Original Article

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Abnormal tyrosine metabolism ! International Headache Society 2016
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DOI: 10.1177/0333102416640502
cep.sagepub.com

Giovanni DAndrea1, Massimo Leone2, Gennaro Bussone2,

Paola Di Fiore2, Andrea Bolner1, Marco Aguggia3,
Maria Gabriella Saracco3, Francesco Perini4,
Giuseppe Giordano5,6, Antonina Gucciardi5 and Alberta Leon1

Abstract
Objective: Episodic cluster headache is characterized by abnormalities in tyrosine metabolism (i.e. elevated levels of
dopamine, tyramine, octopamine and synephrine and low levels of noradrenalin in plasma and platelets.) It is unknown,
however, if such biochemical anomalies are present and/or constitute a predisposing factor in chronic cluster headache.
To test this hypothesis, we measured the levels of dopamine and noradrenaline together with those of elusive amines,
such as tyramine, octopamine and synephrine, in plasma of chronic cluster patients and control individuals.
Methods: Plasma levels of dopamine, noradrenaline and trace amines, including tyramine, octopamine and synephrine,
were measured in a group of 23 chronic cluster headache patients (10 chronic cluster ab initio and 13 transformed from
episodic cluster), and 16 control participants.
Results: The plasma levels of dopamine, noradrenaline and tyramine were several times higher in chronic cluster
headache patients compared with controls. The levels of octopamine and synephrine were significantly lower in
plasma of these patients with respect to control individuals.
Conclusions: These results suggest that anomalies in tyrosine metabolism play a role in the pathogenesis of chronic
cluster headache and constitute a predisposing factor for the transformation of the episodic into a chronic form of this
primary headache.

Keywords
Tyrosine, headache, trace amines, tyramine, norepinephrine, octopamine
Date received: 19 November 2015; revised: 13 January 2016; 18 February 2016; accepted: 21 February 2016

Introduction
Cluster headache (CH) is a trigeminal autonomic
cephalalgia (TAC) characterized by unilateral, excru-
ciating, severe headache attacks. Most of the patients
present with episodic CH in which the painful attacks
occur with a variable frequency, daily or weekly
during the active periods and then subside in remis-
sion periods. The active periods last from weeks to
months and occur in a periodic manner. A minority
of patients present with chronic cluster headache
(CCH) in which the bouts occur continuously from
at least one year from the onset. However, CCH
may also develop from episodic CH (ECCH). In this
case, patients present with a progressive prolongation
of the active periods associated with the absence of the
remission periods (1).
The pathogenesis of CH is unknown; however,
increasing evidence, generated mainly from our
laboratory, shows that profound alterations of tyrosine
(Tyr) metabolism may have an intriguing role in the
occurrence of this primary headache (2,3). Tyr is the
amino acid precursor for the synthesis of
1
Research and Innovation (R&I) s.r.l., Italy
2
Headache Center, Neurology Department, Clinical Neuroscience
Department, C. Besta Neurological Institute IRCCS Foundation, Italy
3
Headache Center, Neurology Department, Asti Hospital, Italy
4
Headache Center, Neurology Department, Vicenza Hospital, Italy
5
Mass Spectrometry and Metabolomic Laboratory, Institute of Pediatric
Research IRP Citta della Speranza, Italy
6
Womens and Childrens Health Department, University of Padova, Italy
Corresponding author:
Giovanni DAndrea, Neurology Clinic Villa Nargherita, Via Costacolonna
20, Institute of Neurology, Arcugnano Vicenza, 36057, Italy.
Email: giovidavi@virgilio.it
2 Cephalalgia 0(0)

