with riboflavin and coenzyme Q10 were effective in several cases of pediatric migraine, but in general, results on metabolic treatment in migraine in children are scarce and nonconclusive. Modulations within the KYN pathway of TRP metabolism induced by changes in TRP content in the diet, may ameliorate FGIDs and support their pharmacological treatment. Pharmacological manipulations of brain KYNs in animals have brought promising results for clinical applications. Obese children show a higher headache prevalence and may be especially predisposed to AM, and KYN metabolites showed an alternated distribution in obese individuals as compared with their normal-weight counterparts.

CONCLUSIONS

In conclusion, controlled placebo-based clinical trials with dietary manipulation to adjust the amount of the product of the KYN pathway of TRP metabolism are justified in children and adolescents with AM, especially those with coexisting obesity. Further preclinical studies are needed to establish details of these trials.

Evaluation of Safety and Efficacy of Add-on Alpha-Lipoic Acid on Migraine Prophylaxis in an Adolescent Population: A Randomized Controlled Trial

Nutraceuticals like alpha-lipoic acid (ALA) may have potential benefits as prophylactic agents for adolescent migraine, with fewer adverse events than existing medications. The present study was conducted to evaluate the safety and efficacy of add-on ALA for prophylaxis in adolescent migraine. A randomized, open-label, add-on clinical trial was conducted with 60 adolescent migraineurs, who were randomized to receive flunarizine or flunarizine with an add-on ALA. A clinical evaluation of the frequency and severity of migraine, responder rate, Pediatric Migraine Disability Assessment (PedMIDAS) scoring, serum thiol, and serum calcitonin gene-related peptide (CGRP) was performed both at baseline and following 12 weeks of treatment. The frequency of acute attacks of migraine decreased significantly (P = .001) in the test group compared with the control group. The responder rate was found to be significantly higher (80%) in the test group than in the control group (33.3%) (P = .001). The mean monthly migraine headache days in the test group showed a significant reduction (-7.7 days, 95%CI -9.1 to -6.3 days; P = .010). The severity of acute migraine attacks (mild, moderate, severe) also showed a significant reduction in the test group (P = .001). PedMIDAS scores showed significant improvement in the test group (P = .021), in comparison with the control group. Serum thiol levels were significantly increased in the test group (18 mmol/L, 95%CI 13.5 to 36.1 mmol/L; P = .001). Serum CGRP levels showed a significant reduction with adjunctive ALA therapy (-122.4 pg/mL, 95%CI -142.3 to -89.0 pg/mL; P = .006). Add-on ALA with flunarizine as a prophylactic agent for migraine in adolescents can improve clinical outcomes by improving clinical and biochemical parameters.

A Study of Diffusion Tensor Imaging in Central Post-Stroke Pain: Traveling Beyond the Pain Pathways

Introduction

Central post-stroke pain (CPSP), seen in the aftermath of a stroke, is an underdiagnosed entity but quite a disabling complication. All the postulated theories regarding the pathogenesis of CPSP point to its origin in the central pain pathways. However, this study attempts to demonstrate the role of other contributing areas in the generation of CPSP.

Materials and Methods

In this single-center tertiary care hospital-based study, 24 patients with both ischemic and hemorrhagic strokes of variable durations were recruited, and Magnetic Resonance Imaging (MRI) imaging with diffusion tensor imaging (DTI) acquisition was done. Fractional anisotropy (FA) and apparent diffusion coefficient (ADC) values of the spinothalamic tract (STT), corticospinal tract (CST), superior thalamic radiation (STR), basal ganglia (BG), and primary somatosensory cortex (SSC) were compared between normal and abnormal sides and also in extrathalamic lesions separately.

Results

Significant differences with lower FA were noted in STT, CST, STR, and SSC and higher ADC values in BG, STR, CST, and SSC on comparison between the normal and lesion sides. On individual sub-analysis, ischemic stroke had significant changes in the FA value of CST and the ADC value of STR and CST, while hemorrhagic stroke had significant changes in the FA and ADC values of STR and SSC, as well as the FA value of STT. In the analysis of the extrathalamic strokes, significance persisted in all the studied parameters except the BG. The CST abnormalities were evident even in patients with clinical motor improvement. On multivariate analysis, visual analogue scale score severity was correlated with thalamic lesions.

Conclusion

Contrary to the belief that STT is solely responsible for CPSP, the role of CST, STR, BG, and SSC as contributing areas is evident from this study and may be more well established if studied in a larger population.

