Changes in oxidative stress and inflammation biomarkers in the pathogenesis of migraine: possible relationships with lipid metabolism

Abstract

Introduction

Migraine is a common neurological disease that limits daily life. Researchers have proposed various mechanisms in the pathogenesis of migraine, including vascular dysfunction, neurogenic inflammation, oxidative stress, and stimulation of the trigeminovascular system. Studies consistently demonstrate the impact of oxidative stress and neurogenic inflammation on lipid metabolism. Although causality cannot be definitively established, several studies suggest that migraine may be associated with alterations in lipid metabolism, potentially resulting in an atherogenic lipid profile. This study aimed to investigate the status of oxidative stress and inflammation during the interictal phase of migraine and explore their potential impact on lipid metabolism.

Methods

The Neurology outpatient clinic included fifty-seven migraine patients and thirty control cases. Migraine diagnosis and classification were made according to the International Classification of Headache Disorders (ICHD-3), with clear categorization into episodic or chronic migraine and migraine with aura (MWA) or without aura (MWoA). Serum levels of malondialdehyde (MDA, a marker of lipid peroxidation), glutathione (GSH, an antioxidant), NOD-like receptor family pyrin domain containing 3 (NLRP3, an inflammasome component), and nuclear factor kappa B (NF-κB, a proinflammatory transcription factor), as well as lipid parameters and headache characteristics, were assessed. CRP levels were measured via standard turbidimetric method; MDA and GSH were determined using spectrophotometric methods; NLRP3 and NF-κB were analyzed using ELISA kits per manufacturer protocols.

Results

In migraine patients, MDA and CRP levels significantly increased, while GSH and NLRP3 levels significantly decreased (p < 0.05). Subgroup analysis revealed that CRP and NLRP3 levels were significantly different between MWA and MWoA groups. Additionally, LDL levels were higher in patients with MWA.

Conclusions

This study demonstrates a statistically significant association between elevated oxidative stress (increased MDA, decreased GSH), altered inflammatory response (elevated CRP, reduced NLRP3), and migraine. Differences between MWA and MWoA suggest subtype-specific pathophysiological mechanisms. Although this study supports a potential link between oxidative stress, inflammation, and lipid metabolism in migraine, they do not establish causality. These biomarkers may represent targets for future diagnostic and therapeutic strategies.

Introduction

Migraine is a common, complex neurological disease that limits daily life [1, 2]. Many studies have shown that migraines are caused by a number of different mechanisms, including vascular dysfunction, neurogenic inflammation, oxidative stress, and stimulation of the trigeminovascular system [3, 4]. Despite extensive research, the primary cause of migraine remains incompletely understood.

Migraines are induced by stimulation of the trigeminovascular system. Several cytokines related with migraine, including tumour necrosis factor (TNF), interleukin 1 (IL-1), and adiponectin, cause inflammation, pain threshold modification, and trigeminal nerve fibre sensitisation [5, 6]. Studies have shown an increase in plasma levels of pro- and anti-inflammatory cytokines during migraine attacks. Neuroinflammation is involved in the pathophysiology of several neurological diseases, including migraine. It has also been linked to comorbid migraine disorders. A small number of studies in rodents have demonstrated the connection between migraine and inflammasome, despite neuroinflammation in migraine indirectly indicating the role of the inflammasome [5, 6]. Based on the current scientific evidence, it appears unreasonable to suggest that C-reaktive protein (CRP) actively contributes to migraine pathogenesis. Instead, it is hypothesized that elevated CRP levels observed in migraine patients may reflect underlying pathogenic mechanisms such as hypertension, diabetes, dyslipidemia, obesity, and depression or pathological conditions like vascular inflammation and/or impaired vascular reactivity, which are common to both migraine and cardiovascular diseases. Alternatively, increased CRP levels may simply represent an epiphenomenon of neurogenic inflammation. When migraine is considered a chronic inflammatory disorder, systemic inflammation can be viewed as a continuous process, and elevated CRP concentrations may serve as a peripheral biomarker reflecting this persistent inflammatory state [7].

