a b s t r a c t

Objectives: We investigated the state of inflammation, PTX3 level and other routine inflammatory mark- ers (high sensitivity C-reactive protein [hsCRP], and white blood cells [WBC]), in patients who presented to the emergency department (ED) with migraine. We also investigated the relationship between the clinical presentation, PTX3 level, and other routine inflammatory markers in the emergency management of these patients.

Methods: The study included 44 patients (group 1) who presented to the ED due to a migraine attack with aura and 44 controls (group 2) with similar demographic characteristics.

Results: The WBC count was 8.82 +- 2.10 x 109/L in group 1 and 7.85 +- 2.04 x 109/L in group 2. The mean PTX3 level was 11.57 +- 3.99 ng/mL in patients who presented at the ED with a migraine attack, and

4.59 +- 1.28 ng/mL in controls. The differences values of WBC and PTX3 between the two groups were significant (respectively; P = 0.031, P < 0.001). ROC analyses indicated significant results for PTX3 as a marker for acute migraine attack. It had a sensitivity of 93% and specificity of 84% at a cut-off value of

5.80 ng/mL.

Conclusion: This is the first study to investigate plasma levels of PTX3 in patients with acute migraine. PTX3 as a biomarker may be used as an additional examination to the current subjective criteria to support the diagnosis of patients presenting to the ED with an acute migraine attack.

(C) 2019

Introduction

Migraine is a Public health problem that affects a significant part of the population and causes significant impairment of func- tionality because of pain. epidemiological data have revealed that there is a clinical connection between migraine and psychiatric disorders [1]. The presence of the aura has been defined as a tem- porary neurological disorder associated with a migraine attack; however, other painless symptoms that may be associated with migraine and occur just before migraine headache are not well known. Auras occur before the onset of migraine headache or dur- ing the initial development of pain and usually last 10-30 min. A visual aura is defined as shimmering light, while a sensory aura is defined as tingling and numbness in the hands and tongue or in the mouth and jaw [2]. Migraine is estimated to affect 1 in 10

* Corresponding author.

E-mail address: [email protected] (M.T. Gokdemir).

people worldwide. Episodic acute migraine has a negative effect on quality of life and a potential for progression from the acute to the chronic type if not managed properly [3]. In the past few years, there have been major developments in the field of migraine; however, there is no definitive information about its etiopathogenesis. Migraine is not only a headache; it is also a unique syndrome composed of several phases [4].

Although the exact mechanisms contributing to the emergence of migraine are unknown, some data suggest that neurogenic inflammation may be its underlying pathophysiology. Identifying biomarkers in migraine-related research will facilitate disease management. Based on the possible roles of inflammation and an impaired immune system in the pathogenesis of migraine, pen- traxin 3 (PTX3) levels, as an inflammation parameter, may increase during acute migraine attacks. No previous studies have investi- gated the relationship between acute migraine attack and serum PTX3 status. Therefore, we investigated the state of inflammation in patients who presented to the emergency department (ED) with

https://doi.org/10.1016/j.ajem.2019.04.004 0735-6757/(C) 2019

a complaint of headache and received a diagnosis of migraine. We investigated the PTX3 level and other routine inflammatory mark- ers (high sensitivity C-reactive protein [hsCRP], and WBC). We also investigated the relationship between the clinical presentation, PTX3 level, and other routine inflammatory markers in the emer- gency management of these patients.

Materials and methods

This study was designed as a prospective case-control study. Ethical approval for the study was obtained from the local Ethics Committee of Harran University Medical Faculty (date: 2012, num- ber: 14). Written informed consent was obtained from all partici- pants in the patient and control groups or their legal guardians, and this study was performed in accordance with the principles of the Declaration of Helsinki.