Beyond the Guidelines: A Narrative Review of Treatments on the Horizon for Migraine in Children and Adolescents

Migraine is common in children and adolescents and can cause significant disability. There are relatively limited evidence-based treatment options available, especially when compared with treatment of migraine in adults. The Pediatric Research Equity Act requires the study of a new drug or biologic in pediatric populations. As such it is mandatory that the newest migraine treatment options available for adults be evaluated in children and adolescents. It will take years before results from clinical trials in pediatric patients become available. In the meantime, there is eagerness among clinicians to seek out the existing evidence that may help provide clarity on utilization of the newer migraine therapies in children and adolescents because many of the currently available, guideline-recommended treatments do not provide benefit for all patients. In this narrative review, the literature regarding onabotulinumtoxinA, neuromodulatory devices, calcitonin gene-related peptide (CGRP) monoclonal antibodies, 5-hydroxytryptamine (1F) agonists (i.e., ditans), and CGRP small-molecule receptor antagonists (i.e., gepants) for the treatment of migraine in children and adolescents will be summarized.

SEEG-RF for revealing and treating Geschwind syndrome's epileptic network: A case study

Stereotypic neural networks are repeatedly activated in drug-refractory epilepsies (DRE), reinforcing the expression of certain psycho-affective traits. Geschwind syndrome (GS) can serve as a model for such phenomena among patients with temporal lobe DRE. We describe stereo-electroencephalogram (SEEG) exploration in a 34-year-old male with DRE and GS, and his treatment by SEEG-radiofrequency (SEEG-RF) ablation. We hypothesized that this approach could reveal the underlying epileptic network and map eloquent faculties adjacent to SEEG-RF targets, which can be further used to disintegrate the epileptic network. The patient underwent a multi-modal pre-surgical evaluation consisting of video EEG (VEEG), EEG source localization, 18-fluorodexyglucose-PET/MRI, neuropsychological and psychiatric assessments. Pre-surgical multi-modal analyses suggested a T4-centered seizure onset zone. SEEG further localized the SOZ within the right amygdalo-hippocampal region and temporal neocortex, with the right parieto-temporal region as the propagation zone. SEEG-RF ablation under awake conditions and continuous EEG monitoring confirmed the abolishment of epileptic activity. Follow-up at 20 months showed seizure suppression (Engel 1A/ILEA 1) and a significantly improved and stable psycho-affective state. To the best of our knowledge this is the first description of the intracranial biomarkers of GS and its further treatment through SEEG-RF ablation within the scope of DRE.

Clinical Potential of Adrenomedullin Signaling in the Cardiovascular System

Numerous clinical studies have revealed the utility of circulating AM (adrenomedullin) or MR-proAM (mid-regional proAM 45-92) as an effective prognostic and diagnostic biomarker for a variety of cardiovascular-related pathophysiologies. Thus, there is strong supporting evidence encouraging the exploration of the AM-CLR (calcitonin receptor-like receptor) signaling pathway as a therapeutic target. This is further bolstered because several drugs targeting the shared CGRP (calcitonin gene-related peptide)-CLR pathway are already Food and Drug Administration-approved and on the market for the treatment of migraine. In this review, we summarize the AM-CLR signaling pathway and its modulatory mechanisms and provide an overview of the current understanding of the physiological and pathological roles of AM-CLR signaling and the yet untapped potentials of AM as a biomarker or therapeutic target in cardiac and vascular diseases and provide an outlook on the recently emerged strategies that may provide further boost to the possible clinical applications of AM signaling.

Predictors of Social Participation Outcome after Traumatic Brain Injury Differ According to Rehabilitation Pathways

Social participation (SP) is one of many objectives in the rehabilitation of patients with traumatic brain injury (TBI). Studies on predictors of SP specific to post-acute universally accessible specialized rehabilitation pathways following TBI are scarce. Our objectives were to: 1) characterize SP, as well as a set of pre-injury, injury-related, and post-injury variables in individuals participating in inpatient-outpatient or outpatient rehabilitation pathways within a universally accessible and organized trauma continuum of care; and 2) examine the ability of pre-injury, injury-related, and post-injury variables in predicting SP outcome after TBI according to rehabilitation path. Participants (N = 372) were adults admitted to an inpatient-outpatient rehabilitation pathway or an outpatient rehabilitation pathway after sustaining a TBI between 2016 and 2020, and for whom Mayo-Portland Adaptability Intentory-4 (MPAI-4) outcomes were prospectively obtained at the start and end of rehabilitation. Additional data was collected from medical files. For both rehabilitation pathways, predicted SP outcome was MPAI-4 Participation score at discharge from outpatient rehabilitation. Multiple regression models investigated the predictive value of each variable for SP outcome, separately for each care pathway. Main findings show that for the inpatient-outpatient sample, three variables (education years, MPAI-4 Ability and Adjustment scores at rehabilitation intake) significantly predicted SP outcome, with the regression model accounting for 49% of the variance. For the outpatient sample, five variables (pre-morbid hypertension and mental health diagnosis, total indirect rehabilitation hours received, MPAI-4 Abilities and Adjustment scores at rehabilitation intake) significantly predicted SP outcome, with the regression model accounting for 47% of the variance. In conclusion, different pre-morbid and post-injury variables are involved in predicting SP, depending on the rehabilitation path followed. The predictive value of those variables could help clinicians identify patients more likely of showing poorer SP at discharge and who may require additional or different interventions.