Oxidative stress is a significant mechanism in migraine’s pathophysiology. Malondialdehyde (MDA), a lipid oxidation end product, is an indicator of oxidative stress and reactive oxygen species (ROS) production [3]. There is strong evidence that oxidative stress has a significant impact on migraine pathogenesis and metabolic alterations. Migraine patients have higher oxidant levels [8]. In migraine, increased oxidative stress leads to an atherogenic lipid profile and metabolic risk [9]. As a result, it is critical to understand migraine complications and identify the factors that increase them. One of these factors is dyslipidaemia’s role in the onset and aggravation of migraine attacks. Some studies have demonstrated that elevated cholesterol levels can be observed in migraine patients, (especially MWA) [10–12]. It is crucial to diagnose dyslipidaemia in order to prevent cardiovascular disease [13]. Some studies have found an association between high serum lipid levels and the frequency and severity of migraine attacks [14, 15]. While some studies have shown an increased risk of cardiovascular diseases such as stroke, atherosclerosis, and even coronary heart disease in migraine patients; one of the possible risk factors for this could be the existence of dyslipidaemia in migraine patients [16–18].

We designed this study to examine the laboratory parameters and individual characteristics that influence the pathogenesis of migraine patients, which is an important health issue. We investigated MDA and glutathione (GSH) levels, which are oxidative stress and antioxidant system parameters, as well as NOD-like receptor family pyrin domain containing 3 (NLRP3) and nuclear factor kappaB (NF-κB) concentrations, which are related with the inflammation process in patients with migraine compared to healthy controls. We hypothesize that migraine patients exhibit altered levels of these biomarkers, reflecting dysregulated oxidative and inflammatory processes, which may be mechanistically linked to metabolic changes observed in migraine.

In summary, this study aims to elucidate the molecular mechanisms underpinning metabolic alterations associated with inflammation and oxidative stress in migraine, thereby providing insights that may facilitate the development of targeted diagnostic and therapeutic strategies.

Materials and methods

Study design

This study included fifty-seven migraine patients (n = 57 women; age: 36 ± 8 years) and age-matched control cases (n = 30 women; age: 37 ± 8 years) who visited the Neurology outpatient clinic at Lokman Hekim Akay Hospital between August 2022 and May 2023. The ethics committee of Lokman Hekim University has granted approval (Code No: 2022111). Date: March 8, 2022, for all procedures.

The study comprised participants who had been diagnosed with migraine using the International Classification of Headache Disorders (ICHD-3) criteria. We categorised them as migraine with aura (MWA), migraine without aura (MWoA), episodic migraine (EM), and chronic migraine (CM). Migraine patients were free of headache at the time of sampling. Migraine patients in the interictal phase, not in the preictal phase (within 72 h of the next headache) or postictal phase (within 24 h of the previous headache) were included in the study. The control group was composed of individuals with similar features who were admitted to the hospital for a variety of reasons, did not experience more than one headache per month, and did not meet the ICHD-3 diagnostic criteria. During the study period, 65 migraine patients participated, 8 of them were male. Due to the insufficient number of male participants for statistical analysis, data from this group were not included in the study. The study did not include pregnant and lactating mothers, patients with certain diseases such as hypertension, myocardial infarction, coronary heart disease, heart failure, diabetes, and obesity, patients using oral contraceptives and cholesterol-triglyceride-lowering drugs, or patients with systemic diseases like cancer and auto-immune diseases.

Specimens and biochemical analyses

Fasting blood samples were collected into vacuum tubes with gel separators (Vacutainer SST, Becton Dickinson), centrifuged the blood samples at 1300 g for 10 min, then transferred them to Eppendorf tubes and stored them at −80 °C until the study day.

Blood samples were collected from participants in the morning, after at least an 8-hour fast. To assess hematological parameters, whole blood samples were collected in EDTA tubes (Vacuette^® Tube 3 mL K2 EDTA) and counted using a Sysmex XN-1000 automated hematology analyzer (Sysmex Corp., Kobe, Japan). The neutrophil/lymphocyte ratio (NLR) and systemic immune-inflammation index (SII) were calculated from these data.

