Pathophysiology of Migraine

Mainero C, Boshyan J, Hadjikhani N. Altered functional magnetic resonance imaging resting-state connectivity in periaqueductal gray networks in migraine. Annals of Neurology 2011;70:838-845. Objective: The periaqueductal gray matter (PAG), a known modulator of somatic pain transmission, shows evidence of interictal functional and structural abnormalities in migraineurs, which may contribute to hyperexcitability along spinal and trigeminal nociceptive pathways, and lead to the migraine attack. The aim of this study was to examine functional connectivity of the PAG in migraine. Methods: Using resting-state functional MRI, we compared functional connectivity between PAG and a subset of brain areas involved in nociceptive/somatosensory processing and pain modulation in 17 subjects with migraine, during a pain-free state, versus 17 genderand age-matched controls. We also assessed the relation between intrinsic resting-state correlations within PAG networks and the average monthly frequency of migraine attacks, as well as allodynia. Results: Our findings show stronger connectivity between the PAG and several brain areas within nociceptive and somatosensory processing pathways in migraineurs versus controls. In addition, as the monthly frequency of migraine attacks worsens, the strength of the connectivity in some areas within these pathways increases, whereas a significant decrease in functional resting-state connectivity between the PAG and brain regions with a predominant role in pain modulation (prefrontal cortex, anterior cingulate, amygdala) can be evidenced. Finally, migraineurs with a history of allodynia exhibit significantly reduced connectivity between PAG, prefrontal regions, and anterior cingulate compared to migraineurs without allodynia. Interpretation: These data reveal interictal dysfunctional dynamics within pain pathways in migraine manifested as an impairment of the descending pain modulatory circuits, likely leading to loss of pain inhibition, and hyperexcitability primarily in nociceptive areas. Comments: Functional neuroimaging techniques have helped elucidate the underlying physiology of migraines. Unlike traditional functional magnetic resonance imaging scans done during a task, resting state functional connectivity is a relatively new neuroimaging technique in which participants are scanned at rest, and the lowfrequency spontaneous fluctuations found to be highly correlated are thought to represent brain areas that are functionally connected at baseline. Mainero et al recently conducted this study to assess the functional connectivity of the periaqueductal gray (PAG) (a region previously implicated in the pathogenesis of migraine) to other brain regions in 17 migraineurs interictally compared with 17 age-/gendermatched controls. They found that compared with the controls, the migraineurs had increased resting state functional connectivity between the PAG, and somatosensory and nociceptive processing pathways. The connections between the PAG and the supramarginal gyrus, anterior insula, and hypothalamus were increased in migraineurs with more frequent attacks, while the connections between PAG and the prefrontal cortex, anterior cingulate, amygdala, and medial thalamus were decreased in migraineurs with more frequent attacks. The 5 migraineurs with allodynia also had significantly reduced connectivity between the PAG and the anterior insula, anterior cingulate, and prefrontal cortex vs genderand age-matched migraineurs without allodynia. This study is one of the first to use resting state functional connectivity analyses to compare the intrinsic neural connections in migraineurs vs controls. As expected, many of the connections between the PAG, and nociceptive and sensory processing pathways were increased in the migraineurs, and some of those connections were stronger in those with more frequent attacks. However, unexpectedly, those with more frequent migraines and those with allodynia had decreased connections between the PAG and areas involved in the cognitive modulation of pain. This suggests that From the Graham Headache Center, Faulkner/Brigham and Women’s Hospital, Boston, MA,