Can calcitonin gene-related peptide (CGRP) and pentraxin-3 (PTX-3) be useful in diagnosing acute migraine attack?

PURPOSE

Even if migraine is not fatal, it is a common and challenging disease with adverse effects on individuals' lives. The lack of objective diagnostic tools causes delays in diagnosis and treatment initiation. The primary aim of this study is to reveal the diagnostic value of Calcitonin Gene-Related Peptide (CGRP) and Pentraxin-3 (PTX-3) in acute migraine. To this aim, we compared the serum CGRP and PTX-3 levels of migraine patients with acute attacks to those in healthy individuals.

MATERIAL AND METHOD

A total of 135 individuals (85 patients with migraine attacks with or without aura and 50 healthy controls) participated in the study. Serum CGRP and PTX-3 levels were measured with ELISA analysis. A p value less than 0.05 was considered significant.

RESULTS

Serum CGRP [146.70 (21.52-413.67) vs. 65.90 (3.80-256.60) pg/mL] and PTX-3 levels [12.71 (0.62-33.97) vs. 1.01 (0.06-9.48) ng/mL] were higher in patients with migraine attack than the control group (p < 0.01 and p < 0.01, respectively). ROC analysis showed that the cutoff value for serum CGRP was 121.39 pg/mL (AUC: 0.751, Sen:%61, Spe:%64) whereas the cutoff value for PTX-3 was 4,06 ng/mL (AUC:0.876, Sen:%73, Spe:%76). Serum CGRP levels were positively correlated with pain intensity. Serum CGRP and PTX-3 levels did not differ across gender groups and presence of aura in subgroup analysis.

CONCLUSION

Patients with acute migraine attacks have higher serum CGRP and PTX-3 levels than controls. Both biomarkers show high potential for the diagnosis of a migraine attack.

Efficacy and Safety of Eptinezumab as Preventive Treatment for Episodic/Chronic Migraine: A Systematic Review and Meta-analysis

BACKGROUND AND AIMS

Migraine, the third most common neurological disorders worldwide, can cause significant burden to the patients. Currently, it has been found that calcitonin gene-related peptide (CGRP) has a significant role in pathophysiology of migraine. This study sought to analyze the efficacy and safety of eptinezumab, one of the CGRP-monoclonal antibody as preventive treatment for episodic/chronic migraine.

METHODS

Specific keywords were used to comprehensively go through the potential articles on ClinicalTrials.gov, Europe PMC, Scopus, and PubMed databases until April 2022. All published RCTs on eptinezumab and migraine were gathered. Statistical analysis was conducted by using Review Manager 5.4 and Comprehensive Meta-Analysis version 3 software.

RESULTS

There were 4 RCT with 2,739 migraine patients in the meta-analysis. In terms of efficacy, our analysis revealed that eptinezumab corresponded with higher reduction in MMD from baseline to week 12 [Std. Mean Difference -0.34 (95% CI -0.41, -0.28), p < 0.00001, I² = 0%], higher 75% and 50% migraine responder rate, reduction in rate of migraine on day-1 after dosing, lower HIT-6 score on week 4 and week 12. In terms of safety, eptinezumab has comparable adverse events when compared with placebo [RR 1.01 (95% CI 0.96 - 1.07), p = 0.63, I² = 0%]. Further regression analysis also revealed that the association between eptinezumab and each outcomes of interest were not influenced by age, gender, BMI, and duration of migraine This article is protected by copyright. All rights reserved.

CONCLUSIONS

This study propose that eptinezumab is generally effective and safe for the preventive treatment of episodic or chronic migraine.

