Are anti-calcitonin gene-related peptide monoclonal antibodies effective in treating migraine aura? A pilot prospective observational cohort study

BACKGROUND

About 15% to one third of migraineurs experience aura symptoms. Aura is a reversible focal neurological phenomenon involving visual, sensory, speech, and motor symptoms that usually precede migraine pain. Monoclonal antibodies against calcitonin-related peptide (anti- CGRP mAbs) are effective in preventing chronic and episodic migraine, but little is known about their effectiveness on specifically preventing migraine with aura.

METHODS

This is a pilot prospective observational cohort study, aiming at evaluating the effectiveness and safety of Erenumab, Fremanezumab or Galcanezumab for the treatment of migraine aura. We enrolled 14 patients at the Headache Centre of University Federico II of Naples. Duration of follow-up was 12 months. We assessed mean monthly days with aura symptoms, with or without subsequent headache, as well as mean monthly days with headache and mean monthly MIDAS score, by reviewing standardized paper patient headache diaries every three months.

RESULTS

A significant decrease in mean monthly aura days was observed throughout the observation period (median baseline: 13, interquartile range: 4-16; after 12 months: 1, interquartile range: 0-3, p < 0.001). We observed a statistically significant decrease in mean monthly headache days as well (median baseline 21, interquartile range: 16-30; after 12 months: 5, interquartile range: 4-7, p < 0.001). During the 12-month treatment period, none of the 14 patients reported mild or serious adverse events.

CONCLUSION

Our findings suggest that anti-CGRP mAbs are highly effective in migraine with aura, both in reducing mean monthly aura days and mean monthly days with headache.

SEEG study of a rare male temporal lobe epilepsy with orgasmic aura originating from the right amygdala

As a primitive driving force for biological reproduction, sexual behavior (and its associated mechanisms) is extremely complex, and orgasm plays an essential role. The limbic system plays a very important role in regulating human sexual behavior. However, it is not clear which components of the limbic system are related to orgasm sensation. We studied a rare case of spontaneous orgasmic aura in a male patient with temporal lobe epilepsy. Stereoelectroencephalography (SEEG) revealed that the right amygdala was the origin of orgasmic aura. Surgical removal of the medial temporal lobe, including the right amygdala, completely eliminated the patient's seizures. This study demonstrates the critical role of the amygdala in human male orgasm.

Different vulnerability of fast and slow cortical oscillations to suppressive effect of spreading depolarization: state-dependent features potentially relevant to pathogenesis of migraine aura

BACKGROUND

Spreading depolarization (SD), underlying mechanism of migraine aura and potential activator of pain pathways, is known to elicit transient local silencing cortical activity. Sweeping across the cortex, the electrocorticographic depression is supposed to underlie spreading negative symptoms of migraine aura. Main information about the suppressive effect of SD on cortical oscillations was obtained in anesthetized animals while ictal recordings in conscious patients failed to detect EEG depression during migraine aura. Here, we investigate the suppressive effect of SD on spontaneous cortical activity in awake animals and examine whether the anesthesia modifies the SD effect.

METHODS

Spectral and spatiotemporal characteristics of spontaneous cortical activity following a single unilateral SD elicited by amygdala pinprick were analyzed in awake freely behaving rats and after induction of urethane anesthesia.

RESULTS

In wakefulness, SD transiently suppressed cortical oscillations in all frequency bands except delta. Slow delta activity did not decline its power during SD and even increased it afterwards; high-frequency gamma oscillations showed the strongest and longest depression under awake conditions. Unexpectedly, gamma power reduced not only during SD invasion the recording cortical sites but also when SD occupied distant subcortical/cortical areas. Contralateral cortex not invaded by SD also showed transient depression of gamma activity in awake animals. Introduction of general anesthesia modified the pattern of SD-induced depression: SD evoked the strongest cessation of slow delta activity, milder suppression of fast oscillations and no distant changes in gamma activity.

CONCLUSION

Slow and fast cortical oscillations differ in their vulnerability to SD influence, especially in wakefulness. In the conscious brain, SD produces stronger and spatially broader depression of fast cortical oscillations than slow ones. The frequency-specific effects of SD on cortical activity of awake brain may underlie some previously unexplained clinical features of migraine aura.

Special considerations in migraine during pregnancy and lactation

Migraine is estimated to affect 959 million people worldwide and has a female preponderance of 3:1. This is thought to be due to the influence of female hormones as before puberty both sexes are affected equally. The prevalence is highest in women of childbearing age at 24%. It is, therefore, important to have a good understanding of how pregnancy influences migraine and how to advise and manage women with migraine during pregnancy and lactation.

Retinal migraine

Retinal migraine is usually characterized by attacks of fully reversible monocular visual loss associated with migraine headache. Retinal migraine is most common in women of child-bearing age who have a history of migraine with aura. In the typical attack, monocular visual features consist of partial or complete visual loss lasting less than 1h. Although the current diagnostic criteria for retinal migraine require fully reversible visual loss, our findings suggest that irreversible visual loss is part of the retinal migraine spectrum. Nearly half of reported cases with recurrent transient monocular visual loss subsequently experienced permanent monocular visual loss.

Volumetric alteration of brainstem in female migraineurs with and without aura

BACKGROUND AND AIM

Brainstem descending modulatory circuits have been postulated to be involved in migraine. Differences in brainstem volume between migraineurs and healthy controls have been demonstrated in previous research, nevertheless, the effect of migraine aura on brainstem volume is still uncertain. The aim of this study was to investigate the brainstem volume in migraineurs and examine the effect of migraine aura on brainstem volume.

METHODS

Our study included 90 female migraine patients without white matter lesions. (29 migraine patients with aura (MwA) and 61 migraine patients without aura (MwoA) and 32 age-matched female healthy controls (HC). Using the FreeSurfer image analysis suite, the volumes of the entire brainstem and its subfields (medulla, pons, and midbrain) were measured and compared between migraine subgroups (MwA vs. MwoA) and the healthy control group. The possible effects of migraine characteristics (i.e., disease duration and migraine attack frequency) on brainstem volume were also investigated.

RESULTS

Migraineurs had greater medulla volume (MwoA 3552 ± 459 mm3, MwA 3424 ± 448 mm3) than healthy controls (3236 ± 411 mm3). Statistically, MwA vs. HC p = 0.040, MwoA vs. HC p = 0.002, MwA vs. MwoA p = 0.555. A significant positive correlation was found between disease duration and the volume of medulla in the whole migraine group (r = 0.334, p = 0.001). Neither the whole brainstem nor its subfields were significantly different in volume between migraine subgroups.

CONCLUSION

Brainstem volume changes in migraine are mainly localized to the medulla and not specific to the presence of aura.

Migraine with brainstem aura

Migraine with brainstem aura has been long described but remains poorly understood. Previously known as "basilar" or "basilar artery" migraine, it is an uncommon subtype of migraine with aura, one seen primarily in children, adolescents, and younger adults. The condition is characterized by migraine headache accompanied by several neurological symptoms conventionally assigned to dysfunction of brainstem structures. Initially felt to be vascular in origin, partly due to prevailing concepts of migraine pathophysiology at the time, most now believe the aura symptoms of migraine with brainstem aura are secondary to neural circuitry dysfunction. The differential diagnosis is reasonably broad, and most patients warrant investigation to exclude conditions bearing high degrees of morbidity and mortality. Neuroimaging, specifically brain MRI without contrast, is recommended for migraine with brainstem aura. Depending on the clinical presentation certain cases may require consideration of contrasted or vascular imaging, EEG, or lumbar puncture with cerebrospinal fluid analysis. Migraine prophylaxis should involve lifestyle adjustments and preventive medical therapies shown to be effective in clinical trials of migraine, following evidence-based guidelines. The acute pharmacological management of attacks of migraine with brainstem aura remains a matter of controversy. The prognosis is generally favorable. Future refinements in the diagnostic criteria might possibly enhance diagnostic specificity and improved clinical research.