For biochemical analyses, serum samples were collected in gel biochemistry tubes (Vacuette^® Tube 5 mL Gel) and analyzed after centrifugation. Ferritin levels were measured using electrochemiluminescence immunoassay (ECLIA) on a Roche Cobas e601 instrument (Roche Diagnostics Corp., Basel, Switzerland). Serum CRP levels were assessed using the turbidimetric method on a Roche Cobas c501 instrument. Other biochemical parameters, including fasting blood glucose, urea, hemoglobin, vitamin B12, vitamin D, folic acid, HDL, LDL, triglycerides, ALT, AST, GGT, creatinine, e-GFR, and TSH, were analyzed using the photometric method on a Roche Cobas c501 instrument.

Analysis of serum NLRP3 and NF-κB concentrations

NLRP3 and NF-κB serum protein levels were analysed by sandwich Enzyme- Linked ImmunoSorbent Assay (ELISA) using a commercial kit according to the manufacturer’s protocols. The human ELISA kit used serum NLRP3 (Nepenthe, Cat. No: NE010650501) and serum NF-B (Nepenthe, Cat. No: NE010069001) concentrations. Inter-assay and intra-assay values were < 8% and < 10%. We diluted the standard solutions in the kits according to the procedure and formed standards at different concentrations. We determined the concentrations based on the standard curve of the respective test. We measured test detection range concentrations of 0.5–32 ng/mL for NLRP3 and 0.09–6.09 ng/mL for NF-κB. All samples were analysed in duplicate, and the mean was used in subsequent calculations.

Analysis of serum MDA and GSH concentration

The spectrophotometric method was used to measure the colour formation that occurred as a result of the reaction between MDA and thiobarbituric acid (TBA) at 532 nm. The results were reported in µmol/L [19].

The modified Ellman procedure was employed to quantify GSH levels. The absorbance values of the samples were read at 412 nm, and the results were reported in µmol/L [20].

Statistical analysis

The IBM SPSS Statistics^® 26.0 and MS-Excel^® 2010 programs were employed to statistically analyse the data collated in the study. The Shapiro-Wilks test was employed to evaluate the conformity of the data to the distribution for continuous variables. One-way ANOVA and Kruskal-Wallis tests were implemented to compare laboratory parameters between migraine and control groups. The Bonferroni correction was applied to reduce false positives that may arise due to multiple comparisons, and the corrected p-values are presented. The Spearman correlation was employed to determine the relationship between two quantitative variables.

If the results show a normal distribution, the mean ± standard deviation was calculated. If the results did not exhibit a normal distribution, they were reported as the median (interquartile range). When r values fall between 0 and 0.25 (or −0.25 and 0), Correlation coefficients (r) were interpreted as “weak or no linear relationship”; for r values between 0.25 and 0.5 (or −0.5 and − 0.25) they were interpreted as “moderate linear relationship”; for r values between 0.50 and 0.75 (or −0.75 and − 0.50) they were interpreted as “moderately strong linear relationship”; for r values between 0.75 and 1 (or −1 and − 0.75) they were interpreted as “very strong linear relationship.” p values < 0.05 were considered statistically significant.

Associated factors of migraine, and multivariate regression analysis was used to determine Odds Ratios (OR). A logistic (logit) transformation was applied in the regression analyses of non-normally distributed parameters (NLRP3, MDA, GSH, LDL, CRP). Since the dependent variable exhibited a continuous distribution between 0 and 1, the logit transformation was employed to meet the assumptions of linear regression analysis. This transformation helped normalize the distribution and stabilize the variance, thereby improving the robustness and validity of the model.

Results

A total of 57 migraine patients and 30 controls were included in the study. MWA was observed in 25 (44%) patients, while MWoA was observed in 32 (56%) patients. CM was present in 6 (11%) of the migraine patients, while the remaining 51 (89%) patients had EM. The mean monthly headache attack frequency was 5.4 ± 4.2 and the disease duration (years) was 10.4 ± 8.0.

Table 1 presented the baseline characteristics of the migraine and control groups. There was no significant difference in age, smoking, or BMI between migraineur and healthy controls. All of the migraine and control group participants were female. Migraine patients had a significantly higher educational status (p = 0.013). Table 2 presented the laboratory results of the migraine groups (MWA-MWoA) and the control group along with the findings of the statistical analysis.