Subjects

The study included 44 patients (group 1) who presented to the ED due to a migraine attack with aura and 44 controls (group 2) with similar demographic characteristics, such as age, sex, and region, but with no known acute or chronic disease. They were informed that 5 mL blood taken from patient and control groups would be evaluated, and that no other procedure would be per- formed. Migraine was diagnosed according to the classification of the latest diagnostic criteria of International Headache Disorders (ICHD-1) accepted by the World Health Organization and World Neurology Federation [5]. The basis of the diagnosis of patients who presented with headache was the story of the patient. There- fore, a detailed medical history, including details of the neurologi- cal symptoms, was obtained from all cases. The patients were provided sufficient time, and the necessary examinations were performed to correctly evaluate their complaints and avoid misdi- agnoses. The aura symptoms of our patients with migraine were visual, sensory, speech and/or language, and motor function related. In some patients, cranial computed tomography and/or magnetic resonance were also performed if deemed necessary to exclude intracranial pathology. In addition to biochemistry, a hemogram, and other imaging tests, an electroencephalographic examination was also performed, and no abnormalities were observed. To rule out possible hypertension, blood pressure was measured in all patients with an upper arm electronic blood pres- sure monitor. All other vital signs of the patients, including fever and pulse were recorded. After taking a blood sample for the study, painkillers were administered at the beginning of the attack. To accelerate absorption, nausea medication was administered before the painkillers.

Exclusion and inclusion criteria

The inclusion criteria were patients >18 years of age who pre- sented to the ED with headache and were known to have migraine or were diagnosed with migraine in the ED, had no known chronic or Acute disease other than migraine, and did not smoke or depend on other substances. The exclusion criteria were patients who had thorough examinations showing any secondary cause that would lead to headache, known inflammatory illness or other cardiovas- cular disease, alcohol detected in their blood or a history of Alcohol intake, a history of somatic disease in the prior month, active somatic or psychiatric disease, a history of drug use for any reason

within days, a history of opiate drug use or addiction, had taken alcohol and drugs such as ecstasy, had chronic disease, were exposed to trauma within the last week, or took drugs for suicide, pregnancy, or suspicion of being pregnant.

Biochemical analyses

The primary independent variables of the study were PTX3, hsCRP, and WBC count, whereas the secondary independent vari- ables were age, sex, and aura types of patients with migraine.

Blood samples were obtained from the antecubital vein with plastic injectors within the first hour of the patients’ admittance to the ED for a migraine attack. The 5 mL blood samples taken from each patient were transferred to biochemistry tubes to determine PTX3 levels. The patient samples were collected and held in tubes containing EDTA and anticoagulant-free tubes overnight. After centrifugation at 4000 rpm for 10 min at 4 ?C, plasma and serum samples were separated in Eppendorf tubes and frozen at –80 ?C until analysis (New Brunswick Scientific, Enfield, CT, USA; model C54285). The same procedure was followed for the blood samples of the control group. Plasma PTX3 concentration was measured in all subjects from frozen samples using a commercially available enzyme-linked immunosorbent assay (ELISA) kit (DTX30 human ELISA, The Netherlands). The results are expressed in ng/mL. Other routine hemogram and Biochemical parameters of the patient and control groups were measured using commercially available test kits (Abbott Laboratories, Abbott Park, IL, USA). The measurements of PTX3 and other biochemical data were performed using an auto- analyzer (Abbott Aeroset).

Statistical method

The statistical analyses were performed using SPSS software (version 20; SPSS Inc., Chicago, IL, USA). The number of participants to be included in the study was determined through power analy- ses. In these, a comparison was made between the PTX3 levels of the patients and controls. With conditions in which the standard deviation of PTX3 with 80% power, a = 0.005 or 95% validity was

0.82 ng/mL and the difference between the two groups was taken as (dd) = 0.50 ng/mL, the number of people needed for each group was calculated to be 43. The Shapiro-Wilk test was subsequently performed to determine a normal distribution of the data. Contin- uous variables are expressed as means (95% confidence intervals [CIs]) and categorical variables are expressed as numbers (%). Nor- mally distributed data are expressed as means +- standard devia- tions, whereas abnormally distributed data are expressed as medians. The intra-group comparisons of normally distributed numerical variables were made using Student’s t-tests. Categorical variables were analyzed using the chi-square or Fisher’s exact tests. Pearson corelation test were performed to determine the possible relationship between data. Receiver operating characteris- tic (ROC) curve analyses were performed to evaluate the diagnostic accuracy of PTX3. The area under the ROC curve was estimated. Specificity and sensitivity values were determined. A p– value < 0.05 was considered significant.

