Meningeal Contribution to Migraine Pain

A Magnetic Resonance Angiography Study

Sabrina Khan; Faisal Mohammad Amin; Casper Emil Christensen; Hashmat Ghanizada; Samaira Younis; Anne Christine Rye Olinger; Patrick J. H. de Koning; Henrik B. W. Larsson; Messoud Ashina


Brain. 2019;142(1):93-102. 

In This Article


Thirty female patients underwent the complete MRA scan protocol, of whom 26 fulfilled the criteria of migraine without aura at the time of the early attack scan (Figure 2 and Table 1). The remaining four patients did not fulfill migraine without aura criteria and were excluded from the analysis.

Figure 2.

Flowchart of study inclusion process. MO = migraine without aura.

Median time from migraine onset to early attack scan ranged from within 1 h after onset to maximum 4 h after onset. All 26 included patients fulfilled the ICHD-3 criteria of migraine without aura (Headache Classification Committee of the International Headache Society (IHS), 2013) at the fixed time of the early attack scan.

After the early attack scan, 11 of 26 patients received treatment with 6 mg subcutaneous sumatriptan, and underwent an additional scan 1 hour (range 25 min to 1 h) after treatment. The remaining 15 patients treated their attacks with promethazine and metoclopramide.

All 26 patients also underwent a late attack scan, median 30 h (range 28–33) after migraine onset for patients treated with sumatriptan, and median 28 h (range 27–33) after migraine onset for patients who did not treat with sumatriptan (Table 2).

Eighteen of 26 patients (69%) reported unilateral headache and eight (31%) reported bilateral headache with a predominant pain side. We tested for side-to-side differences in circumference of all investigated arterial segments at baseline, and found no difference between the pain and non-pain sides (P > 0.05).

Circumference Changes During the Early Migraine Attack

We found a unilateral increase in the circumference of MMA on the pain side, 5.23 ± 0.57 mm, compared to baseline, 5.00 ± 0.50 mm (P = 0.005) (Figure 3). There was no difference in MMA circumference on the non-pain side, 5.13 ± 0.43 mm, compared to baseline, 5.08 ± 0.49 mm (P = 0.473). Correspondingly, the circumference change on the pain side (0.24 ± 0.37 mm) was significantly larger than on the non-pain side (0.06 ± 0.38 mm) (P = 0.002).

Figure 3.

Per cent circumference change (%) and 95% CI error bars of the middle meningeal (n = 24), middle cerebral (n = 19), and the cavernous part of internal carotid artery (n = 24) at baseline and during early migraine attack. **Circumference change of the MMA was significantly larger on the pain side (0.24 ± 0.37 mm) compared to the non-pain side (0.06 ± 0.38 mm) (P = 0.002).

We found a bilateral increase in the circumference of MCA, ICAcerebral, ICAcavernous, and ECA compared to baseline (Table 3). The basilar artery was also dilated. Comparing the circumference change on the pain side with the non-pain side, we found no difference for any of the mentioned arteries. We found no difference in STA circumference between baseline and early migraine attack.

Circumference Changes After Sumatriptan Treatment

Sumatriptan caused bilateral circumference reductions in MMA, ICAcavernous, ECA and STA. There was no difference between the relative circumference reductions on the pain side compared to the non-pain side for these arterial segments (Table 4). Sumatriptan did not alter the circumference of MCA, ICAcerebral or the basilar artery (Figure 3).

Circumference Changes During the Late Migraine Attack

In patients not treated with sumatriptan, we found bilateral dilation of the MMA and ICAcavernous during the late attack scan, while the MCA circumference was not different from baseline. There was no difference between the pain and the non-pain side at this time point for any of the investigated arteries. Descriptive data are presented in Figure 4.

Figure 4.

Temporal evolution of circumference (mm) at baseline, early attack, and late attack of the middle meningeal, middle cerebral, and cavernous part of the internal carotid artery. Ongoing headache at time of late attack (yes/no): MMA (6/4), MCA (5/3), ICAcavernous (8/5). Report of bilateral headache at any time point between early and late scan (yes/no/missing data): MMA (6/4), MCA (4/3/1), ICAcavernous (7/5/1).