Table 1.

Demographic findings of MWA, MWoA and control groups

	Control (n = 30)	MWA (n = 25)	MWoA (n = 32)	p-value
Age	38 (32–44)	37 (32–41)	35 (29–42)	0.671
BMI (Body Mass Index)	23 (21–25)	24 (23–27)	25 (21–28)	0.264
Pre-university graduate/University graduate and above	21/9	11/14	12/20*	0.029
Smoking (No/Yes)	25/5	15/10	20/12	0.335

*Statistical difference with the control group p < 0.05

Bold indicates statistically significant value (p < 0.05)

Table 2.

Laboratory findings of MWA, MWoA and control groups

	Control (n = 30)	MWA (n = 25)	MWoA (n = 32)	p-value
NLRP3 (ng/mL)	2.66 (1.93–9.67)	1.80 (1.50–3.48) *	2.03 (1.54–4.60)	0.011
NFKB (ng/mL)	0.66 (0.60–0.80)	0.68 (0.55–1.16)	0.72 (0.58–1.09)	0.474
MDA (µmol/L)	0.78 (0.54–1.37)	1.82 (0.84–6.07) *	2.83 (1.77–4.92) *	< 0.0001
GSH (µmol/L)	31.3 (26.6–36.5)	27.7 (23.9–31.8) *	27.7 (24.7–32.1) *	0.016
Fasting Blood Glucose (mg/dL)	89 (86–93)	87 (81–93)	92 (84–98)	0.423
Urea (mg/dL)	21.3 (17.1–26.8)	19.0 (16.0–23.0)	20.0 (14.5–25.5)	0.384
Hemoglobin (g/dL)	13.3 (12.0–14.2.0.2)	13.3 (12.6–13.8)	13.5 (12.7–14.0)	0.726
Vitamin B12 (pg/mL)	418 (322–451)	343 (303–404)	363 (290–496)	0.345
Vitamin D (µg/L)	21 (14–28)	19 (13–25)	20 (14–28)	0.941
Folic acid (ng/mL)	7.08 (5.44–8.95)	7.58 (5.40–8.03)	7.42 (6.13–9.98)	0.471
HDL (mg/dL)	53 (45–63)	50 (38–59)	57 (47–65)	0.264
LDL (mg/dL)	103 (95–121)	120 (110–142) *	108 (96–129)	0.007
Triglyceride (mg/dL)	94 (76–114)	121 (89–156)	109 (68–130)	0.050
ALT (U/L)	12 (10–19)	18 (11–22)	13 (11–22)	0.199
AST (U/L)	15 (13–18)	16 (14–20)	18 (15–22)	0.079
GGT (U/L)	13 (10–16)	12 (10–16)	14 (10–17)	0.776
Creatinine (mg/dL)	0,70 (0.63–0.73)	0.72 (0.65–0.79)	0.65 (0.60–0.77)	0.329
e-GFR	108 (98–116)	107 (94–114)	114 (101–120)	0.266
TSH (mIU/L)	1.40 (1.06–2.36)	1.56 (1.39–1.80)	1.39 (0.82–1.97)	0.663
CRP (mg/L)	0.90 (0.47–1.81)	2.10 (1.24–4.70) *	1.17 (0.80–2.41)	0.014
Ferritin (ug/L)	17.7 (10.3–37.7)	26.0 (14.5–38.5)	29.5 (16.8–45.6)	0.253
WBC (10 3 /mm³)	6.32 (5.37–7.33)	7.76 (6.20–8.54)	6.63 (5.65–7.92)	0.073
Neutrophil (10 9 /L)	3.35 (2.78–4.43)	4.16 (3.25–5.10)	3.91 (3.09–4.72)	0.089
Lymphocyte (10³/µL)	2.00 (1.87–2.25)	2.47 (1.90–2.90)	2.10 (1.60–2.60)	0.081
Monocyte (10³/µL)	0.47 (0.39–0.59)	0.50 (0.46–0.59)	0.48 (0.38–0.58)	0.396
Platelet (10³/µL)	285 (249–331)	288 (271–346)	270 (235–306)	0.174
SII	530 (384–617)	473 (386–660)	476 (387–602)	0.917
AISI	248 (158–328)	263 (194–343)	232 (156–323)	0.619
SIRI	0.84 (0.58–1.09)	1.01 (0.67–1.17)	0.81 (0.63–1.15)	0.595
LMR	4.13 (3.54–5.53)	4.49 (3.64–5.56)	4.55 (3.17–5.68)	0.847
PLR	138 (120–172)	119 (97–141)	125 (99–174)	0.177
NLO	510 (384–617)	493 (386–660)	475 (387–578)	0.988
dNLR	1.17 (1.03–1.57)	1.22 (1.04–1.64)	1.37 (1.06–1.66)	0.622
LCR	2.06 (1.20–4.58)	0.9 (0.6–2.8)	1.68 (0.92–2.68)	0.062

