Migraine and Structural Changes in the Brain

These valuable data present some very challenging issues from a pathophysiological perspective. First, there is much good news. Migraine-without-aura patients are not at any important risk for either white-matter abnormalities or infarct-like lesions. Moreover, prospective studies show no cognitive penalty for migraine or for these MRI changes (BMJ 2011; 342:c7357; Cephalalgia 2011; 31:1291; and JAMA 2012; 308:1889). Physicians can thus continue with current practice recommendations that, in patients with migraine and a normal examination, no imaging is required. The infarct-like lesions remain an issue; given that they are no more common in migraine with or without aura than in controls, migraine itself is, arguably, no reason to image. Rather, any concern regarding cerebrovascular disease should be dealt with on its own merits. The volumetric changes, as the authors say, are a research tool. They reinforce the major physiology-related question the review exposes: Are structural brain changes part of the migraine condition (i.e., static and associated with the disorder) or are they a consequence (i.e., progressive in some way with disorder activity), and would that have management implications? As there is no cognitive or other penalty for migraine, and the abnormalities seem static, with the caveat that much more longitudinal data are needed, perhaps the findings simply mark the inheritance of migraine. Resolving this question is hugely important and will require a well-funded, large-scale, population-based imaging study. Perhaps this can be one of the goals of the new large-scale NIH brain-imaging project. To understand what happens with time to the human brain in health and disease would be a wonderful legacy for the next generation.