Results

The aura symptoms of the patients are shown in Table 1. In all, 44 patients with migraine (8 [18.2%] males and 36 [81.8%] females) were included in the patient group and another 44 healthy

Table 1

Aura types of patients with migraine attack presenting to the emergency department.

Types of aura	N, %
Visual	16 (36.4%)
Sensory	13 (29.5%)
Speech and/or language	9 (20.5%)
Motor	6 (13.6%)
Total	44 (100%)

individuals (12 males and 32 females) with similar demographic characteristics were included in the control group (Table 2; P = 0.309). The mean age was 36.52 +- 7.91 years in group 1 and

34.93 +- 8.50 years in group 2 (P = 0.366).As shown in Table 3, the hsCRP level was slightly higher in group 1 than in group 2 (P = 0.967). The WBC count was 8.82 +- 2.10 x 10⁹/L in group 1 and 7.85 +- 2.04 x 10⁹/L in group 2. The mean PTX3 level was

11.57 +- 3.99 ng/mL in patients who presented at the ED with a migraine attack, and 4.59 +- 1.28 ng/mL in controls (Fig. 1). The dif- ferences values of WBC and PTX3 between the two groups were significant (respectively; P = 0.031, P < 0.001).

However, according to Pearson correlation test there was no any association between PTX3 and other inflammatory markers (CRP and WBC).

Table 2

Baseline demographic and other characteristics laboratory of patients with acute migraine attack and Control subjects.

Parameters	Group 1 (50%, n = 44) [N, % or Mean +- SD]	Group 2 (50%, n = 44) [N, % or Mean +- SD]
Gender (Male/Female)	8/36	12/32
Age (years)	36.52 +- 7.91	34.93 +- 8.50
Hemoglobin (g/L)	13.93 +- 4.16	14.18 +- 1.77
LDL cholesterol (mg/dL)	108,68 +- 35,05	114,86 +- 30,84
Ca (mg/dL)	9.76 +- 1.69	10.17 +- 0.91
Glucose (mg/dL)	96,49 +- 24,93	100,36 +- 23,05
AST (U/L)	25,13 +- 9,79	21,06 +- 8,25
ALT (U/L)	27,29 +- 17,80	21,25 +- 7,23
T. Choll (mg/dL)	180,83 +- 51,52	196,76 +- 37,94
Triglserid (mg/dL)	211,20 +- 62,58	149,90 +- 41,44
HDL (mg/dL)	37,66 +- 12,21	40,92 +- 12,29
K (mEq/L)	4,23 +- 0,80	4,19 +- 0,47
LDH (U/L)	281,60 +- 96,26	263,68 +- 101,52
CK (U/L)	120,52 +- 145,77	12,22 +- 64,76
APTT (Sec)	34,37 +- 10,09	31,82 +- 7,72

ALT – Alanine Aminotransferase, APTT – Partial thromboplastin time, AST – Aspartate Aminotransferase, Ca – calcium, CK – Creatine kinase, HDL – high-density lipopro- tein, K – Potassium, T. Choll – total cholesterol, LDL – low-density lipoprotein.

Fig. 1. The mean PTX3 level in patients with a migraine attack and in controls.

Fig. 2. ROC analyse for PTX3 as a marker for acute migraine attack.

Table 3

PTX 3, hsCRP and WBC levels in patients with acute migraine attack and control subjects.

