Citations

Background: Spontaneous coronary artery dissection (SCAD) is a nonatherosclerotic cause of myocardial infarction (MI) occurring most often in young women without cardiovascular disease (CVD) risk factors. SCAD is associated with fibromuscular dysplasia (FMD), pregnant/postpartum state, and extreme mental stress or physical exertion. Migraine headaches have been reported common in SCAD and may increase CVD risk. The objective was to assess differences in presentation, clinical factors, and outcomes in SCAD patients with migraines (M-SCAD) compared to those without, and determine M-SCAD prevalence. Methods: A retrospective cross-sectional observation study of patients with angiographically confirmed SCAD was conducted using the Mayo Clinic SCAD Registry. Participant-provided data and records were reviewed for migraine history, CVD risk factors, SCAD details, CVD and migraine therapies, and outcomes. Ordinal and nominal variables were compared using Pearson's chi squared test, and continuous variables were compared using Student's t-test. Statistical significance was set at p < 0.05. Results: Among 586 patients with complete questionnaires, 236 had a history of migraines; the lifetime and 1-year prevalence of migraines were 40% and 27% respectively. Migraines are more common in SCAD survivors than a comparable population (40% vs 33%, p=0.0002). M-SCAD patients were more likely to be female (99.6% vs 94%, p=0.001), have SCAD at a younger age (45.3 yrs. vs 47.6 yrs., p=0.004), and report a history of aneurysms (7.6% vs 1.7%, p=0.0004), 46% of which occurred in head or neck vessels. There was a trend toward increased head and neck FMD in M-SCAD (32% vs 23%, p=0.095). Prevalence of depression (27% vs 17%, p=0.005), anxiety (32% vs 24%, p=0.038), recurrent angina (62% vs 44%, p=<0.001) and concern for recurrent SCAD (46% vs 37%, p=0.034) were higher in M-SCAD. Triptans were stopped in 39% of migraineurs at the time of MI. Conclusion: As compared to SCAD survivors without migraines, those with M-SCAD are younger, more often report a history of depression, anxiety, and aneurysms, and have more chest pain after SCAD. Further investigation into this association and development of safe, effective treatments of both headache and angina after SCAD is needed.

Abstract Background: OnabotulinumtoxinA has been widely used for control of chronic migraine. The aim of the current study was to evaluate the efficacy of different doses of the onabotulinumtoxinA therapy in patients with chronic migraine.Methods: This is a retrospective paired comparison study on patients with chronic migraine who received at least 3 rounds of 150 units of onabotulinumtoxinA followed by at least 3 rounds of 200 units of onabotulinumtoxinA. The data from the patient-reported questionnaires about headache days, severe headache days and wearing off periods were reviewed. Results: A total of 175 patients were included in this study. The headache days and severe headache days decreased from 13.62±10.79 and 5.88±6.73 to 11.02±10.61and 4.01±4.89 days, after increase in the onabotulinumtoxinA dose, respectively (P<0.001 for both comparisons). The favorable effect of the 200 units compared to the 150 units of the onabotulinumtoxinA, was independent from the headache location and the duration of the onabotulinumtoxinA 150 units therapy; and persisted as patients continued to receive the higher dose of onabotulinumtoxinA. Increase in the onabotulinumtoxinA dose was also associated with a decreased wearing off period (P<0.05). Conclusion: Increase in the onabotulinumtoxinA dose is associated with better headache control and independently improves the numbers of the headache and severe headache days.

Objective “Pain interference” and “headache impact” refer to negative consequences that pain and headache have on one’s life. This study investigated determinants of these negative impacts in a large patient cohort who have chronic migraine with medication overuse. Methods Six hundred and eleven adults were enrolled from 34 headache, neurology, and primary care clinics. Negative consequences of chronic migraine with medication overuse were determined using the Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference 6b questionnaire and the Headache Impact Test 6. Relationships between PROMIS-6b and Headache Impact Test 6 scores with demographics, headache characteristics, medication use, anxiety symptoms, and depression symptoms were assessed with linear regression. Elastic Net regression was used to develop a multiple regression model. Results PROMIS-6b T-Scores averaged 65.2 (SD 5.4) and Headache Impact Test 6 scores averaged 65.0 (SD 5.3), indicating severe negative consequences of chronic migraine with medication overuse. Chronic migraine with medication overuse interfered with enjoyment of life, concentration, daily activities, doing tasks away from home, and socializing. Depression symptom severity had the strongest relationship with pain interference and headache impact. Moderate-to-severe headache frequency, headache intensity, and anxiety symptoms were also associated with pain interference and headache impact. Conclusions Chronic migraine with medication overuse is associated with substantial negative consequences, the extent of which is most strongly related to depression symptoms.