catecholamines and elusive amines. The Tyr hydroxy-

Patients and methods
lase enzyme synthesizes dopamine (DA) and noradren- A sample of consecutive patients presenting at
aline (NE) whereas Tyr decarboxylase results in the Headache Centers of Neurology Departments in three
production of elusive amines such as tyramine (TA), Italian hospitals (Vicenza, Milan and Asti) from
octopamine (Oct) and synephrine (Syn) (4). Both January 2014 to December 2014 were enrolled in the
enzymes are regulated by mitochondrial activity. In study. The inclusion criteria consisted of a history of a
conditions of low mitochondrial function, the activity CH lasting at least one year or more. The diagnosis
of the decarboxylase increases, whereas that of the of CCH was made according to International
hydroxylase enzyme decreases (57). Elusive amines, Classication of Headache Disorders, third edition
previously almost ignored in human pathology for beta (ICHD-3 beta) criteria (14). Thirteen patients
many reasons (diculty of their measurement in bio- were chronic cluster ab initio and 10 patients with clus-
logical uids, unknown receptors for elusive amines), ter shifted from episodic to the chronic form (ECCH).
are now considered to play a signicant role in synaptic All patients were in prophylactic treatment: 13 individ-
transmission within the central nervous system (CNS) uals received verapamil at doses ranging between 400
acting as neuromodulators. Neuromodulators are and 800 mg/day, ve individuals were given 900 mg
chemicals released from the neuron that act to modify daily of sodium valproate (Depakin) and ve patients
the action (increasing or decreasing their activity) of were treated with antiepileptic drugs (three patients
coexisting neurotransmitters that, however, do not with Topamax and two patients with Gabapentin).
change the excitability of postsynaptic cells in the All patients were under cortisone therapy except for
absence of the neurotransmitters DA, NE and 5-HT. two who were treated with Verapamil and Depakin
Furthermore, elusive amines are agonists of the recently alone. The demographic patient characteristics are
discovered trace amine associated receptors (TAARs) shown in Table 1.
(810). TAAR1 is an inhibitory presynaptic receptor in A group of 16 healthy individuals was used as the
catecholaminergic neurons and as such modulates the control group (Table 1). All control participants were
synaptic release of catecholamines in many subcortical free from headaches, diabetes, hypertension or other
structures. TAAR1 is widely distributed in the hypo- relevant pathological disorders. After an informed con-
thalamus and in all the connected structures, such as sent was obtained, the levels of DA, NE, TA, Oct and
the amygdala, thalamus, limbic system and centers of Syn were measured in the plasma of all participants.
the pain matrix (11). The hypothalamus plays an Peripheral venous blood (20 ml) was drawn from the
important role in the pathogenesis of CH as its inhib- antecubital vein at 9 a.m. from participants after
ition, through implantation of a stimulator in the pos-
terior region, may reduce the number of bouts in CH
patients (12).
Table 1. Demographic and clinical characteristics of control
The nature of the hypothalamic dysfunction and its and CH patient groups.
role in the pathogenesis of CH is unknown. Studies
have demonstrated that the levels of DA and TA, Oct Participants, n Controls 16
and Syn are very high in plasma and platelets of CH CH patients 23
patients in remission and active periods, whereas those
Age, years  SD (range) Controls 51.8  8.5 (3464)
of NE are signicantly lower than those of control
CH patients 50.8  11.4 (3167)
individuals (2,3,13). We suggested that if the same bio-
chemical abnormalities are present in the hypothalamus Sex, male n (%) Controls 8 (50 %)
and other centers of the pain matrix, these biochemical CH patients 18 (78 %)
anomalies may be involved in the pathogenesis of epi- Age of symptoms 36.7  11.2
sodic CH (2). onset (mean  SD)
The pathogenesis of chronic CH and the process Years of disease 14.1  8.9
that leads the episodic form to the chronic one are duration (mean  SD)
completely unknown. It is unknown whether the Chronic cluster (n) From episodic 13
anomalies in the synthesis of catecholamines and elu- Ab initio 10
sive amines, found in ECH patients, play a role in the CH Lateralization (n) right side 13
pathogenesis of CCH. In order to explore this hypoth- left side 8
esis, we assessed the plasma levels of NE, DA, TA, Oct side-alternating 2
and Syn in a group of CCH patients and control
CH: cluster headache.
groups.
DAndrea et al.
10 minutes of resting in the supine position, within four
hours after the last bout. The blood was drawn by an
expert operator and collected into tubes with citrate as
an anticoagulant. The blood was centrifuged at
3500 rpm for 15 minutes to obtain poor platelet
plasma (PPP). One ml of PPP was used to measure
the amines. The analysis was performed using high-
performance liquid chromatography (HPLC) as previ-
ously described (15).
Elusive amine and catecholamine plasma levels were
rst tested for normality using the Shapiro-Wilk test
and for equality of variance by Levenes test. All
groups displayed a parametric distribution with equal
variance; therefore, the dierences between groups were
tested using the independent samples t-test. Evaluation
of dierences between the CCH and ECCH patients
was performed for plasmatic levels of DA, NE, TA,
Oct and Syn. Pearsons correlations were performed
between concentration levels and also with clinical vari-
ables assessed during a clinical interview. Dierences in
the plasma levels of DA, NE, TA, Oct and Syn between
males and females were also evaluated. The results were
expressed as the mean SD and the level of signicance
was assumed for a p value <0.05.
Results
CCH and controls displayed a similar age distribution,
with the CCH group including more men than the con-
trols. Detectable levels of NE, TA, Oct and Syn were
found in the plasma levels of all participants. DA was
found below detection limits in plasma of seven control
individuals. Table 2 reports the mean levels of neuro-
transmitters and neuromodulators found in the plasma
of controls and CCH patients. The levels of DA, NE
and TA found in CCH patients were several times
higher compared with those of controls (Table 2).
Signicantly lower amounts of Oct and Syn were
found in the plasma of CH patients than controls.
Table 2. Plasma levels of catecholamines and elusive amines of
controls and cluster headache patients.
Controls Cluster
(n 16) (n 23) p valuea
Norepinephrine 72.29  33.90 214.4  110.4 0.0001
Dopamine 1.92  1.06 10.89  8.24 0.0009
Tyramine 2.06  1.61 12.51  3.83 <0.0001
Octopamine 2.54  1.82 0.21  0.09 <0.0001
Synephrine 3.47  3.75 0.96  0.57 0.0056
a
Results are reported as mean values  SD. P value was obtained by
unpaired t-test.
3
There was no signicant statistical dierence in the
levels of elusive amines and catecholamines in patients
suering from CCH evolved from the episodic form
compared with those with a history of the chronic