Data are presented as median-interquartile range (IQR). Comparisons of three or more groups were made using the Kruskal-Wallis test and Bonferroni correction was applied

Abbreviations: MWA Migraine patients with aura, MWoA Migraine patients without aura, NLRP3 NOD-like receptor family pyrin domain containing 3, NFKB Nuclear Factor kappa B, MDA Malondialdehyde, GSH Glutathione, HDL High Density Lipoprotein, LDL Low Density Lipoprotein, ALT Alanine Aminotransferase, AST Aspartate Aminotransferase, GGT Gamma Glutamyl Transferase, e-GFR Glomerular Filtration Rate, TSH Thyroid Stimulating Hormone, CRP C-reactive protein, WBC White blood cell, SII Systemic Inflammation Index (Platelet*Neutrophil/Lymphocyte), AISI Systemic Inflammation Aggregate Index (Neutrophil*Platelet*Monocyte/Lymphocyte ratio), SIRI Systemic inflammatory response index (Neutrophil Monocyte/lymphocyte), LMR Lymphocyte/Monocyte, PLR Platelet/Lymphocyte, NLO Neutrophil/Lymphocyte, dNLR Derived NLR (Neutrophil/WBC-Neutrophil), LCR Lymphocyte/CRP

Bold indicates statistically significant value (p < 0.05)

*Statistical difference with the control group p < 0.05

MDA levels significantly increased (p < 0.0001) and GSH levels significantly decreased (p = 0.004) in migraine patients, according to analyses of oxidative stress markers. CRP and NLRP3 inflammatory markers showed significant differences between migraine patients and healthy controls. The migraine group exhibited a decrease in NLRP3 levels (p = 0.004), while CRP levels increased (p = 0.015). There was no significant difference in NF-κB levels between patient and the control groups (Fig. 1).

Fig. 1.

Box plots of key oxidative stress and inflammation parameters in migraine. (a) NLRP3 levels in control, MWoA, and MWA groups. (b) NF-κB levels in control, MWoA, and MWA groups. (c) MDA levels in control, MWoA, and MWA groups. (d) GSH levels in control, MWoA, and MWA groups. (e) CRP levels in control, MWoA, and MWA groups

In migraine Patients, lipid metabolism analysis revealed significant changes. Low density lipoprotein (LDL) levels (p = 0.029) were significantly increased in MWA compared to the control group. High-density lipoprotein (HDL) (p = 0.869) and triglyceride levels (p = 0.135) were not significantly different between the two groups. 9 (%16) of the migraine patients and 5 (%17) of the control group patients showed menopausal characteristics. No difference was found between the oxidative stress, inflammation markers and LDL values ​​of the patients with and without menopause in both groups. The study found no significant differences (p > 0.05) in fasting glucose levels, urea, creatinine, AST, ALT, hemogram, ferritin, vitamin B12, folic acid, and TSH.

Correlation analyses were performed for all parameters. Concentrations of NLRP3 and NF-κB were found to have a fair degree of linear positive correlation in patients with migraine. In addition, e-GFR and NF-κB were found to have a moderately strong degree of linear correlation. On the other hand, creatinine and NF-κB were found to have a moderately strong degree of linear negative correlation. The frequency and severity of migraine attacks were not associated with any parameters or elevated serum lipid levels.

