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    Migraine

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    veerraju tv

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    © All Rights Reserved
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    Seal 0 Fercriabncrt PRIMER Migraine Michel D. Ferrari™, Peter J. Goadsby@?-*“, Rami Burstein**, Tobias Kurth®, Cenk Ayata@’*, Andrew Charles?, Messoud Ashina??, Arn M. J. M. van den Maagdenberg:"* ‘and David W. Dodick?? Abstract| Migraine is a common, chronic, disorder that is typically characterized by recurrent disabling attacks of headache and accompanying symptoms, including aura. The aetiology is multifactorial with rare monogenic variants. Depression, epilepsy, stroke and myocardial infarction are comorbid diseases. Spreading depolarization probably causes aura and possibly also triggers trigeminal sensory activation, the underlying mechanism for the headache. Despite earlier beliefs, vasodilation is only a secondary phenomenon and vasoconstriction is not essential for antimigraine efficacy. Management includes analgesics or NSAIDs for mild attacks, and, for moderate or severe attacks, triptans or SHT,sxp receptor agonists, Because of cardiovascular safety concerns, unreliable efficacy and tolerability issues, use of ergots to abort attacks has nearly vanished in most countries. CGRP receptor antagonists (gepants) and lasmiditan,a selective SHT1, receptor agonist, have emerged as effective acute treatments. Intramuscular onabotulinumtoxinA may be helpful in chronic migraine (migraine on 215 days per month) and monoclonal antibodies targeting CGRP or its receptor, as well as two gepants, have proven effective and well tolerated for the preventive treatment of migraine. Several neuromodulation modalities have been approved for acute and/or preventive migraine ‘treatment. The emergence of new treatment targets and therapies illustrates the bright future for migraine management. Migraine isa common chronic, neurovascular brain disorder with major effects on patients and society" “Migraine affects ~15% of the general population glob- ally* and is typically characterized by recurring offen highly disabling’ attacks of severe headache, asusea, vomiting, super-sensitivity to light and sound, and other variable physical, mental and psychological signs and symptoms, lasting for 4-72 h REF}, Up roa third of patients may experience transient focal neuroloai- cal aura symptoms in et least come of thet attacks" Generally, migeaine attacks are multiphasic events with premonitory (sometimes also termed prodro- smal) symptoms 2-48h prior tothe attack" and post- 3 months, and thetisnot beter accounted for by another ICHD-3 clagnosis = Occurring ine patient who has had atleast ve ctacisfulling cri for Migraine without aura oratleast two attacks fuliling criteria for"Migraine with aura. «= Headache securing on 28 daysimonch for>3 months filing any otha following: ceteriafor Migreine without aur crteriefor'Migraine with urs or thet ie BeLeved bythe patient ta be migraine atonsetandrelieved by atrntanorerot derivative. NATURE REVIEWS DISEASE PRIMERS [Ariel catnlO (202) EZ phonophobia, photophobia, transient amners,lodyaia and osmophobia)"*, Spreading depolarization ax a putative trigger for trigeminovascular activation. Experimental data in animal models indicates that SD activate trigeminal nociceptive pathways! and, therefore, might be capa~ ble of triggering headache. SD s csociated with activa tion of pial and dural macrophages and dendritic cells", clovare of the alymphatic pathway", and releate of a variety of potential nociceptive mediators via opening cof aguronal pannexin 1 mega channels with acuivation of caspase 1 RE"). These events may then activate periph eral trigeminovascular neurons with cell bodies in the ‘TG" and subsequently second-order trigeminovasealar ‘neurons in the spinal trigeminal nocleusand upper cer~ vical spinal cord fc |. As mentioned above, whether SD isa trigger for migraine atacks in humans has long been debated, without concencus"™. Regardless, in animal models, SD isa relevant translational model for migraine. Numerous endogenous factors (such ae gene veriants end hormones) and exogenous factors (such as diet and drugs) that modulate migraine in humans also modulate the susceptibility ofbrain tissue to SD im animal models see aso below)”°"” The role of CGRP. Thesoleof CGRP ia migraine pathor physiology har been extensively reviewed elaewhere (e2 ALE), TG stimulation rnaltsin CGRP and subtance P release in cats and humans, CGRP isrelessed into the superior sgitial sinus in rats both of which are atten ated by atimigraine eatments”. Moreover, CGRE, but snot substance Bis released int the cranial eizcuetion of cats with superior sagittal snus stimulation, which ieblockad by atiptan (SHIT. receptoragonie) but not a plasma protein exttavesation inhibitor”. CGRP acts in the dura, TG, TCC, thalamus and periaque- dactal grey (PAG) to mediete and modulate tigers. novascular nociceptive traffic. CGRP has been found to be relessed into the crenil circulation in patients vith prolonged, severe migraine™, and ths velease i sttensated by administration of riptans”, predicting the successful prooF-of principe that CGRP blockade defective in the treatment of migraine” Comparable changes have bezn found in other sadies,bat could not