Table 1 Summary of the evidence of perturbed metabolic pathways from patient studies and in vivo data, and their hypothesised implications in migraine pathophysiology
From: Alterations in metabolic flux in migraine and the translational relevance
Metabolic pathway | Evidence of alterations in patients | Evidence of alterations in animal models | Potential implications in migraine pathophysiology |
|---|---|---|---|
Glucose utilization | • Glucose hypometabolism in migraine patients with and without aura, with associations with disease duration [37,38,39] | • Hypoglycaemia reduced CSD threshold, increased duration and exhibited spontaneous CSD events [29,30,31] | Repeated migraine attacks and activation of nociceptive regions may lead to abnormalities in glucose metabolism |
Lactate production | • Serum and plasma measurements exhibit upregulated lactate in migraine patients both with and without aura [44,45,46] • 1H-MRS studies demonstrated increased lactate in familial hemiplegic migraine and migraine with aura, but not in migraine without aura [48,49,50] | • Rat 1H-MRS studies exhibit increased lactate and reduced pH during CSD [41] | Lactate excess may be produced as a result of tissue hypoxia during metabolically challenging events such as CSD. Lactate may be used as alternative energy substrate and could signify an impaired astrocytic-neuronal interaction |
Lipid metabolism | • Alterations cholesterol and LDL were identified in migraine patients [58,59,60,61] • Higher lipid content in serum was associated with frequency and severity of migraine attacks [59, 60, 62] | Following CSD in mice, blood metabolite measurements exhibit alterations in lipid metabolism including increased prostaglandin and anti-inflammatory lipid mediators [66] | It is unknown if hyperlipemia is a cause or effect of migraine or related to comorbidities. Associations with cholesterol and LDL may provide an explanation for the increased cardiovascular and stroke risk in migraine with aura [63, 64] |
Fatty acid oxidation | • Chronic migraine patients demonstrated differentially metabolized fatty acids compared to controls, with levels correlating with depression [76] • PEA supplementation reduced headache attacks per month and pain intensity in migraine without aura, [78] and reduced pain intensity (in combination with non-steroidal anti-inflammatory analgesics) in migraine with aura [79]. Diets rich in omega 3 fatty acids reduced headache frequency) [80] |  | Fatty acids also play a role in modulating neuroinflammation and supplementation may aid in inflammatory aspects of migraine pathophysiology |
Mitochondrial function and oxidative phosphorylation | • Migraine patients exhibit increased ADP in those with aura and FHM [87,88,89] and decreased phosphorylation potential in both migraine with and without aura [90,91,92] • Co-enzyme Q10 studies exhibit a reduction in migraine attack duration, [99] frequency [100], severity and migraine days per month [101] • Reduction in attack frequency, [104] and severity [104, 105] was also accomplished with use of riboflavin | • CSD causes a surge in ATP production followed by reduced oxidative capacity, [42, 83, 84] and decreased mitochondrial membrane potential [85] | A decreased mitochondrial activity and increased energetic demand which may underlie the inability to maintain optimal intracellular ionic milieu and the reduced threshold for migraine attack |