Increase in white matter hyperintensities seen in migraine patients

Image: CC/JKB

Study author, Dr. Kruit, MD, PhD talks to 2 Minute Medicine Neuroradiologist, Leiden University Medical Center, the Netherlands:  

“The baseline findings that were published in JAMA in 2004 suggested that (migraine) attacks might cause brain lesions. The current findings did not show any effect of attack-rate or attack-number on the risk of progression. Physicians should acknowledge that the disease migraine is a risk factor for ongoing brain changes, but that the total volume of changes is low and diffuse, and that there is no clear effect of these relatively limited changes on cognitive function. Therefore, there is no need for changes in the way migraine patients are treated, based on the study results. Patients should not live with the idea that each migraine attack is potentially “damaging” their brain.” 

Key Study Points:

1. Greater total volume of deep white matter hyperintensities are seen on brain MRI in patients with migraines.
2. Higher incidence of the progression of brain MRI lesions are seen in patients with migraines.
3. No association can be made between migraine-related MRI lesions and cognitive functioning.

Primer: Migraine headaches are amongst the most common neurological conditions, making them the focus of much clinical investigation. One of the major concerns facing migraine headaches has been the details of its pathophysiology and its relation to further neurological disease. Traditionally, migraines have been thought to be related to vascular events in the brain with neurological sequelae; however, more recent studies have suggested the reverse might be true. This is particularly important because vascular compromise of any sort in the brain is concerning for serious, and potentially permanent consequences. In prior studies, patients with migraines were found to have an increased risk of MRI-detected brain lesions which were hypothesized to be associated with an increased risk of stroke, dementia, and death. This study aims to elucidate whether these lesions in patients with migraines progress over time and/or lead to a cognitive decline as compared to individuals without migraines.

Background Reading:  

1. Kruit MC, van Buchem MA, Launer LJ, Terwindt GM, Ferrari MD. Migraine is associated with an increased risk of deep white matter lesions, subclinical posterior circulation infarcts and brain iron accumulation: the population-based MRI CAMERA study. Cephalalgia. 2010;30(2):129–136.

2. Cutrer FM. Pathophysiology of migraine. Semin Neurol. 2006;26(2):171–180.

3. Debette S, Markus HS. The clinical importance of white matter hyperintensities on brain magnetic resonance imaging: systematic review and meta-analysis. BMJ. 2010;341:c3666.

This [prospective, population-based observational] study: This was a 9-year follow-up study in which 203 migraine patients and 83 control patients (n=286, 71% women) were included. Repeat brain MRI was performed for comparison to baseline imaging. Cognitive function testing and a questionnaire assessing for patterns in migraine attack occurrences were also performed. The primary outcomes measured were the number and volume of cerebral deep white matter hyperintensities (DWMH), infratentorial hyperintensities, and posterior circulation infarct-like lesions. Cognitive function was tested as a secondary analysis.

The study found that women, not men, in the migraine group had a greater total volume of DWMH, both at baseline and follow-up. They also found that of the female participants, 77% in the migraine group had progression of DWMH compared to 60% in the control group (p=.02). These MRI changes, however, were not found to have any significant association to changes in cognition or patterns of migraine attack occurrence.

In sum: This study demonstrates that over a 9-year period, there is a significant increase in brain MRI lesions in women with migraines as compared to control. These findings suggest that migraine disease may be associated with structural changes in the deep cerebral white matter. However, the clinical significance of such findings remains unclear, as there was no association made between the increase in lesions and cognitive functioning, nor was there any significant difference in the progression of these lesions based on frequency and duration of migraine attacks.

Though very consistent methods of data collection were used at baseline and at follow-up, the small sample size and overwhelming majority of female participants (71%) challenge the generalizability of this study. While the study indicates no association of DWMH with migraines for men, a larger investigation would be necessary to verify this.  Furthermore, given a follow up interval of only 9 years, a longer time period may be needed to find an association between migraine-related MRI changes and cognitive functioning. Thus, the current findings warrant further investigation into the role of migraine headaches in structural damage to the brain, and more refined testing to look for clinical correlates of the imaging findings.

Click here to read the study [JAMA]

By [SM] and [RR]

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