be replicated in one major sady, possibly because of smportant difference in contro and sty designs” Ta supportof arolefoc CGRP in sigraine pathophysiol oy, CGRP infusion may provoke migraine without eur attacks in migraineurs (but not in son-migraincurs)’ Caletonin-ke receptor and receptor aciiny modifying, protein 1 (which compris the CGRP receptor) heve been found in migraine-relevant brain structures such as TG, TCC and trigeminal afferents, and CGRP ‘monoclonal antibodies prevent activation and sensiti- tion of Ad meningza nociceptors (hich are involved in migraine pathogenesis)" and HT tigeminovascalar searone inthe TCC™, Clintcal manifestations of peripheral and central sen- sitization. Over the courte ofan hours-long migraine attack, headache intensity increases and a variety of, PRIMER Box? | Putative mechanisms for stroke and myocardial infarction in migraine lechaemie stroke Spreading dopoarzation (SO) evans may also occur inthe setting of stoke anc braninjay’*"" Although SD snot belevedtobe injurious nheatty cote, emey \worsoninjuryinichacmictissue"™*"-S0 alo has profound effects on corebralvasculs- 1re.incucing long lasting vasoconstriction and blood-brain barrier disuption”-In ‘experimental stroke, per inflaret SD occured more frequently in fara emiplegic tigraine type 1(FHAUY mica and occured sooner than in wil sype mica, neoasing the retabolcsuppty-demand mismatch and useeptibity to lchaema. Aecoraingy, ‘thevisbilty threshold foriscrzemic cerebral blod flow Wass, andinarction occured ‘arin waz more extensive and wes associated witha higher more”. The efecto infarct ize was greater in female than n male mutant rice (nine withthe higher rk ‘ofstrake in women with migraine) and in 2181. than in R192C mice (consistent with the ‘greater dystunccionof C471 channels and moraseverephenetypa than in S218L ico). ‘Tha NMDA glramacsrecoprar antagonist K-01 itedinfarct iz and improved both ussue and cea outcome. Incaresingly, Leaner mics, unlike FHM micahave a lossof function mutation in Casnaia and deplayed smaller infarcts than controls ‘Altogether SD may explain, atleast n part the increased rik ischaemic trokein migraine with aure™= Patients who are more susceptible to SD lucha those with ie ee ee ceree ee peer einer ieee leehaemia™ ‘Another potantial rik stor for stoke in migraine males patent foremen ovale Multiple stuctechave indested an aszocation between migrsine, pecteally m grain ‘ith aura and patent foramen ovale. Wriletis often assumed that trokein those with rigraine with aura s due to migrainausinfarction fsroke occuringas the resltot Imigane mechani. sn fact raraor stroke 9 occur inthesertig of amigtzine stack Convers. cryptogeni stoke stoke with a denifable caus) associated \wtthboth pateneframan ovale and migraine with aura" Accordingly. the nereasad sk ‘oftake inthose with migra witn aur could possbiy be elated to patent foramen ‘ovaleasa common sk factor This could expan the cbsenations that stroke skin migraine particularly incressedin younger individuals and those with causes of hypercoeguability suchas smoking and th use of eral contraceptives containing highose cesogen, whichincreaethenskof embotsm srcugh apatent foramen ova. Myocardial infarction ‘Anextensivestudy integrating mukiplesateofthe-art biological approacheswasthe frsrto show thatthe Galle of the non-coding DNAWarlancs0349879 n tho PHACTR, locuson p24 rats tha nek af ryocardal infarction and reduces therisko migraine, ‘cervical artery dissection fibromuscular dsplasiaand hypararsio" Migrane nereases ‘theriskof myocariainfaction and cereal artary dssecion™"* The variant was shown toincreae EDN! (encoding vascular endtelin 1) expression raising the levels ‘oF endothelin 1.2 potent vasacorstrictorand atherosclerosis promoter Whether this ‘variant isirwolvedin promoting myocardial infarction n migraine requires further Investigation associated sensory symptoms appear. This within-attack rogrecsion ie believed to reflect enhanced excitability and responsivity (collectively termed sensitization) ‘of peripheral and central trigeminovesculer neurons. Sensitization of meningeal nociceptors, which probe bly occurs as a result oftheir continuous exposure to algogenic pro-inflammatory molecules (such as CGRE, ltr oxide and PGE.) that are capable of altering their ‘membrane resting potential, become spontaneously ‘active and begin to respond to mechanical stimulation ‘of the dure to which they normally chow minimal or zo reeponse'™ fi, 4). Sensitization of central tiger- inovascular neurons in laminae T and V of the TCC, thalamic posterior and ventral porteromedial nucle, neurons (1c 5) leads to increases in spontaneous activ 4 receptive feld expansion, and response to innocuous ‘strmulation of cephalic and extracephalic skin areas and miuscle stretching". Clinical manifestations of these ‘processes, which typically develop during the migraine {tack and often outlast ite termination by 2-3 days, could include (1) transient intensification of headache daring activites that increase intracranial pressure, such as bending over or coughing [peripheral sensitication; (@) cephalic allodynia with scalp and muscle tender- ness and hypersensitivity to touch, often described by patients as avoiding earrings, glasses, hats, or any other items that contact the fecal chin" (TCC sensitisation); and (3) extracephalic allodynia often causing patients ‘to remove tight clothing and jewellery, and to avoid ‘being touched ™ (thalamic sensitization), People with 2 high frequency of migraine attacks, euch as those with chronic migraine, may consequently show permanent Ibypereenatization. Trerole of the brainstem and diencephalon Subcortical structures are ell placed to play a role in migraine given the diffuse and diverse nature of migraine symptoms from pain through sensory sensi- ‘uvity to cognitive dyefunction, Indeed, arle of eubcor tical steuctores in migraine is supported by data from ‘man imaging studies, and theres good basicscience rationale tolink these structures tothe pathophysiology cof migraine (for review see RES"), ‘Human studies. During the premonitory phate of migraine, prior to the onset of headache and aura, functional imaging studies have thown activations in ‘the region of the hypothalamus, PAG and dorsolat- eral pons”. These findings raise the possibility that rigraine begins in thorestruczares and that nociceptive signalling i not required forthe initiation ofa migraine attack. However, this concept is complicated by stud- ies showing that hypothalamic activation before atack onset might happen in the absence of premonitory. symptoms", Nausea involves activation of the medulla in the premonitory phase. Activation of the dorsolateral ppons occurs during the pain phase'", which is lateral- ized in unicteral headache. This pattern is very distinct from that in the trigeminal autonomic cephalalgias™, in which activation of a more posterior hypothalamic region is seen Animal studies. ARhough many animal studies evalu- sting the pathophysiology of migraine have been car ried out, only key results are discussed here; for an cexensive review of the lterature, cee REF". \ctivation of trigeminal neurons with darovascular inputs ean bbe achieved by chemical or electrical mesne and each has advantages and drawbacks, Administration of ‘the Ca,2.1 (P/Q type) voltage-gated calcium channel blocker o-agetoxin [VA into the PAG can facilitate ‘igeminocervicel durovascular nociceptive trafic” Local PAG injections of acutely effective entimigraine agente inhibit TCC activation. Dopamine has a role in yawning, a prominent premonitory symptom in migraine". The TCC hae dopamine receptors that are inhibitory when activated". The posterior hypotha- lamic nucleus AI isan important source of descending dopaminergic impute the dorsal horas activation of ALI Inhibits TCC nociceptive trafic and lesioning facilitates ‘that traffic, which can be reversed by administration of atriptan'™ wowwnatre.com/iarde ‘The role of intracranial blood vessels ‘An intimate role for blood vessels in migraine patho: physiology is not surprising given that the brain itelf is devoid of nociceptive innervation, and that intra ‘cranial pain perception is largely limited tothe menin- ‘ges and large cerebral arteries. Moreover, « marked long-lasting reduction of cerebral blood flow has been ‘observed in the aftermath of migraine attacks, particu lly after migraine with aura”. Finally, oly vaso dlilating substances have thus far been shown to provake smigraine like etacks in migraineurs” ‘Whether migraine headache is caused by cerebral, smeningeel or exracrenial vacodilation is debated" In human magnetic resonance angiography stud~ ‘ee, placebo-controlled aitric axide- provoked’ end spontaneous” migraine attacks were not ascociated seth meningeal or exracranial vasodilation, However, attacks induced by CGRP cilostazol or sildenafil were associated ‘with ictal dilation ofthe middle meningeal artery": ‘Of note, middle cerebral arterial dilation during spon taneous attacks persisted after relief with sumatriptan, ‘whereas extracranial erteries constricted”. These data, ‘together with the clinieal efficacy of non-vasoconstritor _gepante in migraine (cee below), suggest that (1) cer bral arterial dilation is an epiphenomencn reflecting activation of perivascular afferents in response 10 vaso diletory neurotransmitter such as CGRP; (2) the acute lntimigraine effects of sumatriptan and gepants are mediated, either by aselactive but non-vasaconetrictor effect on extracranial arteries, or by 2 non-rascular neu zona effect; end (3) various signaling molecules (such ‘as CGRP and pituitary adenylate eyclase-activating ‘peptide initiate acascede of intracellslar processes that zesalt in opening of ATP-sensitive potassium channels ‘on vascular smoath muscle cells within the intracranial arteries. Eflux of potassium causes byperpolarization and vasodilation of these arteries, and an increase {in extracellular potassium lesding to sensitization of Box3 | Experimental provocation of migraine without aura attacks ‘Systematicanalyssof the effects of naturally occuring Salling moleculeshas provided important dataon migraine mechanisms and potential therapeutic targets ‘Tha rte eile donor glycan trntate (GTN) x tha most extorshvalystudiod™. “ypcaly.TNinfsion induces artacks of migraine without aura fron with promontory sympeare)Inup to 33% of patients wth migraine without ura, 67% of thes with migraine with crand in 30% of patents of hose ith hemiplegic mgraine™. Attacks ‘arenotprovckedin controls whe donot hve migraine and GIN doesnot induce aura Assldenaflaselectne inhibitor of CGMP-hydealysing PDE, induces marae atacksin 77%oF patents. upregulation of

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