All parameters were categorized accordingly, and their univariate logistic regression analyses were performed. While univariate logistic regression analyses indicated NLRP3, MDA, GSH, LDL, CRP, LCR and prophylactic treatment listed on Table 3 as statistically significant parameters associated with migraine; multivariate regression analysis only indicated MDA (cut-off = 1.28 µmol/L, OR = 0.326, 95% confidence interval (CI) = 0.163–0.652, p = 0.002) and glutathione (cut-off = 32.75 µmol/L, OR = 1.146, 95% CI = 1.015–1.294, p = 0.028), as independent risk factors.

Table 3.

Univariate end multivariate binary logistic regresyon analyses among parametres related to migraine

	Univariate analysis			Multivariate analysis
	p-value	OR	95% CI for OR	p-value	OR	95% CI for OR
NLRP3 (ng/mL)	0.007	1.356	1.053–1.747
MDA (µmol/L)	0.001	0.349	0.189–0.644	0.002	0.326	0.163–0.652
GSH (µmol/L)	0.004	1.130	1.039–1.229	0.028	1.146	1.015–1.294
LDL (mg/dL)	0.026	0.976	0.956–0.997
CRP (mg/L)	0.094	0.836	0.678–1.031
Lymphocyte/CRP (LCR)	0.018	1.356	1.053–1.747

Discussion

We examined the impact of oxidative stress and inflammation on the pathogenesis of migraine and migraine-related metabolic disorders in female migraine patients during the interval between headache attacks in this study. We discovered a significant increase in migraine patients MDA levels, regardless of aura symptoms. Similar to the study by Bernecker et al. [9] in female migraine patients, MDA represents an alternative pathway of oxidative stress MDA indicates an alternative pathway of oxidative stress.

This result is consistent with previous findings reporting that migraine patients have higher oxidative stress levels than the control group even during the interepisodic period [8, 21–23]. Migraine patients experience more oxidative and nitrosative stress than the healthy population, which is explained by increased serum levels of MDA, a lipid oxidation end product, and nitric oxide (NO), an oxidant/vasodilator [24–27]. At the same time, in this population, low antioxidant defence has also been demonstrated, as shown by the most well-known antioxidant enzymes (catalase (CAT), superoxide dismutase (SOD), glutathione peroxidase (GPx-1)) [24]. Furthermore, a meta-analysis of 19 migraine studies found that patients with migraines had higher oxidative stress parameters and lower activity of the antioxidant enzyme SOD compared to controls [28]. Similar findings have been supported by a number of other studies [29–32]. GSH and TAC (total antioxidant activity) levels were found to be low in the study by Gyanesh et al. [30] GSH and TAC levels increased significantly following treatment. Serum levels of paraoxonase-1 (PON-1) and TAC antioxidant markers were found to be low in a separate study conducted by Calisir et al. [23] In that study, the migraine group’s antioxidant GSH levels were significantly lower than the control group. This result strongly supports the role of oxidative stress in migraine. Nevertheless, there are studies that have identified no difference between the oxidative and antioxidative enzyme levels of migraine patients and control groups [32, 33]. This situation may be due to many factors and the effect of technical differences in the tests used to determine oxidative stress metabolites especially is emphasised.