Current Update on Categorization of Migraine Subtypes on the Basis of Genetic Variation: a Systematic Review

Migraine is a complex neurovascular disorder that is characterized by severe behavioral, sensory, visual, and/or auditory symptoms. It has been labeled as one of the ten most disabling medical illnesses in the world by the World Health Organization (Aagaard et al Sci Transl Med 6(237):237ra65, 2014). According to a recent report by the American Migraine Foundation (Shoulson et al Ann Neurol 25(3):252-9, 1989), around 148 million people in the world currently suffer from migraine. On the basis of presence of aura, migraine is classified into two major subtypes: migraine with aura (Aagaard et al Sci Transl Med 6(237):237ra65, 2014) and migraine without aura. (Aagaard K et al Sci Transl Med 6(237):237ra65, 2014) Many complex genetic mechanisms have been proposed in the pathophysiology of migraine but specific pathways associated with the different subtypes of migraine have not yet been explored. Various approaches including candidate gene association studies (CGAS) and genome-wide association studies (Fan et al Headache: J Head Face Pain 54(4):709-715, 2014). have identified the genetic markers associated with migraine and its subtypes. Several single nucleotide polymorphisms (Kaur et al Egyp J Neurol, Psychiatry Neurosurg 55(1):1-7, 2019) within genes involved in ion homeostasis, solute transport, synaptic transmission, cortical excitability, and vascular function have been associated with the disorder. Currently, the diagnosis of migraine is majorly behavioral with no focus on the genetic markers and thereby the therapeutic intervention specific to subtypes. Therefore, there is a need to explore genetic variants significantly associated with MA and MO as susceptibility markers in the diagnosis and targets for therapeutic interventions in the specific subtypes of migraine. Although the proper characterization of pathways based on different subtypes is yet to be studied, this review aims to make a first attempt to compile the information available on various genetic variants and the molecular mechanisms involved with the development of MA and MO. An attempt has also been made to suggest novel candidate genes based on their function to be explored by future research.

Headache Is a Common Aura in Patients with Generalized Seizures

Background and Purpose

Although aura in epilepsy is usually considered as a phenomenon in patients with focal seizures, headache can occur as an aura or solitary epileptic symptom in patients with generalized seizures.

Methods

We performed a 14-year retrospective study of patients with generalized seizures and analyzed the proportion and characteristics of patients with auras including headache.

Results

Among the 102 patients diagnosed with generalized seizures, aura was reported in 45 patients and headache was the most common aura in 26 patients. The age of onset of seizures was significantly lower in patients with headache as an aura than in patients without headache (14.8±3.8 vs. 24.7±16.2; p=0.003).

Conclusions

Our study showed that headache was the most common aura in patients with generalized seizures and patients with a younger age of onset of seizures were more likely to experience headache as an aura in these patients.

Expression of NF-κB-associated lncRNAs in different types of migraine

PURPOSE

NF-κB partakes in the pathophysiology of neurologic conditions. We quantified levels of NF-κB-associated genes in 119 patients with migraine versus healthy controls.

METHODS

We measured levels of NF-κB-associated genes in 42 patients with migraine compared with age- and sex-matched controls.

RESULTS

Comparison between patients without aura and controls revealed down-regulation of PACER [expression ratio (95% CI) 0.15 (0.06-0.36), P value < 0.0001]. Similar results were detected when comparing expression of PACER in patients with aura and controls [expression ratio (95% CI) 0.05 (0.02-0.12), P value < 0.0001]. Both DILC and CEBPA were over-expressed in patients with aura [expression ratio (95% CI) 4.9 (2.96-7.83), P value < 0.0001 and expression ratio (95% CI) 3.65 (2.39-5.24), P value < 0.0001, respectively] and in patients without aura compared with controls [expression ratio (95% CI) 3.6 (2.21-5.69), P value < 0.0001 and expression ratio (95% CI) 4.5 (2.53-7.11), P value < 0.0001, respectively]. ADINR was over-expressed in patients with aura [expression ratio (95% CI) 4.98 (3.09-8.33), P value < 0.0001] as well as patients without aura compared with controls [expression ratio (95% CI) 13.15 (7.41-23.58), P value < 0.0001]. Notably, ADINR levels were lower in patients with aura compared with patients without aura. When comparing ATG5 levels in patients with aura and controls, significant up-regulation was detected [expression ratio (95% CI) 4.4 (3.01-6.32), P value < 0.0001]. This pattern was also detected in patients without aura compared with controls [expression ratio (95% CI) 3.5 (2.28-5.35), P < 0.0001]. Finally, expression of DICER1-AS1 was elevated in patients with aura compared with patients without aura [expression ratio (95% CI) 2.47 (1.14-5.85), P = 0.03]. This lncRNA was under-expressed in patients without aura compared with controls [expression ratio (95% CI) 0.4 (0.21-1.31), P = 0.03]. CEBPA, ATG5 and ADINR had the best AUC values for distinguishing patients with aura from controls (AUC values = 0.91, 0.85 and 0.83, respectively). The AUC values for separation between patients without aura and controls were 0.90, 0.86 and 0.75 for CEBPA, ATG5 and ADINR, respectively.

CONCLUSION

Taken together, several genes in the NF-κB pathway has been revealed to be dysregulated in migraineurs and expression of these genes can be used as markers for this neurological condition.

Electrophysiological findings in migraine may reflect abnormal synaptic plasticity mechanisms: A narrative review

BACKGROUND

The cyclical brain disorder of sensory processing accompanying migraine phases lacks an explanatory unified theory.

METHODS

We searched Pubmed for non-invasive neurophysiological studies on migraine and related conditions using transcranial magnetic stimulation, electroencephalography, visual and somatosensory evoked potentials. We summarized the literature, reviewed methods, and proposed a unified theory for the pathophysiology of electrophysiological abnormalities underlying migraine recurrence.

RESULTS

All electrophysiological modalities have determined specific changes in brain dynamics across the different phases of the migraine cycle. Transcranial magnetic stimulation studies show unbalanced recruitment of inhibitory and excitatory circuits, more consistently in aura, which ultimately results in a substantially distorted response to neuromodulation protocols. Electroencephalography investigations highlight a steady pattern of reduced alpha and increased slow rhythms, largely located in posterior brain regions, which tends to normalize closer to the attacks. Finally, non-painful evoked potentials suggest dysfunctions in habituation mechanisms of sensory cortices that revert during ictal phases.

CONCLUSION

Electrophysiology shows dynamic and recurrent functional alterations within the brainstem-thalamus-cortex loop varies continuously and recurrently in migraineurs. Given the central role of these structures in the selection, elaboration, and learning of sensory information, these functional alterations suggest chronic, probably genetically determined dysfunctions of the synaptic short- and long-term learning mechanisms.

One-year changes in clinical and balance parameters in individuals of different subtypes of migraine

BACKGROUND

Migraine has been associated with balance dysfunction, more pronounced in patients with aura and chronic migraine. Also, it has been suggested that balance deficits are progressive through the migraineurs lifetime.

OBJECTIVE

To analyze the one-year progression of balance parameters and clinical parameters associated with balance in female patients with and without migraine.

DESIGN

Prospective cohort study.

METHODS

The participants were distributed in four groups: control (CG; n = 27) migraine with aura (MA; n = 25), migraine without aura (MwA; n = 26), and chronic migraine (CM; n = 27). They performed the Sensory Organization Test, Motor Control Test and Adaptation Test protocols of dynamic posturography tests. Questionnaires about fear of falls, dizziness disability, and kinesiophobia were administered. These assessments were performed twice: baseline and after 1-year (follow-up). No intervention was performed for balance improvement, and the participants maintained their usual migraine treatment prescribed.

RESULTS

None of the groups differed in balance tests between baseline and follow-up. We observed a reduction in migraine frequency in MA (-2.2 days, p = 0.01) and CM (-10.8 days, p < 0.001) groups, and in the migraine intensity (-2.3 points, p = 0.001) in CM group. Significant decreases in the scores of fear of falling, dizziness disability, and kinesiophobia were observed in the migraine groups (p < 0.05), but the differences did not exceed the minimal detectable change of the questionaries scores.

CONCLUSION

Women with different migraine subtypes did not present balance changes in a one-year interval. The improvements in migraine's clinical features were not accompanied by improvements in balance parameters.

Balance disorders and migraine

BACKGROUND

Migraine is associated with motion sensitivity symptoms such as kinetosis, vestibular symptoms and balance alterations. While focus is given to headache management, addressing these symptoms is often neglected, although they are related to additional migraine burden and increased disability.

PURPOSE

Our aim is to disseminate the current understanding of the motion sensitivity symptoms among patients with migraine, with focus on balance impairments. We discuss the susceptibility of migraine to motion sensitivity, its suggested mechanisms, the balance alterations during quiet standing, mobility tasks and reactions to external perturbations. The role of migraine subdiagnosis, implications for clinical practice and future perspectives are also acknowledged.

IMPLICATIONS

Balance disorders are one of the signs reflecting a broader and complex spectrum of motion sensitivity, which are present even between attacks. Migraineurs are especially inherent to these symptoms probably due to brain hyperexcitability and to shared pathophysiological mechanisms. Patients, especially with aura and chronic migraine, exhibit balance instability during quiet standing under different surface and visual input conditions. Migraineurs demonstrated reduced limits of stability and lower performance on walk, transposing obstacles and sit to stand tasks. Only patients with aura present impairment of motor control reactions following external perturbations. Balance alterations are associated with falls and are influenced by aura, migraine frequency and psychosocial aspects, but not by vestibular symptoms or vestibular migraine diagnosis. There is a high demand for high quality of evidence regarding the assessment and care of motion sensitivity symptoms in migraineurs, considering approaches to manage not just the pain, but its associated symptoms.