Is calcitonin gene-related peptide a reliable biochemical marker of migraine?

PURPOSE OF REVIEW

The aim of this study was to provide an overview of clinical studies on calcitonin gene-related peptide (CGRP) measurements in body fluids of migraine patients and to discuss the validity of CGRP measurement as a clinical biomarker of migraine.

RECENT FINDINGS

Several studies have reported increased CGRP levels in venous blood, saliva and tear fluid of migraine patients compared with healthy controls and in migraine patients during attacks compared with the interictal state, suggesting that CGRP may be a feasible biomarker of migraine. However, the findings of studies investigating CGRP levels in migraine patients are generally conflicting and measurements of CGRP levels are challenged by several methodological issues. Reported differences in CGRP levels between patients with chronic migraine relative to episodic migraine have also been inconsistent. There is also a well documented involvement of CGRP in several nonmigraine pain disorders, including cluster headache and common pain conditions such as osteoarthritis.

SUMMARY

Current evidence does not justify the usage of CGRP levels as a biomarker for diagnosing migraine or for determining the severity of the disease in individual patients. However, CGRP measurements could prove useful in the future as clinically relevant biomarkers for predicting the response to therapy, including anti-CGRP migraine drugs.

Migraine Pathophysiology in Children and Adolescents: A Review of the Literature

Although migraine in adult and pediatric patients are overall very similar to each other, differences in prevalence, presentation, and treatment efficacy may reflect slight differences in the pathophysiological processes underlying migraine in these patient groups, perhaps because of ongoing development of the nervous system during childhood and adolescence. Although major gains have been made in understanding the pathophysiology of migraine in adults in recent years, equivalent research on migraine in pediatric patients continues to lag behind. In this review, we will describe the current state of migraine research in pediatric patients with regard to presentation and frequency of prodromal and postdromal symptoms, ictal and interictal calcitonin gene-related peptide elevation, and evidence for cortical spreading depression, thus covering all phases of migraine, and discuss how the findings seen here may relate to possible underlying pathophysiological mechanisms of migraine. We aim to elucidate possible differences between migraine in children and adults, and the need for further research specific to pediatric patients with migraine in order to improve treatment in this patient group.

CGRP in Childhood and Adolescence Migraine: (Patho)physiological and Clinical Aspects

Purpose of Review

To summarise and analyse the current knowledge of CGRP metabolism in childhood and adolescence and its role in childhood and adolescence migraine.

Recent Findings

Influencing CGRP pathways is nowadays one of the main mechanisms to treat migraine. In adults, several clinical trials with different drug classes have supported this finding. However, only very little is known on these mechanisms in children and adolescents with migraine. Based on a literature search, it can be concluded that substantial parts of the CGRP pathways are already developed and working in the preterm fetus of animals. Newborn animals show high CGRP levels and high density of CGRP positive neurons and nerve fibres. In human studies, increased levels of CGRP were observed in childhood and adolescent migraine patients. Remedies based on influencing CGRP metabolism are also working in that age group. For triptans, this has clearly been shown; for gepants, no data are available, and for CGRP ligand/receptor antibodies, positive evidence is only available from case series.

Summary

Only very little is known on CGRP metabolism in childhood and adolescence. However, placebo-controlled clinical trials both on CGRP antagonists and on CGRP ligand/receptor antibodies are under way and will show in some years whether these drug classes are efficacious also in children and adolescents.

Predicting quality of life outcomes in children with migraine

INTRODUCTION

Several studies have shown that the response of children with migraine to medications is suboptimum and inferior to the response reported in adults, despite the similar pathogenesis and biological mechanisms. The poor response may be related to the significant differences that make assessment and treatment of children with migraine more challenging than in adults.

AREAS COVERED

The purpose of this review is to discuss the whole process of assessment of children with migraine, the necessary skills for eliciting the clinical features, making the correct diagnosis and exploring lifestyle issues, co-morbid conditions (psychological and physical) and social influences on disease presentations. Also, to establish and address peculiarities of migraine in children that would enable clinicians to advise on lifestyle modifications, co-morbid conditions and the correct choice of treatment options including non-pharmacologic therapies and medications.

EXPERT OPINION

The choice of treatment should be based on an assessment of each individual child taking into account, age, gender, pubertal status, body weight, comorbid disorders and family history. Also considering the profile of migraine episodes, frequency, duration, associated symptoms and effects of nausea and vomiting. Using the appropriate medications in appropriate dosage, formulation and route and timing of administration may improve adherence to treatment and outcome.

