Are some patient-perceived migraine triggers simply early manifestations of the attack?

DOI: https://doi.org/10.1007/s00415- 020- 10344- 1

Abstract-Summary To study the agreement between self-reported trigger factors and early premonitory symptoms amongst a group of migraineurs in both spontaneous and pharmacologi- cally provoked attacks.

Fifty-three subjects with migraine with and without aura, with ≤ 22 headache days/month, with spontaneous premonitory symptoms associated with migraine attacks were recruited nationally.

A detailed history was taken by a study investigator to confirm diagnosis and extended phenotyping was performed to identify patient-reported triggers for migraine attacks, premonitory symptom phenotype and headache characteristics, using a standardised physician-administered questionnaire.

Percentage agreement and Cohen’s kappa measure of agreement were used to identify concordance between patient-reported triggers and the corresponding spon- taneous and triggered premonitory symptoms.

There was statistically significant agreement between perception of light as a migraine trigger and spontaneous premonitory photophobia; perception of sound as a trigger and triggered premonitory phonophobia; skipping meals as a trigger and spontaneous premonitory food cravings; and food triggers and spontaneous pre- monitory food cravings.

At least some patient-reported triggers, such as light, sound, foods and skipping meals, may represent early brain manifestations of the premonitory phase of the migraine attack.

Extended: These differences are important to recognise, and highlight the impor- tance of large-scale population-based prospective diary studies going forwards, to further inform on these relationships in the future.

Introduction We wished to examine reported triggers and premonitory symptoms amongst the same individuals in patients with migraine with and without aura, to look for such an association in both retrospectively reported spontaneous attacks, and prospec- tively observed nitroglycerin-triggered attacks.

Our results show an association between some spontaneous patient-reported trig- gers, and spontaneous and nitroglycerin-triggered premonitory symptoms within the same subject.

Going forwards, use of electronic diary systems and device application technol- ogy, following patient education, to allow prospective recording of perceived trig- gers, premonitory symptoms and their association to headache during spontaneous attacks, would be a valuable means of assessing these relationships, understanding better the mechanisms behind attack initiation and advancing therapeutics.

3.2 Medical history

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Whilst we do not consider that there are likely to be fundamental biological dif- ferences between pharmacologically -provoked and spontaneously occurring migraine attacks (akin to alcohol-induced migraine attacks), the drug itself, the study environment and the recording of triggered symptoms may have impacted on the results and caused the observed differences in premonitory symptom association with triggers between spontaneous and triggered attacks.

Conclusions Despite the limitations discussed, there does seem to be a relationship between some triggers and premonitory symptoms.

Emerging functional imaging work, as well as animal migraine models looking at some premonitory symptoms, has suggested that early activation of brain areas, pathways and neuropeptide systems occur during the premonitory phase and are responsible for mediating some of these symptoms via hypothalamic and other diencephalic mechanisms [148].

There is, therefore, a neuroimaging correlate for how these symptoms may be mediated centrally, for example, with the thalamus and connections to visual cortex likely being involved in photophobia and hypothalamic connections to pontine areas and pontine connections to cortical areas being involved in regulation of feed- ing [149].

Acknowledgement A machine generated summary based on the work of Karsan, Nazia; Bose, Pyari; Newman, Jayde; Goadsby, Peter J. 2021 in Journal of Neurology.

Fluctuations in episodic and chronic migraine status over the course of 1 year: implications for diagnosis, treatment and clinical trial design