Levcromakalim provokes an acute rapid-onset migraine-like phenotype without inducing cortical spreading depolarization

BACKGROUND

Migraine headache attacks and accompanying sensory augmentation can be induced by several agents including levcromakalim (LVC), that is also capable of provoking aura-like symptoms in migraineurs. We investigated whether single LVC injection causes acute migraine-like phenotype in rats and induces/modulates cortical spreading depolarization (CSD), a rodent model of migraine aura.

METHODS

Wistar rats were administered LVC (1 mg/kg, i.p.) and compared to control (CTRL, vehicle, i.p.) and nitroglycerin (NTG, 10 mg/kg, i.p.) groups. Von Frey filaments were used to examine the periorbital and hind paw mechanical allodynia. Dark-light box (DLB), elevated plus maze (EPM), and open field arena (OFA) were used to evaluate light sensitivity and anxiety-related behaviors. The effects of LVC on CSD parameters, somatosensory evoked potentials, and baseline dural EEG (electroencephalography) were investigated. Possible CSD-induced c-fos expression was studied with Western Blot. Blood-brain barrier integrity in cortex was examined with Evans blue assay.

RESULTS

LVC and NTG administration robustly reduced periorbital mechanical thresholds in rats and induced anxiety-like behaviors and photophobia within 30 and 120 min, respectively. LVC induced migraine-like phenotype recovered in 2 h while NTG group did not fully recover before 4 h. Both LVC and NTG did not provoke DC (direct current) shift, EEG alterations or cortical c-fos expression characteristic to CSD. LVC did not induce de novo CSD and affect KCl (potassium chloride)-induced CSD parameters except for an increase in propagation failure. However, NTG significantly increased both CSD susceptibility and propagation failure. Somatosensory evoked potential (SSEP) configurations were not altered in both LVC and NTG groups, but SSEP latencies were prolonged after CSD. Acute LVC or NTG injection did not increase cortical BBB permeability.

CONCLUSIONS

Single LVC administration induced the fastest manifestation and recovery of acute migraine-like phenotype which was not mediated by CSD waves in the cerebral cortex. We suppose LVC triggered rapid-onset migraine-like symptoms are probably related to functional alterations in the trigeminal nociceptive system and K⁺ channel opening properties of LVC. Understanding the neurobiological mechanisms of this nociceptive window, may provide a novel target in migraine treatment.

Estrogen modulation of cortical spreading depression

BACKGROUND AND AIMS

Cortical spreading depression (CSD), a transient neuronal and glial depolarization that propagates slowly across the cerebral cortex, is the putative electrophysiological event underlying migraine aura and a headache trigger. Migraine is three times more prevalent in women than men, linked to circulating female hormones. High estrogen levels or estrogen withdrawal may be a migraine trigger for many women. We, therefore, aimed to examine whether sex, gonadectomy, and female hormone supplementation and withdrawal affect the susceptibility to CSD.

METHODS

To determine CSD susceptibility, we recorded the frequency of CSDs triggered during 2-h topical KCl application in intact or gonadectomized female and male rats, without or with estradiol or progesterone supplementation via daily intraperitoneal injections. Estrogen or progesterone treatment followed by withdrawal was studied in a separate cohort. To take the first step towards identifying potential mechanisms, we studied glutamate and GABA_A receptor binding using autoradiography.

RESULTS

The CSD frequency in intact female rats was higher than intact male and ovariectomized rats. We did not detect a change in CSD frequency during different stages of the estrous cycle in intact females. Daily estrogen injections for three weeks did not change CSD frequency. However, one-week estrogen withdrawal after two weeks of treatment significantly increased CSD frequency compared with the vehicle group in gonadectomized females. The same protocol of estrogen treatment and withdrawal was ineffective in gonadectomized males. In contrast to estrogen, daily progesterone injections for three weeks elevated CSD susceptibility, and one-week withdrawal after two weeks of treatment partially normalized this effect. Autoradiography did not reveal significant changes in glutamate or GABA_A receptor binding density after estrogen treatment and withdrawal.

CONCLUSIONS

These data suggest that females are more susceptible to CSD, and sexual dimorphism is abrogated by gonadectomy. Moreover, estrogen withdrawal after prolonged daily treatment enhances CSD susceptibility. These findings may have implications for estrogen-withdrawal migraine, although the latter tends to be without aura.

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.

Microvascular involvement in migraine: an optical coherence tomography angiography study

OBJECTIVE

The aim of this study was to evaluate the microvasculature of the macula and the optic nerve in patients affected by migraine with aura (MA) and without aura (MO) by optical coherence tomography angiography (OCTA), comparing the findings with healthy controls (HC).

METHODS

We collected data from ocular and orthotic examinations, including eye motility, intraocular pressure measurement, best-corrected visual acuity (BCVA) measurement, objective refraction measurement, fundus examination, macular and optic disk OCTA examination. All subjects were imaged with solix fullrange OCT. The following OCTA parameters were recorded: macular vessel density (VD), inside disc VD, peripapillary VD, disc whole image VD, fovea choriocapillaris VD, fovea VD, parafovea VD, peripapillary thickness, fovea thickness, parafovea thickness, macular full retinal thickness, and foveal avascular zone (FAZ) parameters. Clinical and demographical data about migraine patients were collected by a neurologist.

RESULTS

We included 56 eyes from 28 patients with a diagnosis of MO, 32 eyes from 16 patients with a diagnosis of MA, and 32 eyes from 16 HC subjects. The FAZ area was 0.230 ± 0.099 mm² in the MO group, 0.248 ± 0.091 mm² in the MA group and 0.184 ± 0.061 mm² in the control group. The FAZ area was significantly larger in the MA group than in the HC group (p = 0.007). The foveal choriocapillaris VD was significantly lower in MA patients (63.6 ± 2.49%) when compared with MO patients (65.27 ± 3.29%) (p = 0.02).

CONCLUSION

An impairment of retinal microcirculation can be detected in patients with MA, as demonstrated by the enlargement of FAZ. Moreover, the study of choroid circulation may reveal microvascular damage in patients with migraine with aura. OCTA is a useful non-invasive screening tool for the detection of microcirculatory disturbance in patients with migraine.

Migraine symptoms, healthcare resources utilization and disease burden in a large Polish migraine cohort : Results from 'Migraine in Poland'-a nationwide cross-sectional survey

BACKGROUND

The Migraine in Poland study is the first large scale nationwide cross-sectional online survey of symptoms, approaches to management, treatment patterns, quality of life, and sociodemographic characteristics of the Polish migraine patients' cohort, conducted from August 2021 to June 2022.

METHODS

A cross-sectional online survey was designed based on the American Migraine Prevalence and Prevention (AMPP) Study. Participants were recruited through broad advertisement through various channels. The survey included questions allowing for the diagnosis of migraine without aura (MwoA) based on the third edition of the International Classification of Headache Disorders (ICHD-3). Moreover, the questionnaire assessed sociodemographic and headache features, comorbidities, consultation rates with medical professionals, as well as the use of abortive or preventive treatment, including non-pharmacological methods, psychological symptoms and the burden of migraine.

RESULTS

A structured online questionnaire was submitted by 3225 respondents aged 13 to 80 (mean age 38.9, 87.1% women). In this group 1679 (52.7%) of participants fulfilled ICHD-3 diagnostic criteria for MwoA, which was in most cases (88.3%) confirmed by a medical professional in the past. In this group the average number of monthly headache days was 4.7, while 47.8% of participants had at least 4 migraine days per month. Mean Migraine Disability Assessment score was 42.65 (median 32). Among MwoA respondents, 1571 (93.6%) had consulted their headache with a medical professional in the past - mostly neurologists (n = 1450 (83.4%) and primary care physicians (n = 1393 (82.9%). In the MwoA cohort, 1553 (92.5%) of participants declared the current use of some form of treatment, although only 193 (11.5%) respondents were currently on preventive medications. The most prevalent comorbidities included: chronic rhinitis (37.1%), allergies (35.9%) and low blood pressure (26.9%). Anxiety (20.4%) and depression (21.3%) were highly prevalent among participants.

CONCLUSIONS

People with migraine in Poland face similar difficulties as their peers in other countries. Despite relatively high access to neurologist consultations and good diagnosis accuracy, migraine still poses diagnostic and therapeutic difficulties. In this context, migraine undertreatment in Polish population must be underlined, especially in context of high disease burden.