Multispectral optoacoustic tomography for non-invasive disease phenotyping in pediatric spinal muscular atrophy patients

Proximal spinal muscular atrophy (SMA) is a rare progressive, life limiting genetic motor neuron disease. While promising causal therapies are available, meaningful prognostic biomarkers for therapeutic monitoring are missing. We demonstrate handheld Multispectral Optoacoustic Tomography (MSOT) as a novel non-invasive imaging approach to visualize and quantify muscle wasting in pediatric SMA. While MSOT signals were distributed homogeneously in muscles of healthy volunteers (HVs), SMA patients showed moth-eaten optoacoustic signal patterns. Further signal quantification revealed greatest differences between groups at the isosbestic point for hemoglobin (SWL 800 nm). The SWL 800 nm signal intensities further correlated with clinical phenotype tested by standard motor outcome measures. Therefore, handheld MSOT could enable non-invasive assessment of disease burden in SMA patients.

A Review of the Quality of Life after Therapeutic Maneuvers in Patients with Benign Paroxysmal Positional Vertigo

INTRODUCTION

Benign paroxysmal positional vertigo (BPPV) is a common cause of peripheral vestibular disturbances. Particle repositioning or liberatory maneuvers provide relief of symptoms in the majority of patients. However, studies mainly focus on success. This study aims to review the conditions that may have an impact on residual dizziness or recurrence following therapeutic maneuvers in patients with BPPV.

MATERIALS AND METHODS

A review of the literature about the analysis of quality of life after therapeutic maneuvers was conducted. Three hundred and seven articles after search in the PubMed database were classified into eight main groups after exclusion of those that are not suitable to predetermined criteria.

RESULTS

Thirty-eight articles for residual dizziness in BPPV, eighty-three articles for the duration of BPPV, forty articles for the type of canal involvement, forty-three articles for the impact of age, one hundred and nine articles for the gender difference, forty-seven articles for co-morbid conditions, one hundred and twenty-four articles for medication and sixty-eight articles for vestibular exercises in BPPV were selected.

CONCLUSION

VEMP abnormality is a reliable indicator to demonstrate the risk of recurrence. Duration of dizziness has no significant impact on recurrence. But the length of duration is important for residual dizziness. Vestibular rehabilitation or medication alone has no place in treatment but may help to reduce the symptoms in addition to maneuver. Self-perceived evaluation of balance after therapeutic maneuvers is recommended for the selection of those who need rehabilitation or additional medication.

CGRP measurements in human plasma - a methodological study

Background

Calcitonin gene-related peptide plasma levels have frequently been determined as a biomarker for primary headaches. However, published data is often inconsistent resulting from different methods that are not precisely described in most studies.

Methods

We applied a well-proven enzyme-linked immunosorbent assay to measure calcitonin gene-related peptide concentrations in human blood plasma, we modified parameters of plasma preparation and protein purification and used calcitonin gene-related peptide-free plasma for standard solutions, which are described in detail.

Results

Calcitonin gene-related peptide levels are stable in plasma with peptidase inhibitors and after deep-freezing. Calcitonin gene-related peptide standard solutions based on synthetic intercellular fluid or pooled plasma with pre-absorbed calcitonin gene-related peptide influenced the measurements but yielded both comprehensible results. In a sample of 56 healthy subjects the calcitonin gene-related peptide plasma levels varied considerably from low (<50 pg/mL) to very high (>500 pg/mL) values. After a 12-hour exposure of these subjects to normobaric hypoxia the individual calcitonin gene-related peptide levels remained stable.

Conclusion

Buffering with peptidase inhibitors and immediate freezing or processing of plasma samples is essential to achieve reliable measurements. Individuals show considerable differences and partly high calcitonin gene-related peptide plasma levels without detectable pathological reason. Thus plasma measurements are suited particularly to follow calcitonin gene-related peptide levels in longitudinal studies.

The use of data for this study was approved by the Ethics Committee of the Medical

University of Innsbruck (https://www.i-med.ac.at/ethikkommission/; EK Nr: 1242/2017).

