Headache Neuroimaging in Migraine—Recent Advances and Perspectives for the Future Brian K Day, MD, PhD,1 David W Dodick, MD2 and Todd J Schwedt, MD, MSCI3
1. Resident Neurologist, Department of Neurology, Washington University School of Medicine; 2. Professor of Neurology, Mayo Clinic; 3. Assistant Professor of Neurology and Anesthesiology, and Director, Washington University Headache Clinic, Washington University School of Medicine
Abstract
Migraine is a very common disorder that imposes substantial individual and societal costs. A better understanding of migraine mechanisms may lead to the development of new therapies and thus improve the management of migraine patients. Magnetic resonance imaging (MRI) techniques and positron emission tomography (PET) have revolutionized our understanding of migraine pathophysiology as a primary central nervous system (CNS) disorder, advanced the search for a central migraine generator, clarified the role of cortical spreading depression (CSD) and central sensitization in the pathogenesis of migraine, and revealed some potential sites of action of migraine medications. Structural imaging has shed light on relationships between migraine and stroke, white matter lesions, iron deposition, microstructural brain damage, and other gray and white matter aberrations. Emerging neuroimaging techniques, such as arterial spin labeling (ASL) and functional connectivity MRI (fcMRI), are beginning to provide further evidence of functional brain alterations in migraine patients. Ultimately, it is hoped that advanced neuroimaging will benefit the individual migraine patient by enhancing our diagnostic abilities, allowing for development of better treatments and serving as an important tool in medical decision-making.
Keywords Migraine, magnetic resonance imaging, neuroimaging, headache, functional magnetic resonance imaging
Disclosure: Brian K Day, MD, PhD, has no conflicts of interest to declare. David W Dodick, MD, has in the past 12 months consulted for Allergan, Pfizer, Merck, Zogenix, Coherex, Neuralieve, Neuraxon, Boston Scientific, Medtronic, MAP, Nautilus, Novartis, and Eli Lilly, has received research support from ANS, Medtronic, and St Jude, and has received editorial stipends from Wiley-Blackwell and SAGE. Todd J Schwedt, MD, MSCI, was supported by National Institutes of Health (NIH) KL2RR024994 for work that went into this manuscript, and in the last 12 months he has received research support from the NIH, the American Headache Society, the National Headache Foundation, AGA Medical, and Merck Inc. and has consulted for VerusMed. Received: May 16, 2010 Accepted: June 30, 2010 Citation: US Neurology, 2010;6(1):82–6 Correspondence: Todd J Schwedt, MD, MSCI, Washington University School of Medicine, 660 South Euclid Avenue, Campus Box 8111, St Louis, MO 63110. E:
schwedtt@neuro.wustl.edu
Migraine is a highly prevalent disorder, affecting 27 million women and 10 million men in the US.1
and 18% of men will experience migraine.2 from migraine exceed $15 billion per year in the US alone.3
Over the course of a lifetime, 43% of women Direct and indirect costs Migraine
patients suffer the burdens of acute and sometimes chronic pain, discomfort from environmental sensitivities, and inability to fully contribute in their personal and professional lives. A better understanding of migraine mechanisms is needed so that more successful migraine therapeutics can be developed. Functional and structural neuroimaging has played and will continue to play an essential role in elucidating migraine pathophysiology. Advanced neuroimaging techniques may eventually assist in the diagnosis and treatment of individual migraine patients and may facilitate the development of new migraine therapies.
Neuroimaging Techniques and Timing Multiple neuroimaging techniques have been utilized to investigate structural and functional aberrations associated with migraine. Most of
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the recently published migraine studies have used magnetic resonance imaging (MRI) techniques such as perfusion weighted imaging (PWI), diffusion tensor imaging (DTI)/tractography, functional MRI (fMRI), voxel-based morphometry (VBM), high-resolution MRI, and MR angiography (MRA).
PWI is a technique that requires a contrast bolus to quantify cerebral blood flow. PWI also provides data about cerebral blood volume and mean transit time—the time it takes the bolus material to travel from the arterial to the venous phase. DTI utilizes the anisotropic movement of water molecules to identify and display the orientation of white matter tracts. High-resolution MRI provides information about paramagnetic compounds in the brain such as iron. fMRI provides information about functional activity in the brain based on the underlying assumption that changes in the blood-oxygen-level- dependent (BOLD) signal reflects neural activity. VBM is a technique that uses voxel-wise parametric statistical tests to investigate regional differences in brain anatomy. MRA images arteries either by using a
© TOUCH BRIEFINGS 2010
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