The Association between Migraine and Fetal-Type Posterior Cerebral Artery in Patients with Ischemic Stroke

OBJECTIVE

The aim of the study was to determine if migraine is associated with fetal-type posterior cerebral artery (PCA) in patients with ischemic stroke.

METHOD

In this cross-sectional study, patients with acute ischemic stroke were enrolled from two hospitals. The history of migraine headache was evaluated during a face-to-face interview. The variants of fetal-type PCA were assessed with MRA, CTA, or DSA. Patients with and without migraine were compared in terms of fetal-type PCA status and other clinic characteristics. Multivariate logistic regression analyses were performed to adjust for confounders and provide risk estimates for observed associations.

RESULT

In 750 patients qualified for analysis, 85 (11.3%) were determined with migraine. Patients with migraine had a higher proportion of female gender (51.8% vs. 31.0%, p < 0.001), hypertension (72.9% vs. 57.7%, p = 0.007), and fetal-type PCA (36.5% vs. 20.1%, p = 0.001), while lower proportion of current smoking (25.9% vs. 38.3%, p = 0.025) than patients without migraine. National Institutes of Health Stroke Scale (NIHSS) score (3 vs. 2, p = 0.016) was also higher in migraineurs than in non-migraineurs. After adjustment for confounders, fetal-type PCA status was independently associated with migraine (odds ratio [OR] = 2.06; 95% confidence interval [CI], 1.25-3.38; p = 0.005). Other factors associated to migraine included female gender (OR = 2.03; 95% CI, 1.13-3.62; p = 0.017), hypertension (OR = 1.97; 95% CI, 1.17-3.34; p = 0.011), and NIHSS score (OR = 1.08; 95% CI, 1.01-1.16; p = 0.018).

CONCLUSION

Migraine was associated with fetal-type PCA in patients with ischemic stroke. This finding supported the hypothesis that vascular mechanisms get involved in the migraine-stroke association.

Clinical significance of asymmetric hypointense signals in minimum intensity projections of brain magnetic resonance imaging in children with primary headache

PURPOSE

This study aimed to observe the changes of venous continuity using the susceptibility weighted imaging-minimum intensity projection (SWI-MinIP) images in children with primary headache.

METHODS

The headache types were classified following the International Headache Society's diagnostic criteria. Patients with secondary headaches were excluded. The presence of asymmetric vasculature in SWI-MinIP images was visually assessed. Moreover, the relationship between headache patterns and asymmetric hypointense signals was analyzed.

RESULTS

In this single-center, retrospective study from 2016 to 2020, among 251 cases of primary headache (male/female, 108/143; mean age, 11.4 ± 4.0 years), 137 (54.6%), 75 (29.9%), and 39 (15.5%) patients had migraine, tension-type headache, and other primary headaches, respectively. On SWI-MinIP images, 14 (5.6%) patients showed an asymmetric venous pattern. All patients with SWI-MinIP asymmetry were included in the migraine group, accounting for 10.2% of patients with migraine. Five (35.7%) and nine (64.3%) patients were included in the aura and non-aura groups, respectively, without a significant difference in the frequency of asymmetric hypointense signals between the two groups (p = 0.325). All 14 patients with asymmetric hypervascularity had brain MRI within 12 h of headache onset. Ten (71.4%) of the 14 patients showed consistency between the laterality of headache and the hemisphere of predominant vascularity in SWI-MinIP.

CONCLUSION

Patients with migraine had increased cerebral venous perfusion in the most involved region of the headache on the SWI-MinIP view on a 3.0 T scanner, which can be used as a qualitative indicator with low sensitivity and high specificity for the diagnosis of primary headache in the acute phase (< 12 h).

Stereoelectroencephalography-based research on the value of drug-resistant temporal lobe epilepsy auras: A retrospective single-center study

PURPOSE

To explore the localization value of drug-resistant temporal lobe epilepsy (TLE) aura for preoperative evaluation, based on stereoelectroencephalography (SEEG), and its prognostic value on the surgical outcome.

METHODS

The data of patients with drug-resistant TLE who had SEEG electrodes implanted during preoperative evaluation at the First Affiliated Hospital of the University of Science and Technology of China (Hefei, China) were retrospectively analyzed. The patients were divided into aura-positive and aura-negative groups according to the presence of aura in seizures. To explore the clinical features of aura, we evaluated the localizing and prognostic values of aura for the outcome of anterior temporal lobectomy based on SEEG.

RESULTS

Among forty patients, twenty-seven patients were in the aura-positive group and ten (25.0%) patients had multiple auras. The most common TLE aura was abdominal aura [thirteen (34.2%) patients]. The postoperative seizure frequency was significantly reduced in the preoperative aura-positive patients compared to the preoperative aura-negative patients (P = 0.011). Patients with abdominal (P = 0.029) and single (P = 0.036) auras had better surgical prognoses than aura-negative patients. In the preoperative evaluation, aura-positive patients had a better surgical outcome if the laterality of positron emission tomography-computed tomography (PET-CT) hypometabolism was concordant with the epileptogenic focus identified with SEEG (P = 0.031). A good postoperative epileptic outcome in aura-positive patients was observed among those with hippocampal sclerotic medial temporal lobe epilepsy (P = 0.025).

CONCLUSION

Epileptic aura is valuable for the localization of the epileptogenic focus. Abdominal aura and single aura were good predictors of better surgical outcomes. Among patients with a preoperative diagnosis of hippocampal sclerosis or with laterality of PET-CT hypometabolism concordant with the epileptogenic focus identified using SEEG, those with aura are likely to benefit from surgery.

Epileptic Prodromes: Insights from Surveying 196 Patients and 150 Caregivers

OBJECTIVE

Uncontrolled epilepsy creates a constant source of worry for patients and puts them at a high risk of injury. Identifying recurrent "premonitory" symptoms of seizures and using them to recalibrate seizure prediction algorithms may improve prediction performances. This study aimed to investigate patients' ability to predict oncoming seizures based on preictal symptoms.

METHODS

Through an online survey, demographics and clinical characteristics (e.g., seizure frequency, epilepsy duration, and postictal symptom duration) were collected from people with epilepsy and caregivers across Canada. Respondents were asked to answer questions regarding their ability to predict seizures through warning symptoms. A total of 196 patients and 150 caregivers were included and were separated into three groups: those who reported warning symptoms within the 5 minutes preceding a seizure, prodromes (symptoms earlier than 5 minutes before seizure), and no warning symptoms.

RESULTS

Overall, 12.2% of patients and 12.0% of caregivers reported predictive prodromes ranging from 5 minutes to more than 24 hours before the seizures (median of 2 hours). The most common were dizziness/vertigo (28%), mood changes (26%), and cognitive changes (21%). Statistical testing showed that respondents who reported prodromes also reported significantly longer postictal recovery periods compared to those who did not report predictive prodromes (P < 0.05).

CONCLUSION

Findings suggest that patients who present predictive seizure prodromes may be characterized by longer patient-reported postictal recovery periods. Studying the correlation between seizure severity and predictability and investigating the electrical activity underlying prodromes may improve our understanding of preictal mechanisms and ability to predict seizures.

Choroidal thickness in eyes of migraine patients measured using spectral domain-optical coherence tomography: A meta-analysis

Recent developments in high-resolution optical coherence tomography allow evaluation of even the slightest changes of choroidal thickness in various disorders, including migraine. In this review, we analyze the choroidal thickness measurements reported in various studies that compare results between migraineurs and healthy individuals. We searched PubMed, Scopus, and EMBASE to identify relevant literature reporting choroidal thickness in the migraineurs' different macular regions compared with healthy controls. A fixed-effects or random-effects model was applied for the meta-analysis based on the heterogeneity level. Moreover, subgroup analyses, meta-regression, publication bias, and quality assessment were also performed. We identified ten studies involving 580 migraineurs (173 with aura, 128 without aura, and 279 without specification for the presence of aura) and 407 healthy controls to be included in this meta-analysis. Results indicated that average choroidal thickness was significantly decreased in the migraine cases (SMD, -1.28; 95% CI, -2.47 to -0.08; P = 0.04) compared to healthy individuals. Furthermore, both with aura (SMD, -1.16; 95% CI, -1.39 to -0.92; P < 0.0001) and without aura migraine patients (SMD, -0.81; 95% CI, -1.28 to -0.34; P < 0.001) had significantly thinner subfoveal choroid compared to healthy controls. Moreover, subfoveal choroidal thickness in the migraineurs with aura was significantly lower than those without aura (SMD, -0.45; 95% CI, -0.84 to -0.05; P = 0.03). The alterations in choroidal thickness, suggestive of migraine's neurovascular pathophysiology, were tentatively confirmed by this study's findings. Further longitudinal studies with more diverse settings are required to derive more definitive conclusions.