Migraine with Brainstem Aura Accompanied by Disorders of Consciousness

Migraine with brainstem aura (MBA) accompanied by disorders of consciousness (DOC) is a rare subtype of migraine. The pathophysiology of MBA with DOC has not been elucidated yet. Some patients have a family history of migraine, and women are more affected than men. The aura symptoms are diverse; however, when MBA is combined with DOC, the clinical manifestations are more complicated. Coma is the most common clinical manifestation. The overall duration of the patient’s DOC is short and can often return to normal within half an hour. Headache often occurs after regaining consciousness and can also occur at the same time as DOC. The most common headache is located at the occipital region. Although DOC is reversible, considering the current small number of cases, we still need to improve our understanding of the disease to avoid misdiagnosis. The MBA patient’s electroencephalogram and cerebral blood flow perfusion may have transient changes and may return to normal in the interictal period or after the DOC. Although triptans have traditionally been contraindicated in MBA under drug instructions, the evidence of basilar artery constriction, as postulated in MBA, is lacking. Lasmiditan is currently the first and only 5-HT 1F receptor agonist approved by the Food and Drug Administration. The calcitonin gene-related peptide receptor antagonists and monoclonal antibody therapies may be the most promising for future consideration. Here, the pathophysiology, clinical manifestations, diagnostic tools, and treatment progress for MBA with DOC are reviewed.

α6GABAA Receptor Positive Modulators Alleviate Migraine-like Grimaces in Mice via Compensating GABAergic Deficits in Trigeminal Ganglia

Migraine is caused by hyperactivity of the trigeminovascular system, where trigeminal ganglia (TG) play an important role. This hyperactivity might originate from an underfunctional GABAergic system in TG. To investigate this possibility, we adapted a mouse model of migraine by inducing migraine-like grimaces in male mice via repeated injections of nitroglycerin (NTG, 10 mg/kg, i.p.), once every 2 days, for up to 5 sessions. Migraine-like facial pain scores were measured using the mouse grimace scale. Repeated NTG treatments in mice caused significant increases in migraine-like grimaces that were aborted and prevented by two anti-migraine agents sumatriptan and topiramate, respectively. After 5 sessions of NTG injections, the GABA-synthesizing enzyme, 65-kDa glutamate decarboxylase (GAD65), but not the GABA transporter 1 (GAT1) or the α6 subunit-containing GABAA receptors (α6GABAARs), was downregulated in mouse TG tissues. Taking advantage of the unaffected TG α6GABAAR expression in NTG-treated mice, we demonstrated that an α6GABAAR-selective positive allosteric modulator (PAM), DK-I-56-1, exhibited both abortive and prophylactic effects, comparable to those of sumatriptan and topiramate, respectively, in this migraine-mimicking mouse model. The brain-impermeable furosemide significantly prevented the effects of DK-I-56-1, suggesting its peripheral site of action, likely via preventing α6GABAAR modulation in TG. Results suggest that a decreased GABA synthesis caused by the reduced GAD65 expression in TG contributes to the trigeminovascular activation in this repeated NTG-induced migraine-mimicking model and that the unaltered α6GABAARs in TG are potential targets for migraine treatment. Thus, α6GABAAR-selective PAMs are potential anti-migraine agents for both abortive and preventive therapies.

Cystatin C as a potential biomarker to evaluate migraine

BACKGROUND

Migraine is a multifactorial neurovascular syndrome and closely associated to inflammation. Cystatin C (Cys C) is a neuroendocrine polypeptide which also plays a role in inflammation. Objective: To investigate the levels of Cys C in migraine patients without aura.

METHODS

A total of 80 participants were included in the study; 40 patients and 40 healthy controls. Serum Cys C levels were investigated by using enzyme-linked immunosorbent assay (ELISA). Statistical analysis were performed using Statistical Package for the Social Sciences (SPSS) version 22.0 (SPSS Inc, IL, USA).

RESULTS

Serum Cys C levels were found as 73.88 ng/mL in the patient group and 24.92 ng/mL in the healthy control group, being significantly higher among patients (p=0.000). Serum Cys C levels were significacntly different across age subgroups among patients (p=0.049), but not among controls. However, visual analog scale (VAS) (p=0.707), disease duration time (p=0.725) and body mass index (p=0.136) were not significantly different between the two groups.

CONCLUSION

Our findings demonstrate that high serum Cys C levels are independently associated to migraine without aura. To the best of our knowledge, this is the first study to determine the serum levels of Cys C in patients with migraine. Thus, serum Cys C may be a potential biomarker of migraine.

Plasma levels of CGRP and expression of specific microRNAs in blood cells of episodic and chronic migraine subjects: towards the identification of a panel of peripheral biomarkers of migraine?