AbstractBackgroundCurrently, there is no biologically based rationale for drug selection in migraine prophylactic treatment.MethodsTo investigate the genetic variation underlying treatment response to verapamil prophylaxis, we selected 225 patients from a longitudinally established, deeply phenotyped migraine database (N = 5983), and collected uninterrupted quantitated verapamil treatment response data and DNA for these 225 cases. We recorded the number of headache days in the four weeks preceding treatment with verapamil and for four weeks, following completion of a treatment period with verapamil lasting at least five weeks. Whole‐exome sequencing (WES) was applied to a discovery cohort consisting of 21 definitive responders and 14 definitive non‐responders, and the identified single nucleotide polymorphisms (SNPs) showing significant association were genotyped in a separate confirmation cohort (185 verapamil treated patients). Statistical analysis of the WES data from the discovery cohort identified 524 SNPs associated with verapamil responsiveness (p < 0.01); among them, 39 SNPs were validated in the confirmatory cohort (n = 185) which included the full range of response to verapamil from highly responsive to not responsive.ResultsFourteen SNPs were confirmed by both percentage and arithmetic statistical approaches. Pathway and protein network analysis implicated myo‐inositol biosynthetic and phospholipase‐C second messenger pathways in verapamil responsiveness, emphasizing the earlier pathogenic understanding of migraine. No association was found between genetic variation in verapamil metabolic enzymes and treatment response.ConclusionOur findings demonstrate that genetic analysis in well‐characterized subpopulations can yield important pharmacogenetic information pertaining to the mechanism of anti‐migraine prophylactic medications.

Background Spontaneous coronary artery dissection (SCAD) is a cause of acute coronary syndrome predominantly in women without usual cardiovascular risk factors. Many have a history of migraine headaches, but this association is poorly understood. This study aimed to determine migraine prevalence among SCAD patients and assess differences in clinical factors based on migraine history. Methods and Results A cohort study was conducted using the Mayo Clinic SCAD “Virtual” Multi‐Center Registry composed of patients with SCAD as confirmed on coronary angiography. Participant‐provided data and records were reviewed for migraine history, risk factors, SCAD details, therapies, and outcomes. Among 585 patients (96% women), 236 had migraine history; the lifetime and 1‐year prevalence of migraine were 40% and 26%, respectively. Migraine was more common in SCAD women than comparable literature‐reported female populations (42% versus 24%, P <0.0001; 42% versus 33%, P <0.0001). Among all SCAD patients, those with migraine history were more likely to be female (99.6% versus 94%; P =0.0002); have SCAD at a younger age (45.2±9.0 years versus 47.6±9.9 years; P =0.0027); have depression (27% versus 17%; P =0.025); have recurrent post‐SCAD chest pain at 1 month (50% versus 39%; P =0.035); and, among those assessed, have aneurysms, pseudoaneurysms, or dissections (28% versus 18%; P =0.018). There was no difference in recurrent SCAD at 5 years for those with versus without migraine (15% versus 19%; P =0.39). Conclusions Many SCAD patients have a history of migraine. SCAD patients with migraine are younger at the time of SCAD; have more aneurysms, pseudoaneurysms, and dissections among those imaged; and more often report a history of depression and post‐SCAD chest pain. Clinical Trial Registration URL: https://www.clinicaltrials.gov . Unique identifiers: NCT01429727, NCT01427179.

Premise Migraine can present with a wide range of neurological symptoms. Problem Based on currently available data, the symptoms of typical migraine aura are most likely related to cortical spreading depression (CSD), and evidence supports that CSD can lead to trigeminovascular activation resulting in the headache phase of migraine. Potential Solution An alternative diagnosis to migraine aura should be considered if migrainous headaches present with transient neurological symptoms that have features inconsistent with aura.

Objective To report a case series of a novel migraine subtype, which we term as episodic status migrainosus (ESM), characterized by attacks of migraine exclusively lasting more than 72 hours. We hypothesized that this would represent a novel nosologic entity, possibly an unstable migraine phenotype with a high conversion rate to chronic migraine (CM). Methods We conducted a retrospective review of patients diagnosed with status migrainosus at the Mayo Clinic, Rochester, between January 2005 and December 2015. All the records were then manually reviewed for patients with migraine headaches exclusively lasting more than 72 hours. Results We identified 18 patients with ESM, with a female predominance (15(83.3%)) and a median age of onset of 16.5 (IQR 13–19) years. The median monthly attack frequency was two (IQR 1–3), with each attack lasting a median duration of seven (IQR 4–12.5) days. Stress was the most commonly reported precipitant (11 (61.1%)). Migraine with aura was common (10 (55.6%)), as was comorbid depression (10 (55.6%)). Fifteen (83.3%) patients developed CM at a median of 7.8 (IQR 2.6–21.9) years from their first attack. There was no significant association between the time to the development of chronic migraine with either attack frequency or duration. Conclusions and relevance We report the existence of a novel migraine subtype, episodic status migrainosus. This migraine subtype appears to have similar clinical characteristics to episodic migraine with or without aura, except for a notably high tendency to progress to chronic migraine.

This report reviews a series of 3 patients who developed superficial siderosis following posterior fossa operations in which dural closure was incomplete. In all 3 patients, revision surgery and complete duraplasty was performed to halt the progression of superficial siderosis. Following surgery, 2 patients experienced resolution of their CSF xanthochromia while 1 patient had reduced CSF xanthochromia. In this paper the authors also review the etiology, pathophysiology, diagnosis, and treatment of this condition. The authors suggest that posterior fossa dural patency and pseudomeningocele are risk factors for the latent development of superficial siderosis and recommend that revision duraplasty be performed in patients with posterior fossa pseudomeningoceles and superficial siderosis to prevent progression of the disease.