History of migraine

Migraine symptoms were described in ancient Babylonia, and supernatural forces were felt to play a role in etiology and treatment. This changed in the Greco-Roman period, when the (dis)balance of humors was considered in (patho)physiology and treatment based on this. Aretaeus distinguished between cephalalgia, cephalea, and heterocrania. The latter term was changed to hemicrania by Galen. Physicians in the 17th century attributed headache to the meninges, extracranial periost, and cranial blood vessels. As for the pathophysiology, Willis suggested intracranial vasoconstriction with subsequent dilatation. Tissot and Fothergill gave comprehensive descriptions of migraine, including visual symptoms. Symptomatic and idiopathic hemicrania were distinguished in the early 19th century. Vasomotor pathophysiology was scientifically studied in the 1860s, leading to sympathicotonic and angioparalytic theories. Latham combined them, stating the latter follows the first. Ergot was introduced in 1868; ergotamine was isolated in 1918. This led to the vasodilatation theory of migraine (Wolff), the discovery of 5-HT, and later the specific agonists. Aura and cortical spreading depression were studied in the early 1940s and related to spreading oligemia in the 1980s. Subsequently, hyperemia followed by oligemia after CSD was found. After the discovery of CGRP, a new a class of drugs became the subject of clinical studies.

Fake cells and the aura of life: A philosophical diagnostic of synthetic life

Synthetic biology is often seen as the engineering turn in biology. Philosophically speaking, entities created by synthetic biology, from synthetic cells to xenobots, challenge the ontological divide between the organic and inorganic, as well as between the natural and the artificial. Entities such as synthetic cells can be seen as hybrid or transitory objects, or neo-things. However, what has remained philosophically underexplored so far is the impact these hybrid neo-things will have on (our phenomenological experience of) the living world. By extrapolating from Walter Benjamin's account of how technological reproducibility affects the aura of art, we embark upon an exploratory inquiry that seeks to fathom how the technological reproducibility of life itself may influence our experience and understanding of the living. We conclude that, much as technologies that enabled reproduction corroded the aura of original artworks (as Benjamin argued), so too will the aura of life be under siege in the era of synthetic lifeforms. This article zooms in on a specific case study, namely the research project Building a Synthetic Cell (BaSyC) and its mission to create a synthetic cell-like entity, as autonomous as possible, focusing on the properties that differentiate organic from synthetic cells.

Galcanezumab Effects on Migraine Severity and Symptoms in Japanese Patients with Episodic Migraine: Secondary Analysis of a Phase 2 Randomized Trial

INTRODUCTION

Galcanezumab, a humanized monoclonal antibody against calcitonin gene-related peptide, is a preventive migraine treatment. In global, randomized, placebo-controlled trials, galcanezumab reduced migraine headache severity and the frequency of migraine headaches associated with nausea and/or vomiting, photophobia and phonophobia, prodromal symptoms, or aura. We report secondary analyses from a Japanese phase 2 trial that assessed the effect of galcanezumab on migraine headache severity, frequency of migraine-associated symptoms, and frequency of migraine headaches during menstrual periods in Japanese patients with episodic migraine.

METHODS

Adults with migraine (International Classification of Headache Disorders, 3rd edition; 4-14 migraine headache days/month) were randomized (2:1:1) to a monthly placebo (n = 230), 120 mg galcanezumab (240 mg loading dose; n = 115), or 240 mg galcanezumab (n = 114) for 6 months (double-blind). Patients recorded migraine headache days, severity, and symptoms in an electronic diary. Changes from baseline were analyzed (mixed model for repeated measures).

RESULTS

Both galcanezumab doses significantly reduced the number of monthly moderate-to-severe and severe migraine headache days compared with placebo, overall (difference in least-squares mean change from baseline, 120 mg/240 mg versus placebo: moderate-to-severe, -1.9/-1.8 days; severe: -0.4/-0.4 days) and in each month; mean severity score was significantly reduced in the 240 mg group. Both galcanezumab doses significantly reduced the number of migraine headache days with nausea/vomiting (-1.1/-1.0 days), photophobia/phonophobia (-2.3/-1.7 days), prodromal symptoms (-0.7/-0.8 days), and aura (-0.7/-0.7 days). In most cases, the proportion of migraine headache days with these symptoms was reduced by galcanezumab. Both galcanezumab doses reduced the number of migraine headache days occurring during menstrual periods (n = 269; -0.8/-0.9 days).

CONCLUSION

Once-monthly galcanezumab significantly reduced the frequency of migraine headache days with moderate-to-severe or severe headache, migraine headache days with migraine-associated symptoms, and migraine headache days during menstrual periods in Japanese patients with episodic migraine, consistent with results from global studies.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT02959177).

E. H. Sieveking and his cephalalgia epileptica

Edward Henry Sieveking (1816-1904) was a professionally successful and well respected nineteenth-century London physician who, over the span of some half a century, continuously held appointment to British royalty, including Queen Victoria and King Edward VII. In 1858, he published a monograph On Epilepsy and Epileptiform Seizures, with a second edition in 1861. In both editions, he described an entity cephalalgia epileptica that comprised the occurrence of headache in association with phenomena that resembled the premonitory symptom of some epileptic seizures. However, the sufferers did not have epilepsy, in that they did not experience generalized convulsions. Sieveking, like most of his British contemporaries, had little awareness of the existence of the variety of migraine phenomena apart from headache itself. In retrospect, it seems likely that migraine with aura probably was the main basis of the disorder Sieveking designated, one that later may have been termed migralepsy.

Non-aura visual disturbance with high visual aura rating scale scores has stronger association with migraine chronification than typical aura

OBJECTIVES

To investigate the clinical correlates of visual symptoms in patients with migraine.

METHOD

Patients with migraine that attended our headache clinics were enrolled. Headache profiles, disability, and comorbidities were acquired with structured questionnaires. A semi-structured visual phenomenon questionnaire was also used to assess the characteristics of visual symptoms, including visual aura in patients with migraine with aura and transient visual disturbance in patients with migraine without aura. Headache specialists interviewed with the participants for the ascertainment of diagnosis and verification of the questionnaires.

RESULT

Migraine with aura patients with visual aura (n = 743, female/male = 2.3, mean age: 34.7 ± 12.2 years) and migraine without aura patients with non-aura transient visual disturbance (n = 1,808, female/male = 4.4, mean age: 39.4 ± 12.6 years) were enrolled. Patients with transient visual disturbance had higher headache-related disability and more psychiatric comorbidities. Chronic migraine was more common in migraine without aura than migraine with aura patients (41.9% vs. 11.8%, OR = 5.48 [95% CI: 4.33-7.02], p < 0.001). The associations remained after adjusting confounding factors.

CONCLUSION

Presence of non-aura transient visual disturbance may suggest a higher migraine-related disability and is linked to higher risk of chronic migraine than typical migraine aura in migraine patients. Further studies are needed to elucidate the potential mechanism.

Visual stimulation and frequency of focal neurological symptoms engage distinctive neurocognitive resources in migraine with aura patients: a study of resting-state functional networks

Introduction

Several functional neuroimaging studies on healthy controls and patients with migraine with aura have shown that the activation of functional networks during visual stimulation is not restricted to the striate system, but also includes several extrastriate networks.

Methods

Before and after 4 min of visual stimulation with a checkerboard pattern, we collected functional MRI in 21 migraine with aura (MwA) patients and 18 healthy subjects (HS). For each recording session, we identified independent resting-state networks in each group and correlated network connection strength changes with clinical disease features.

Results

Before visual stimulation, we found reduced connectivity between the default mode network and the left dorsal attention system (DAS) in MwA patients compared to HS. In HS, visual stimulation increases functional connectivity between the independent components of the bilateral DAS and the executive control network (ECN). In MwA, visual stimulation significantly improved functional connectivity between the independent component pairs salience network and DAS, and between DAS and ECN. The ECN Z-scores after visual stimulation were negatively related to the monthly frequency of aura.

Conclusions

In individuals with MwA, 4 min of visual stimulation had stronger cognitive impact than in healthy people. A higher frequency of aura may lead to a diminished ability to obtain cognitive resources to cope with transitory but important events like aura-related focal neurological symptoms.