Background

Migraine can manifest with an episodic or a chronic pattern in a continuum of disease severity. Multiple factors are associated with the progression of the pattern from episodic to chronic. One of the most consistently reported factors is the overuse of medications (MO) for the acute treatment of migraine attacks. The mechanisms through which MO facilitates the transformation of episodic migraine (EM) into chronic migraine (CM) are elusive. In order to provide insights into these mechanisms, the present study aims to identify possible peripheral biomarkers associated with the two forms of migraine, and with the presence of MO.

Methods

We evaluated the plasma levels of calcitonin gene-related peptide (CGRP) and the expression of miR-34a-5p and miR-382-5p in peripheral blood mononuclear cells of subjects with EM (n = 27) or CM-MO (n = 28). Subjects in the CM-MO group were also tested 2 months after an in-hospital detoxification protocol.

Results

CGRP, miR-382-5p, and miR-34a-5p levels were significantly higher in CM-MO subjects when compared to EM patients (p = 0.003 for all comparisons). After correcting for age, sex, and disease duration, miRNAs expression was still significantly associated with migraine phenotype (EM vs. CM-MO: p = 0.014 for miR-382-5p, p = 0.038 for miR-34a-5p), while CGRP levels were not (p = 0.115). CGRP plasma levels significantly and positively correlated with miR-382-5p (Spearman’s rho: 0.491, p = 0.001) and miR-34a-5p (Spearman’s rho: 0.303, p =0.025) in the overall population. In the CM-MO group, detoxification significantly decreased CGRP levels and miRNAs expression (p = 0.001). When comparing responders and non-responders to the detoxification, the former group (n = 23) showed significantly higher levels of CGRP at baseline, and significantly lower expression of miR-382-5p after the detoxification.

Conclusions

Our findings identify a potential panel of peripheral markers associated with migraine subtypes and disease severity. CGRP levels as well as miRNAs expression were influenced by MO, and modulated by detoxification in subjects with CM-MO.

Trial registration

The study protocol was registered at www.clinicaltrials.gov (NCT04473976).

Plasma levels of vasoactive neuropeptides in pediatric patients with migraine during attack and attack-free periods

BACKGROUND

Increasing evidence suggests that vasoactive neuropeptides such as pituitary adenylate cyclase-activating polypeptide-38 (PACAP-38), substance P, calcitonin gene-related peptide, and vasoactive intestinal peptide are involved in the pathophysiology of migraine in adults, but their role in pediatric migraineurs remains unclear. We prospectively investigated plasma levels of these vasoactive neuropeptides in pediatric migraine patients without aura and compared the results with those of age-matched healthy controls.

METHODS

Thirty-eight children aged 6-18 years with migraine without aura and 20 age-matched control subjects were included in the study. Neuropeptides in plasma samples from the controls, and in either the ictal or interictal periods in pediatric migraine without aura, were measured using ELISA.

RESULTS

PACAP-38 and vasoactive intestinal peptide levels in both ictal and interictal plasma were higher in the patients with pediatric migraine without aura than in the controls (p < 0.001), although calcitonin gene-related peptide and substance P levels remained unchanged. Otherwise, no significant difference was determined between ictal and interictal periods in terms of all neuropeptide levels.

CONCLUSIONS

This study demonstrates increased plasma PACAP-38 and vasoactive intestinal peptide levels, but not calcitonin gene-related peptide and substance P levels, in pediatric patients with migraine during both attack and attack-free periods. The study findings suggest that PACAP-38 and vasoactive intestinal peptide may be implicated in the pathophysiology of migraine, particularly in pediatric migraineurs.

Early clinical experience with a monoclonal antibody against the calcitonin gene-related peptide receptor in adolescents with migraine: A case series

Management of migraine in adolescents poses a great challenge, as many of the approved pharmacological migraine preventive agents have age restrictions. Following favorable safety and efficacy reports of the new class agent calcitonin gene-related peptide (CGRP) monoclonal antibody for use in migraine prevention, there is growing interest in its application in pediatric migraine. We present here a case series detailing our experience of using erenumab, a CGRP monoclonal antibody, in six adolescent patients. Two patients had a reduction of at least 50% in the mean number of monthly migraine days, one patient reported subjective improvement, while three patients did not respond to the first dose of erenumab and discontinued treatment. One patient reported constipation associated with erenumab use. We speculate that CGRP monoclonal antibody could potentially be a viable option in adolescent patients with migraine. Further evidences that support efficacy and safety of erenumab in this group is needed.