form ab initio (Table 3). Comparison between males
and females in all groups of participants did not show
signicant dierences, as well as correlations between
metabolites and clinical parameters (age, sex, side
aected, the age of the beginning of the bouts and dur-
ation of disease).
Discussion
This study clearly shows that abnormalities of Tyr
metabolism occur in CCH patients. In comparison to
control individuals, these patients have very high plas-
matic levels of DA and NE along with TA, whereas
those of Oct and Syn are signicantly lower. The high
DA and TA levels are suggestive of increased decarb-
oxylase activity since this enzyme converts Tyr in TA
and levodopa (L-DOPA) in DA. This conrms the
results found in ECH patients in remission and active
periods and suggests that there occurs, as in a migraine,
a metabolic shift toward an increased decarboxylase
enzyme activity (16). The origin of the anomalous
high plasma levels of DA and TA, as reported in the
episodic cluster, is likely a consequence of the activa-
tion of the sympathetic autonomic system since TA and
DA are released from the nerve endings surrounding
the trigeminovascular bed of the CNS (17,18). In add-
ition, increased functionality of the dopaminergic
system is more than probable. In fact, it has been
reported that the abnormal 24-hour prolactin secretion
and the blunted response to thyrotropin-release hor-
mone found in CH patients occur as a consequence of
the increased synthesis and release of DA from the
dopaminergic tuberoinfundibular system, which is
the main inhibiting factor of prolactin release from
Table 3. Plasma levels of catecholamines and elusive amines
(mean  SD) of chronic CH patients evolved from the episodic
form and those with the chronic form ab initio.
Chronic ab initio From episodic
(n 13) (n 10) p valuea
Norepinephrine 245.20  139.80 194.70  86.70 0.29
Epinephrine 23.08  13.31 20.51  14.02 0.66
Dopamine 11.67  8.60 10.39  8.38 0.75
Tyramine 12.55  4.43 12.48  3.48 0.96
Octopamine 0.22  0.07 0.20  0.10 0.58
CH: cluster headache. aUnpaired t-test. P value was obtained by unpaired
t-test.
4 Cephalalgia 0(0)
the pituitary gland (19,20). The neurons of this system
are located in the arcuate and periventricular nuclei of
the hypothalamus. It is well known that an anomaly of
hypothalamic function plays a pivotal role in the patho-
physiology of CH, a result in line with numerous neu-
roendocrinological, neuroimaging and pharmacological
studies (2123). Although the nature of this abnormal
function of the hypothalamus in CH is uncertain, the
abnormally high levels of TA may, at least in part, oer
an explanation. TA, like Oct and Syn, is a neuromodu-
lator regulating the physiological function of dopamin-
ergic synaptic clefts (24). If the high levels of TA, here
found in plasma, are also present in the CNS, TAAR
receptors, particularly TAAR1, are stimulated. These
receptors are located abundantly in the hypothalamus
and in other interconnected dopaminergic and noradre-
nergic brainstem nuclei. The high levels of TA together
with the elevated levels of DA may aect the function-
ality of TAAR1 receptors, resulting in changes of their
inhibitory function on the presynaptic catecholaminer-
gic neurons (25). These alterations may aect the
release of DA in the competent synaptic clefts of all
dopaminergic bers connected to the hypothalamus
and of the synaptic clefts within the hypothalamus
itself. This biochemical dopaminergic dysregulation
may contribute to the abnormal hypothalamic function
in CH patients.
The elevated level of NE in chronic CH patients is an
unexpected result and not in line with those previously
reported in ECH patients in which such levels are
reported to be lower than those found in control indi-
viduals. This may be because the synthesis of NE is
dependent on mitochondrial energy shown to be
reduced in CH (26). One possible explanation for the
abnormally high levels of NE in our patients is that,
as in chronic migraine, there occurs an interaction
between TA and its TAAR1 receptors. As described
above, TA, like b-phenylethylamine (b-PEA) and DA,
is a potent agonist of TAAR1 receptors. It is possible
that, as hypothesized in chronic migraine, the
abnormal high TA availability in DA and NE circui-
tries results in anomalies of TAAR1 functionality (24).
Changes in TAAR1 inhibitory function may determine
alterations in NE in the synaptic clefts of the neurons of
the noradrenergic and sympathetic system and its
release into the circulation from the sympathetic
endings.
The signicant low levels of Oct and Syn here found
in CH are in contrast to those showed in platelets and
plasma of ECH patients published in our previous
study (2). The reasons for this biochemical discrepancy
are unclear; one possibility is that the DA hydroxylase
enzyme activity that converts TA into Oct is reduced
because of impairment of mitochondrial functions
demonstrated in the muscles and brain of ECH
patients (27). It is possible that the mitochondrial
function is further reduced in CCH resulting in an accu-
mulation of TA along with reduced synthesis of Oct
and Syn.
In conclusion, our data suggest the occurrence of
a biochemical abnormality of Tyr metabolism in
CCH patients: Tyr decarboxylase enzyme activity is
increased, resulting in an accumulation of TA and
DA whereas the plasma levels of Oct and Syn are sig-
nicantly low, suggesting that the hydroxylase enzyme
activity is reduced. The high levels of noradrenaline are
probably a consequence of abnormal functionality of
TAAR1s, which are the presynaptic inhibitory recep-
tors aecting catecholamine release in the synaptic
clefts of the hypothalamus and pain matrix. Our
hypothesis is that the high levels of DA and TA may
constitute the biochemical abnormal milieu that causes
the hypothalamic and pain matrix dysfunctions in CCH
patients. The high levels of NE and low levels of
Oct and Syn may be the cause of the vegetative symp-
toms that accompany the CH attacks as these amines
are neurotransmitters and neuromodulators of the
sympathetic system (28,29). It is possible that treat-
ment(s) that normalize(s) this abnormal biochemical
background of CCH may prevent the transformation
of ECH to the chronic form and may treat the CCH
itself.
This study has some limitations. The rst is that all
patients considered were undergoing pharmacological
treatments, the impact on our results of which is
unknown. However, in previous studies, similar Tyr
anomalies were found in patients in remission (without
treatments) and active (in treatment) periods sug-
gesting that the treatments may have had a limited
inuence. A prospective study enrolling CCH patients
out of therapy is required to conrm our results. The
second limitation is that we have not contemporarily
enrolled ECH patients in this study, allowing for
comparison with previous studies in this patient
group. The third limitation is that we did not evaluate
the levels of the biomarkers considered during the
bout. We do not know if the metabolism of Tyr further
changes during the painful attack.
DAndrea et al. 5