Mental disorders as an indication for surgical treatment of drug-resistant temporal lobe epilepsy

This study recruited 82 patients with temporal lobe epilepsy (TLE): 41 men and 41 women, who underwent an open epilepsy surgery to remove the epileptic focus from 1963 to 1970. The patients before surgery were divided into two groups: group I included 49 patients with minor mental disorders and group II included 33 patients with major mental disorders. Features of mental disorders in patients with monotemporal lobe epilepsy were identified. The significance of mental disorders for topical diagnosis of the epileptic focus has been emphasized. The course of mental disorders in patients with TLE after open surgery for epileptic focus removal was carefully monitored. The role of mental disorders as an indication for surgical treatment of TLE has been shown. The patients were followed up for 14±6years.

Myocardial infarction, stroke and cardiovascular mortality among migraine patients: a systematic review and meta-analysis

BACKGROUND

An increasing number of studies have shown an association between migraine and cardiovascular disease, in particular cardio- and cerebro-vascular events.

METHODS

Three electronic databases (PubMed, Embase and Scopus) were searched from inception to May 22, 2021 for prospective cohort studies evaluating the risk of myocardial infarction, stroke and cardiovascular mortality in migraine patients. A random effects meta-analysis model was used to summarize the included studies.

RESULTS

A total of 18 prospective cohort studies were included consisting of 370,050 migraine patients and 1,387,539 controls. Migraine was associated with myocardial infarction (hazard ratio, 1.36; 95% CI, 1.23-1.51; p =  < 0.001), unspecified stroke (hazard ratio, 1.30; 95% CI, 1.07-1.60; p = 0.01), ischemic stroke (hazard ratio, 1.35; 95% CI, 1.03-1.78; p = 0.03) and hemorrhagic stroke (hazard ratio, 1.43; 95% CI, 1.07-1.92; p = 0.02). Subgroup analysis of migraine with aura found a further increase in risk of myocardial infarction and both ischemic and hemorrhagic stroke, as well as improved substantial statistical heterogeneity. Migraine with aura was also associated with an increased risk of cardiovascular mortality (hazard ratio, 1.27; 95% CI, 1.14-1.42; p =  < 0.001).

CONCLUSION

Migraine, especially migraine with aura, is associated with myocardial infarction and stroke. Migraine with aura increases the risk of overall cardiovascular mortality.

A comparative study on the effectiveness of topiramate and propranolol in patients with migraine with aura

Background: Migraine is considered as one of the most common and disabling diseases of the nervous system that has a great impact on quality of life (QOL) and a little risk of neurologic complications such as stroke. Migraine aura is known to be the result of cortical spreading depression and is associated with higher risk of this complication. Thus, the present study was conducted with the aim to compare the effects of topiramate as an antiepileptic, and propranolol in patients with migraine with aura. Methods: The present randomized clinical trial was conducted on patients with migraine with aura referred to the neurology clinic of Golestan Hospital, Ahvaz, Iran, in the period of 2019-2020. The patients were randomized into two groups and received either topiramate or propranolol. The Migraine Disability Assessment Scale (MIDAS) score was evaluated before and at the end of three months after initiating the treatment. Results: Reduction in the MIDAS score in patients taking topiramate (-16.94) was greater than that in the propranolol group (-14.5), but this difference was not statistically significant (P > 0.005). No significant relationship was found between gender and changes in the MIDAS score after the treatment of both groups (P > 0.050). However, the changes in the MIDAS score were greater in younger patients, and this relationship was statistically significant (P < 0.050). Conclusion: There was no significant difference in the efficacy of topiramate and propranolol in patients with migraine with aura. No significant relationship was found between gender and changes in the MIDAS score after the treatment in both groups, but the reduction in the MIDAS scores was significantly higher in younger patients of both groups.

Olfactory acuity based on Brief Smell Identification Test (BSITⓇ) in migraine patients with and without aura: A cross-sectional, controlled study

OBJECTIVE

The aim of this study was to evaluate olfactory acuity in migraine patients with and without aura (MwA and MwoA) MATERIAL AND METHODS: The study included 30 MwA patients, 30 MwoA patients, and 30 age- and gender-matched controls. Demographic features and odor-related symptoms (osmophobia, odor offensiveness, and odor-triggered attack status) were noted. Olfactory acuity was measured using the Brief Smell Identification Test (BSIT®), a 12-item derivative of the University of Pennsylvania Smell Identification Test (UPSIT®). BSIT® scores were compared between the migraine patients and controls.

RESULTS

The mean BSIT® score did not differ significantly between the MwA patients (8.7 ± 0.9) and MwoA (9.17 ± 0.9) patients (P = 0.094); however, the mean score in the control group was higher (10.4 ± 0.6) than in the MwA and MwoA patients (P < 0.001). The mean BSIT® score did not differ significantly between patients with and without odor-triggered migraine attacks (9 ± 0.9 and 8.8 ± 0.8, respectively) (P = 0.4). Osmophobia and odor-triggered attacks were more common in the MwA patients than in the MwoA patients (odor-triggered attacks: 66% vs. 40% [P = 0.04]; osmophobia: 76.6% vs. 60% [P = 0.16]) CONCLUSION: Olfactory acuity is lower during attack-free periods in migraine patients, as compared to controls. Migraine aura status does not affect olfactory acuity. Odor-triggered attacks, osmophobia, and offensive odors between attacks were more common in the MwA patients than in the MwoA patients.

Atypical Perfusion Manifestation in Migraine with Aura

Migraine with aura may be confused with a stroke. Magnetic resonance imaging is an important tool for the differential diagnosis. Cerebral hypoperfusion has been described in classic migraine, mainly during the aura. A 47-year-old male had an unremarkable past medical history. After sneezing, he developed a left hemi hypoesthesia, bitemporal vision loss, photopsia, and some distortion in the position of letters and words. This lasted <1 h, and it was followed by a severe headache. A magnetic resonance angiography was performed during the headache. It showed a left hemispheric hypoperfusion that did not correlate with the symptoms described by the patient. It is believed that during the aura, cerebral blood flow decreases, leading to hypoxia and decreased cellular energy generation, and these metabolic alterations define the symptoms of the patient. In our case, we documented brain hypoperfusion during the headache in the ipsilateral brain hemisphere to the symptoms, which has no clinical correlation. This condition could be due to spasm in the capillary arteries, and it may persist and influence the clinical manifestations during the headache phase in migraine with aura. A state of generalized cerebral hyperperfusion has been suggested, and there may be a coexistence of both phenomena for some period. This may open a new line of research regarding the pathophysiology and vascular changes of migraine with aura.

Interictal Cognitive Deficits in Migraine Sufferers: A Meta-Analysis

While a significant proportion of the population suffer from migraine, the existing research literature does not provide a clear indication as to whether migraineurs experience objective cognitive deficits outside of acute migraine attacks. This meta-analysis was conducted to investigate which cognitive domains if any were affected by migraine, by synthesising the existing research quantitatively. The meta-analysis was prospectively registered with the PROSPERO International prospective register of systematic reviews (registration no.: CRD42019134138). A search of the electronic databases PubMed, Ovid MEDLINE, and PsycINFO was conducted for journal articles published between January 1980 and January 2020. Seventeen studies met the inclusion criteria, allowing for the calculation of pooled effect sizes between migraineurs (with and without aura) and healthy controls in the several cognitive domains. During the interictal period, migraineurs demonstrated a moderate, negative effect on complex attention immediate and delayed memory, spatial cognition, and executive functioning. This effect was not attributable to migraine history, attack frequency, or participant age. However, the lack of performance validity testing, and limited data on mood symptomatology and migraine medication use in the included studies may be confounds potentially overestimating the magnitude of effect. Comparison with a clinical control group, which may have accounted for some these extraneous variables, was unable to be conducted. Recommendations for comprehensive future neuropsychological research are provided.

Migraine with aura

Around 15% to one-third of migraineurs experience aura. Aura is a fully reversible focal neurological phenomenon involving visual, sensory, speech, and/or motor symptoms that develops gradually and usually precedes the headache phase. The pivotal role of cortical spreading depression (CSD) as a mechanism underlying aura has been widely supported by a large body of studies. The diagnosis is based on the International Headache Classification Disorders III edition criteria. Aura is characterized by gradual development, duration of each symptom no longer than one hour, a mix of positive and negative features, and complete reversibility. Visual aura is the most common type of aura, occurring in over 90% of patients. When aura symptoms are multiple, they usually follow one another in succession, beginning with visual, then sensory, then aphasic; but the reverse and other orders have been noted. The accepted duration for most aura symptoms is one hour, but motor symptoms, which are rare, are often longer lasting. When a patient experiences for the first time a possible aura phase it's sometimes difficult to know if there was gradual or brutal onset of the symptoms. If the patient has no visual aura symptoms or simultaneous neurological symptoms, or presents neurological symptoms corresponding to a cerebral vascular territory, emergency exploration of a possible transient ischemic attack is necessary. Long duration (greater than one hour) of what may or may not be an aura phase, late onset of aura, or a dramatic increase in aura attacks should also be explored. The relative risk of ischemic stroke is significantly increased in migraine with aura. Combined hormonal contraception with estrogens significantly increases the risk of stroke in women with migraine with aura. It is recommended to start non-steroidal anti-inflammatory drugs (NSAIDs) or aspirin as soon as possible during the aura phase, not to treat the aura, but to avoid or to diminish the headache phase. In case of failure of NSAIDs or aspirin it is recommended to use a triptan when the headache begins. The prophylactic treatments for migraine with aura are those used in migraine without aura based on very few randomized clinical trials specifically dedicated to migraine with aura.