Migraine Pathophysiology

Migraine is the leading cause of years lost due to disability in individuals aged 15 to 49 years. Much has changed over the last three decades about our understanding of this complex neurological disorder. Various phases of migraine have been characterized and are the focus of this review. The premonitory phase involves bothersome symptoms experienced hours to days before migraine pain. Behavioral changes and functional neuroimaging studies point toward hypothalamic involvement during the premonitory and other migraine phases. Migraine aura is a disruptive, reversible neurological phenomenon that affects up to one-third of all migraineurs, and can overlap with the headache phase. The mechanism responsible for this phase is thought to be cortical spreading depolarization through the cortex. This process leads to temporary disruptions in ion homeostasis and the ensuing neuronal dysfunction. The headache phase involves activation of the trigeminocervical complex. Neuropeptides are implicated in trigeminal activation, and calcitonin gene-related peptide in particular has become a promising target of therapeutic intervention for migraine. The final phase of migraine is the postdrome, the period of time from the resolution of headache symptoms until return to baseline following a migraine. People often report neuropsychiatric, sensory, gastrointestinal, and general symptoms during this time, which can limit activity. Elucidating the neuroanatomical, chemical, and neuroimaging correlates of these migraine phases allows for an improved comprehension of the underlying changes associated with migraine symptomatology and can assist with evaluation of arising therapeutics for migraine management.

Hsa-miR-34a-5p and hsa-miR-375 as Biomarkers for Monitoring the Effects of Drug Treatment for Migraine Pain in Children and Adolescents: A Pilot Study

MicroRNAs (miRs) have emerged as biomarkers of migraine disease in both adults and children. In this study we evaluated the expression of hsa-miR-34a-5p and hsa-miR-375 in serum and saliva of young subjects (age 11 ± 3.467 years) with migraine without aura (MWA), while some underwent pharmacological treatment, and healthy young subjects were used as controls. miRs were determined using the qRT-PCR method, and gene targets of hsa-miR-34a-5p and hsa-miR-375 linked to pain-migraine were found by in silico analysis. qRT-PCR revealed comparable levels of hsa-miRs in both blood and saliva. Higher expression of hsa-miR-34a-5p and hsa-miR-375 was detected in saliva of untreated MWAs compared to healthy subjects (hsa-miR-34a-5p: p < 0.05; hsa-miR-375 p < 0.01). Furthermore, in MWA treated subjects, a significant decrease of hsa-miR-34a-5p and of hsa-miR-375 was documented in saliva and blood compared to MWA untreated ones. Altogether, these findings suggested thathsa-miR-34a-5p and hsa-miR-375 are expressed equally in blood and saliva and that they could be a useful biomarker of disease and of drug efficacy in patients with MWA.

Effect of Electroacupuncture on Hyperalgesia and Vasoactive Neurotransmitters in a Rat Model of Conscious Recurrent Migraine

Migraine onset is associated with the abnormal release of vasoactive neurotransmitters from perivascular nerves, and these neurotransmitters are involved in the pathophysiology of migraine. Hyperalgesia is a key feature of migraine, and accumulating evidence indicates that electroacupuncture (EA) at the single acupuncture point (Fengchi [GB20]) is effective in ameliorating hyperalgesia. In clinical practice, multiple acupuncture points are widely used, especially GB20 and Yanglingquan (GB34). However, the role played by vasoactive neurotransmitters in acupuncture antihyperalgesic effect at the single or multiple acupuncture points remains unknown. We aimed to determine whether EA would exert its antihyperalgesic effects by modulating vasoactive neurotransmitter release from the perivascular nerves. Furthermore, we examined whether targeting multiple acupuncture points would be more effective than targeting a single point in reducing hyperalgesia. The mechanical and thermal hyperalgesia were evaluated by measuring the facial and hind-paw mechanical withdrawal thresholds, tail-flick and hot-plate latencies. Plasma concentrations of vasoactive neurotransmitters were determined using rat-specific ELISA kits from jugular vein, including calcitonin gene-related peptide (CGRP), substance P (SP), vasoactive intestinal peptide (VIP), neuropeptide Y (NPY), pituitary adenylate cyclase-activating polypeptide (PACAP), nitric oxide (NO), and endothelin-1 (ET-1). The result suggested that EA significantly ameliorated the mechanical and thermal hyperalgesia, reduced c-Fos levels in the trigeminal ganglion, and attenuated plasma and dural levels of vasoactive neurotransmitters, especially in the multiple acupuncture points group (GB20+GB34). In conclusion, EA exerts antihyperalgesic effect in a rat model of conscious recurrent migraine, possibly via modulation of the vasoactive neurotransmitters. Furthermore, targeting multiple acupuncture points is more effective than targeting a single point in reducing hyperalgesia.