High levels of MDA, a sign of oxidative stress, have been linked to cortical spreading depression (CSD) in both animal and human studies. CSD is one of the main pathological mechanisms thought to cause migraine pain, especially in MWA [34–38]. This study found no difference in MDA levels between MWA and MWoA. Despite the lack of conclusive proof regarding the role of oxidative stress in the pathophysiology of migraine, there is a hypothesis that the increased production of NO metabolites and ROS, along with proinflammatory mediators, could cause peroxidation of cell membrane phospholipids, destruction of intracellular molecules (particularly proteins and DNA), and ultimately disrupt the normal function of cells [24, 35, 39]. After protein and DNA oxidation, headache occurs through loss of receptor function, disruption of signalling pathways, hyperexcitability of cortical neurones in the transport system, CSD, neurogenic inflammation, and stimulation of the trigeminovascular system [35, 39]. Another study by Gupta et al. [8] showed that oxidative stress persisted in migraine patients in the inter-attack period, whereas it did not persist in patients with tension-type headaches (TTH). This may be due to the different pathophysiologic mechanisms of these two headaches. Oxidative damage is believed to be involved in the pathophysiology of diabetes, atherosclerosis, ageing, and various neurological disorders [9]. In this study, we found that LDL and oxidised LDL levels were significantly elevated in migraine patients (especially MWA), suggesting an atherogenic lipid profile associated with migraine as previously described [10, 11, 40]. This study, in support of other studies, showed that migraine is associated with metabolic changes in lipid metabolism, leading to an atherogenic lipid profile [10–12, 41–43]. In summary, our findings indicate a connection between migraine and elevated oxidative stress. This stress also triggers the production of nitrosative stress, leading to metabolic changes related to migraine and atherogenesis with severe clinical consequences. Thus, oxidative stress may represent an important mechanism in migraine pathophysiology and may be a suitable therapeutic target. However, further study is needed to understand the role of oxidative stress in migraine management.

Secondly, in this study, CRP and NLRP3 inflammatory markers showed significant differences between migraine patients and healthy controls. A decrease in NLRP3 levels and an increase in CRP levels were observed in the migraine group. Neuroinflammation is a mechanism that causes the development of numerous neurological diseases, including migraine and its comorbid disorders. Identifying the role of neuroinflammation in migraine provides new information about the disease’s development. The importance of inflammasome complexes in the central nervous system, as well as which inflammasome complexes interact in which situations, remains unknown. Further investigation is required to understand the roles of NLRP1, NLRP2, and AIM2 inflammasome units in migraine and its comorbidities. Neuroinflammatory mediators, particularly those involving inflammasome proteins, appear to be strong candidates as therapeutic targets and perhaps even biomarkers in migraine. The development of compounds targeting NLRP3 inflammasome signalling pathways in migraine is promising but it should be re-evaluated [5]. Clinical and experimental trials examining neuroinflammation in migraine have indirectly implicated the role of the inflammasome through inflammasome complexes such as IL-1β, IL-18, and caspase-1. So far, few rodent studies have examined the link between the inflammasome and migraine. One study showed that the NLRP3 inflammasome pathway induces a peripheral TG response in a rat model of intracranial pain caused by inflammatory dural stimulation [6]. Another study showed increased expression of the NLRP3 inflammasome in a mouse model of migraine-related pain (i.e., pain was created by repetitive NTG stimulation) and an increase in NLRP3 release associated with IL-1β activation. Studies have confirmed that decreased NLRP3 expression following increasing autophagy activity induces microglial activation and inflammatory re-reactions, leading to chronic worsening of migraine [44]. This study demonstrated the impact of the inflammatory mechanism of NLRP3 reduction in MWA during the interictal period. These data showed that the increase in NLRP3 was higher during the attack period and in chronic migraine patients. The decrease in NLRP3 observed in our study may be attributed to the fact that it was measured in episodic migraine patients during the interictal period.

We found significant changes in CRP levels in MWA, but we did not observe a correlation with oxidative stress parameters. Some studies supporting this study have reported that inflammatory processes play a role in migraine development, particularly MWA [45–47]. CRP is an important marker of active systemic inflammation and an independent risk indicator for cardiovascular diseases, such as ischaemic stroke [48, 49]. In that study, the fact that interictal CRP levels were increased in migraine patients compared to the healthy group is consistent with the studies conducted by Bhoi et al. [22] and Vanmolkolt et al. [48] Another study has shown that neuroinflammation, microglial activation and neurotransmitter imbalance in the brain persist during migraine attacks as well as outside of migraine attacks, which may increase overall systemic inflammation and lead to elevated CRP levels [50]. These findings suggest that CRP elevation in migraine is due to the pathophysiological processes of migraine associated with neuroinflammation, systemic inflammation and vascular changes. Considering that migraine is a chronic inflammatory disease, systemic inflammation in migraine is an ongoing process and CRP elevation may indicate this.