Evaluation of migraine patients with optical coherence tomography angiography

PURPOSE

To compare optical coherence tomography angiography (OCTA) findings in cases with migraine and healthy controls.

METHODS

Thirty-eight eyes of 19 patients with migraine with aura and 38 eyes of 19 healthy subjects were enrolled in this prospective and comparative study. All patients and healthy controls were evaluated with OCTA (Triton, Topcon®, Tokyo, Japan). Central macular thickness (CMT), optic disc parameters (such as retinal nerve fibre layer [RNFL] thickness and rim and disc areas), foveal avascular zone (FAZ) and parafoveal superficial vessel density (VD) measurements were analysed.

RESULTS

The optic disc rim area was significantly larger in the migraine group compared to the control group (p = 0.009). In OCTA measurements, the FAZ area was significantly larger in migraine patients (p = 0.001). The parafoveal superficial VD measurements were found to be lower in the migraine patients in all quadrants, but not statistically significant. Weak negative correlations were found between superior parafoveal VD and disease duration in migraine patients.

CONCLUSION

Migraine with aura was associated with optic disc rim changes, but without any remarkable foveal vascular decrements. It is possible for migraine to cause structural changes due to its chronic nature.

Genetics of migraine

Migraine is a complex brain disorder explained by the interaction of genetic and environmental factors. In monogenic migraines, including familial hemiplegic migraine and migraine with aura associated with hereditary small-vessel disorders, the identified genes encode proteins expressed in neurons, astrocytes or vessels, which all increase the susceptibility to cortical spreading depression. Study of monogenic migraines showed that the neurovascular unit plays a prominent role in migraine. Genome-wide association studies have identified multiple susceptibility variants that only cause a small increase of the global migraine risk. The variants belong to several complex networks of "pro-migraine" molecular abnormalities, which are mainly neuronal or vascular. Genetics has also underscored the importance of genetic factors shared between migraine and its major co-morbidities including depression and high blood pressure. Further studies are still needed to map all of the susceptibility loci for migraine and then to understand how these genomic variants lead to migraine cell phenotypes. Thanks to the advent of new technologies such as induced pluripotent stem cells, genetic data will hopefully finally be able to lead to therapeutic progress.

Shorter visual aura characterizes young and middle-aged stroke patients with migraine with aura

OBJECTIVE

To identify the clinical profile and aura characteristics of patients with Migraine with Aura (MwA) having acute cerebral ischemia, we compared stroke phenotype and risk factors in stroke patients with (S+MwA+) or without (S+MwA-) MwA and aura features in MwA patients with (S+MwA+) or without (S-MwA+) stroke.

METHODS

In this retrospective multicenter case-control study, we reviewed stroke phenotypes and vascular risk factors in S+MwA+ and S+MwA- patients younger than 60 years and risk factors and aura type, duration, onset age, and the frequency in the previous year in S+MwA+ patients and S-MwA+ subjects matched for age and disease history, investigated for patent foramen ovale (PFO).

RESULTS

539 stroke (7.7% S+MwA+) and 94 S-MwA + patients were enrolled. S+MwA+ patients were younger (p =.0.004) and more frequently presented PFO [OR 4.89 (95% CI 2.12-11.27)], septal interatrial aneurism [OR 2.69 (95% CI 1.15-6.27)] and cryptogenic ischemic stroke (CIS) [OR 6.80 (95% CI 3.26-14.18)] than S+MwA- subjects. Significant atherosclerosis was not detected in S+MwA+ patients. Compared to S-MwA+, S+MwA+ patients were characterized by visual [OR 3.82 (95% CI 1.36-10.66)] and shorter-lasting (20.0 min IQr 13.1 vs 30.0 min IQr 25.0; p < 0.001) aura, and PFO [OR 1.26 (95% CI 1.03-1.54)]. Regression analysis evidenced that only shorter aura duration associated with stroke (p = 0.001). High-risk PFO was equally represented in S+MwA-, S+MwA+, S-MwA+ groups.

CONCLUSIONS

Shorter visual aura and CIS characterize MwA patients with stroke. Although more prevalent, PFO can not be considered the main responsible for the increased stroke risk in MwA patients but as a part of a complex multifactorial condition.

Migraine and Vascular Risk: An Update

Background

Migraine is a common neurological disorder with significant morbidity and disability. There is growing evidence that migraine is associated with cardiovascular diseases and stroke.

Objective

The aim of this study was to provide an update on the association of migraine with some common vascular diseases in persons suffering from the disease and discuss the clinical implications.

Methods and Materials

We searched PUBMED database using the MeSH terms "Stroke", "Coronary Artery Disease", "Myocardial Ischemia", "Atrial Fibrillation", "White Matter" and "Dementia, Vascular", in combination with "Migraine Disorders", "Migraine with Aura" and "Migraine without Aura" and reviewed the relevant studies. We studied articles mostly in English for the past 10 years, without excluding older articles that were relevant to this review. We also searched the reference lists of articles obtained and included some insightful reviews on 'Migraine and Vascular Risk'.

Results

The association between migraine and vascular diseases is strong and consistent for ischemic stroke and migraine with aura especially in young women, with oral contraceptive use and smoking. Although literature reports a higher prevalence of obesity, dyslipidemia, and family history of cardiovascular diseases in migraineurs, the 'migraine-vascular' connection persists in models where the traditional vascular risk factors are adjusted, implicating a migraine-specific pathophysiology at work. There is some evidence linking an adverse vascular risk factor profile to incident myocardial infarction in people with migraine. The association with hemorrhagic stroke is more variable.

Conclusion

Although the absolute effect of migraine on 'vascular risks' is small, good practice parameters dwell on treating and reducing existing cardiovascular risk factors through lifestyle modification, encouraging smoking cessation, and advocating the wise use of agents like ergot alkaloids and oral contraceptives, after a risk-benefit analysis.

The unusual course of a migraine attack during COVID-19 infection - Case studies of three patients

The effect of the coronavirus disease 2019 (COVID-19) on the nervous system remains undefined. Some studies have shown that headache is one of the most common symptoms and often the first neurological symptom in patients with confirmed infection. There are only a few reports concerning the effects of COVID-19 on the course of migraine.

This article investigates three female patients with prolonged history of migraine, in which atypical phenomenology and course of migraine attacks were observed during COVID-19 infection.

Comparison of retinal nerve fiber layer, macular ganglion cell complex and choroidal thickness in patients with migraine with and without aura by using optical coherence tomography

BACKGROUND

We compared the choroidal thickness (CT), peripapillary retinal nerve fibre layer thickness (pRNFLT) and macular ganglion cell complex thickness (mGCCT) by using spectral domain optic coherence tomography (SD-OCT) in patients with migraine with aura (MWA), migraine without aura (MWoA), and healthy controls.

METHODS

Thirty-seven patients with MWA, 40 patients with MWoA, and age and sex-matched 50 healthy controls were included in this cross-sectional study. CTs at fovea, nasal to fovea and temporal to fovea, global pRNFLT, four quadrants of pRNFLTs, mGCCTs in superior and inferior hemisphere were measured by SD-OCT. The duration of migraine, monthly attack number and the migraine disability assessment (MIDAS) questionnaire scores were recorded.

RESULTS

The mean foveal CT, nasal CT, and temporal CT in patients with MWA were significantly thinner than those of patients with MWoA and control (p < 0.001) while CTs of patients with MWoA were similar with those of controls. Patients with MWA and MWoA had thinner global pRNFLT, superior and inferior pRNFLT compared to controls but there were no significant differences between two migraineurs groups. Only nasal quadrant of pRNFLT was significantly thinner in patients with MWA than other groups. The superior and inferior mGCCTs were significantly thinner in patients with MWA and MWoA than controls.

CONCLUSION

Our results suggested that dysregulation of blood flow in ocular tissues caused by impairment of autoregulation in migraine. Patients with MWA might have an additional risk of choroidal and retinal ischemia than patients with MWoA and healthy controls.

functional (psychogenic) seizures

PURPOSE

To compare auras between three groups of people with seizures [i.e., Idiopathic generalized epilepsies (IGE) vs. Temporal lobe epilepsy (TLE) vs. Functional seizures (FS)].