Clinical implications
. Plasma levels of products of tyrosine (Tyr) metabolism are altered in chronic cluster headache (CCH)
patients with respect to those of control individuals.
. The very high level of dopamine (DA) and tyramine (TA) found in our patients provides a possible explan-
ation of the hypothalamic dysfunctions and related neuroendocrine abnormalities previously described in
CH suerers.
. Higher plasma levels of noradrenaline (NE) together with lower levels of octopamine (Oct) and synephrine
(Syn) found in CCH patients, unlike those reported in episodic CH patients, may be associated with chron-
icity of a CH.
. The possible dysfunction of the trace amine associated receptor TAAR1, due to the high levels of TA, may
explain the high levels of the neurotransmitters.
. The synthesis of pharmacological agents modulating the function of TAAR receptors may constitute a
future avenue for a better comprehension of CH pathophysiology, the process involved in its chronicity
and eventually its treatment.

Funding 8. Borowsky B, Adham N, Jones KA, et al. Traces amines:

The authors disclosed receipt of the following nancial
support for the research, authorship, and/or publication of
this article: The research was partially funded by the
F.I.C.E.F. (Italian Foundation for Headache Research,
Naples, Italy).
Declaration of conflicting interests
The authors declared no potential conicts of interest with
respect to the research, authorship, and/or publication of this
article.
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