NF-κB is a master regulator of inflammation. The NO and CGRP-mediated loop initiated in the trigeminal ganglia may trigger migraine through NF-κB activation, suggesting a link between neuroinflammation and migraine [51]. Yang et al. [52] showed that hypoxia-inducible factor-1 alpha (HIF-1α) activators reduced inflammatory cytokine levels in serum and trigeminal nucleus caudalis (TNC) via the NF-κB pathway in a chronic migraine model induced by nitroglycerin injection in mice. In our study, no significant difference was found in NF-κB levels, which may be explained by the fact that patients with episodic migraine were examined in the interictal period. It may be more meaningful to study in chronic migraines and acute attacks.

Prophylactic migraine treatment aims to reduce the frequency, duration, and intensity of headache attacks. Flunarizine, a calcium antagonist used in prophylaxis, has been shown to be effective in limiting oxidative reactions [53]. The role of oxidative stress has been more clearly understood as a result of the development of novel drugs for migraine prophylaxis. In the future, these antioxidant drugs will serve as a new treatment option [54]. Furthermore, these therapies may reduce neurological damage and stroke risk, particularly in patients with MWA [33]. The role of mitochondrial damage and disorders in the electron transport system in the pathophysiology has been proven by the usefulness of substances that increase mitochondrial phosphorylation, such as riboflavin, coenzyme Q, niacin, and thioctic acid, in migraine prophylaxis [53, 55]. Statins have immunomodulatory, anti-inflammatory, antioxidant, and antiapoptotic functions besides their lipid-lowering effects. Therefore, treatment of hyperlipidaemia in migraine patients may reduce the frequency and intensity of headaches by affecting migraine pathogenesis in addition to atherosclerosis. An increasing number of studies have shown that inflammatory diseases are important targets for statin medications. A review provided data supporting the effect of statin medications on NLRP3 inflammasomes in relation to atherosclerosis [12, 56].

This study has several limitations that should be acknowledged. First, due to the insufficient number of male participants, data from this group were excluded from the statistical analysis, which may limit the generalizability of the findings across sexes. Second limitation of this study is that it was conducted during the interictal period, and the small number of chronic migraine patients involved. This study should be confirmed in a larger population and in different types and periods of migraine headache. Another, although oxidative stress and inflammatory parameters were evaluated in migraine patients, mediation analyses aimed at elucidating the relative contributions of these two mechanisms to migraine pathophysiology could not be performed. This limitation stems primarily from the study’s cross-sectional design and limited sample size. Mediation analyses require larger cohorts and prospective designs to support robust and reliable multivariate modeling. Therefore, future large-scale, longitudinal studies are warranted to provide a clearer understanding of the comparative roles of oxidative stress and inflammation in the pathogenesis of migraine.

Conclusions

In summary we found a strong and highly significant association between migraine and high MDA and low GSH levels, indicating oxidative stress. This study also demonstrated that inflammatory processes are effective in migraine pathophysiology, particularly with increased CRP and decreased NLRP-3 levels in MWA. In MWA, LDL and oxidized LDL levels were also significantly elevated. Our results suggest that oxidative stress and inflammation play a role in migraine pathophysiology and can lead to migraine-related metabolic changes. Our study is valuable in terms of demonstrating that inflammation is more effective in pathogenesis and predisposition to atherogenic lipid metabolism is higher in MWA. Additional research is required to gain a more comprehensive understanding of the role of inflammation and oxidative stress in the pathogenesis of migraine. Furthermore, the investigation of the impact of statin treatment on the pathogenesis of migraine-related hyperlipidaemia may contribute to the development of alternative treatment options.

Authors’ contributions

All authors conceptualised and designed the study. EE data acquisition, analysis, interpretation of findings, review, critique and manuscript drafting. YA analysis, interpretation of findings, review, and critique. NAK analysis, interpretation of findings, review, and critique. SG analysis, interpretation of findings, review, and critique. All authors have read and approved the final version of the manuscript.

Funding

This research did not receive any specific grant from fund agencies.

Data availability

Data is provided within the manuscript or supplementary information files.

Declarations

Ethics approval and consent to participate

The study protocol was approved by the ethics committee of Lokman Hekim University (Code No: 2022111/Date: March 8, 2022) and performed in accordance with the principles of The Declaration of Helsinki. Written informed consent was collected from all participants.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.