METHODS

All patients, 10 years of age or older, with a diagnosis of IGE, TLE, or FS were prospectively registered in an electronic database and retrospectively studied at the outpatient epilepsy clinic at Shiraz University of Medical Sciences, Shiraz, Iran, from 2008 until 2020.

RESULTS

One thousand and three hundred ninety-one patients were studied (480 with IGE, 617 with TLE, and 294 with FS). Among patients with TLE, 63.5% of individuals reported auras; this figure was 68% in the FS and 12.7% in the IGE groups (p < 0.00001). Odds ratio of having auras in the TLE group compared with the IGE group was 11.96 (95% CI: 8.73-16.39; p = 0.0001). Odds ratio of having auras in the TLE group compared with the FS group was 0.81 (95% CI: 0.61-1.10; p = 0.1840). Odds ratio of having auras in the FS group compared with the IGE group was 14.61 (95% CI: 10.15-21.02; p = 0.0001). The following auras were more frequent among patients with TLE: emotional, cognitive, epigastric, and olfactory/gustatory. The following auras were more frequent among patients with FS: headache and dizziness/vertigo.

CONCLUSION

Auras are not specific to focal epilepsies. Future studies should investigate auras in large cohorts of patients with focal or generalized epilepsies and also those with FS to determine the exact clinical value of each aura.

The presence of aura is not related to changes in the cervical performance and mobility of patients with migraine

BACKGROUND

Migraine may be associated with neck impairment and migraine chronicity is related to greater disability. However, whether other subclassifications of migraine, such as migraine with aura, are related to neck impairment is currently unknown. The aim of this study was to assess the musculoskeletal aspects of the neck in patients with migraine with and without aura.

METHODS

Consecutive patients diagnosed with migraine were recruited from a tertiary headache clinic. The patients were divided into two groups according to the presence (MA, n = 37) and absence of aura (MoA, n = 88). The self-report of neck pain and neck disability was assessed using the Neck Disability Index (NDI). The patients underwent the flexion rotation test (FRT) and craniocervical flexion test (CCFT).

RESULTS

There was no association between the presence of aura and neck pain (χ²: 1.32, p = 0.25). No differences in the extent of neck disability (MA: 10.73, SD: 6.22; MoA: 9.63, SD:8.13, p = 0.25) or disability severity (χ² = 6.17, p = 0.10) were found between groups. The FRT did not differ between the groups (MA: 35.07°, SD: 7.90 and MoA: 34.60°, SD: 8.70, t = -0.22, p = 0.83) and there was no association between positive FRT and aura (χ² = 0.004, p = 0.56). The absence of difference between groups was also verified in the CCFT test (U = 1648.0, p = 0.89).

CONCLUSION

There was no association between aura and neck pain disability, reduced upper cervical spine mobility or reduced neck muscle performance. No differences in the neck impairment level between patients with and without aura during the clinical assessment of the cervical spine are expected.

Auras in intractable frontal lobe epilepsy: Clinical characteristics, values, and limitations

Auras are essential in preoperative evaluation and can provide valuable information for delineating seizure onset zones. Frontal lobe epilepsy (FLE) is the second most common focal epilepsy, while a few studies have focused on auras in FLE. To better understand FLE, we analyzed the clinical characteristics, values, and limitations of auras in FLE. The incidence rate of aura in FLE was 37.9% in our study. We included 54 patients and 76 auras in 11 categories were reported. The rate of auras in the decreasing order are as follows: autonomic aura; emotional aura; somatosensory aura; psychic aura; cephalic aura; abdominal aura; whole-body sensory aura, visual aura; auditory aura; and vestibular and unclassified aura. A significant number of aura types can be reported by FLE patients; autonomic aura was the most frequent category and somatosensory auras are most likely associated with the contralateral motor areas.

Epileptic olfactory auras: a clinical spectrum

OBJECTIVE

To investigate the relative frequency of olfactory aura in a large number of patients with focal epilepsy, and examine the full clinical spectrum of epileptic olfactory auras (OAs) and their relationship to hemispheric lateralization and localization of epileptogenic focus.

METHODS

This retrospective study was based on the medical records of 1384 patients with focal epilepsy. Of these, 71 (5.1%) patients were present with OAs, comprising 25 (35.2%) men and 46 (64.8%) women with a mean age of 35.43 ± 12.89 years. These 71 patients were classified according to the clinical features of the OAs, and the electroencephalography and magnetic resonance imaging findings were examined.

RESULTS

The relative frequency of OAs was 5.1% in the focal epileptic patients. The clinical spectrum of OAs in our cases was outlined as follows, complex OAs and elementary OAs. Elementary OAs were divided into three subgroups: elementary neutral OAs, elementary unpleasant OAs, and elementary pleasant OAs. In our cases, there was no difference between the right and left hemispheres in terms of lateralization of the epileptogenic focus. In all the 71 patients, the epileptogenic zone was most commonly localized in the temporal lobe (n = 58; 81.7%).

CONCLUSIONS

The relative frequency of OAs in focal epilepsies is likely to be found higher than expected. Elementary OAs occur much more frequently than complex OAs. Among the elementary OAs, elementary unpleasant OAs and elementary neutral OAs are the most common types, whereas elementary pleasant OAs are extremely rare.

Migraine in transient global amnesia: a meta-analysis of observational studies

BACKGROUND

PURPOSE: Although many studies have investigated the relationship between transient global amnesia (TGA) and migraine, to date, no meta-analysis has confirmed the existence and size of their association.

METHODOLOGY

Literature search involved MEDLINE, EMBASE, CENTRAL and PsycINFO. Observational controlled studies including TGA patients (Caplan, Hodges and Warlow) were retrieved. Quality evaluation was based on the Newcastle-Ottawa scale. The prevalence of migraine was compared in TGA patients vs. healthy controls (HC), as well as in TGA against TIA individuals. Data from case-control, cross-sectional and cohort studies were pooled separately.

RESULTS

Literature search yielded 1178 articles, 12 of which were included in the present meta-analysis. Results from case-control (ten), cohort (one) and cross-sectional (one) studies were compatible with an association between TGA and migraine. The nationwide inpatient cross-sectional study was of lesser value due to its inpatient orientation. The high-quality, population-based, retrospective cohort (158,301 participants per group) determined a higher relative-risk (RR) of TGA for migraine vs. non-migraine individuals [RR = 2.48, 95%confidence-interval (95% CI) = (1.32, 4.87)]. Sensitivity testing based on stricter diagnostic criteria strengthened the estimated association [RR = 3.84, 95% CI = (1.57, 9.38)]. Additionally, pooled data from eight case-control studies (700 TGA, 746 HC) yielded similar results [Odds-Ratio, OR = 2.51, 95% CI = (1.85, 3.41)], with the association mainly driven by the three high-quality studies, rather than the five articles of moderate quality. Finally, pooled findings from four case-control studies of moderate-quality revealed a higher prevalence of migraine among TGA compared to TIA patients [OR = 1.82, 95% CI = (1.22, 2.73)].

CONCLUSIONS

A significant association between TGA and migraine was established. The underlying connecting mechanism remains undetermined, yet.

Differential Expression of Cytokine-Coding Genes among Migraine Patients with and without Aura and Normal Subjects

Migraine is a prevalent disorder in humans and represents one of the top 10 causes of years lived with disability. Several genetic and environmental factors are involved in the pathobiology of migraine. A number of studies have underscored the role of dysregulated immune reactions. We compared the expression levels IL-2, IL-4, CXCL8, IL-17, IFN-γ, TGF-β and TNF-α cytokines in blood specimens of patients with migraine and those of healthy persons to identify any possible dysregulation in their expression and to propose mechanisms for this disorder. Expression of INF-γ was suggestively higher in migraine cases than in healthy individuals (posterior beta = 0.35, adjusted P value = 0.017). In addition, expression of this cytokine was lower in female subjects than in male subjects (posterior beta = -0.712, adjusted P value = 0.012). Expression of IL-4, TGF-β and TNF-α was also higher in cases compared with controls (posterior beta = 1.34, adjusted P value = 0.04; posterior beta = 0.849, adjusted P value = 0.036; posterior beta = 0.451, adjusted P value = 0.042, respectively). On the other hand, CXCL8 expression was lower in migraine cases than in controls (posterior beta = -0.78, adjusted P value = 0.039). Expression levels of IL-1B, IL-17 and IL-2 were not meaningfully different between cases and controls. The current study highlights the dysregulation of cytokine-coding genes in the blood of patients with migraine.