ROC analyses indicated significant results for PTX3 as a marker for acute migraine attack (Fig. 2). It had a sensitivity of 93% and

Parameters Group 1 (50%,n = 44)

	[Mean +- SD]	[Mean +- SD]
hsCRP (mg/dl)	0.56 +- 1.22	0.55+-,85	0.967
WBC (mcL)	8.82 +- 2.10	7.85 +- 2,04	0.031
PTX 3 (ng/mL)	11.57 +- 3.99	4.59 +- 1.28	<0.001

Group 2 (50%,n = 44) P^a

specificity of 84% at a cut-off value of 5.80 ng/mL.

Discussion

hs-CRP – high sensitive C reactive protein, PTX 3 – Pentraxin 3, a novel biomarker for inflammatory disease, WBC-white blood cells.

^a Student t-test.

We hypothesized that plasma levels of PTX3 would be elevated in patients presenting to the ER due to an acute migraine attack. The majority of patients with migraine in the study were middle-

aged women. While ferritin levels were significantly lower, PTX3 levels were significantly higher in patients with migraine, which supports our hypothesis. Moreover, PTX3 was strongly negatively correlated with ferritin. The cut-off value of PTX3 was 5.80 ng/mL, with a sensitivity and specificity of 93% and 84%, respectively.

Headache is a brain-based disorder that leads to an inflamma- tory cascade involving the cerebellum, meningeal vessels, and cor- tical material with activation of the trigeminovascular system by the release of various neurotransmitters [6]. The diagnosis of migraine is based on a detailed medical history, subjective clinical criteria, and exclusion of conditions mimicking migraine [5]. In the absence of any reliable biomarker or objective testing, a history and clinical data are of great importance for diagnosing migraine. Consistent with other advances in migraine research, studies on migraine have described some biomarkers. Levels of glutamate, calcitonin gene-related peptide, b-endorphin, and nerve growth factor increase significantly or decrease in cerebrospinal fluid and blood [7,8]. Togha et al. investigated the relationship between serum levels of vitamin D and migraine and reported that the prevalence of vitamin D deficiency among patients with migraine was 53.7%, significantly higher than the general population [8]. Although various studies have investigated PTX3 levels, no study supports the role of this marker in patients with acute migraine attacks.

PTX3 is a secretory glycoprotein produced by vascular endothe- lial cells and macrophages, particularly in response to injury and stress [9]. In contrast to the short-arm opposite side of CRP, which is expressed in the liver and thus reflects systemic inflammation, PTX3 is locally synthesized in the vascular system and is specu- lated to be closely associated with endothelial dysfunction [10]. Increased PTX3 levels are associated with the risk for various dis- eases, including cardiovascular, renal, and female reproductive sys- tem diseases, as well as severe traumatic brain injury [11]. In addition, high plasma levels of PTX3 are correlated with the sever- ity of endothelial dysfunction in patients with chronic kidney dis- ease and preeclampsia [12,13]. Patients with acute cholecystitis have elevated PTX3 levels [14]. However, the levels in patients with idiopathic sudden sensorineural hearing may or may not be elevated [16]. PTX3 has been used as an early marker of acute myocardial infarction, and can be used to identify pulmonary con- gestion by acute phase reactants and trauma cases of patients with rheumatoid arthritis [15-17].

The diagnosis of migraine is based on certain subjective clinical features. As with any diagnostic classification system designed for a largely subjective disease, the ICHD criteria for migraine may be useful for the diagnosis of these patients in the ED. No objective clinical data or biomarkers are available for diagnosing migraine [7,8]. In this study, a high PTX3 level in patients with migraine pro- vides us with a preliminary view. In our study, PTX3 levels were significantly higher in patients presenting to the ED with acute migraine attacks compared to controls, whereas ferritin levels were significantly lower. Furthermore, a negative correlation was observed between PTX3 and ferritin. In these patients who pre- sented to the ED with migraine and aura, PTX3 had a cut-off value of 5.80 ng/mL, with a sensitivity and specificity of 93% and 84%, respectively.

Limitations

Our study had several limitations. In general, the fact that the criteria for the migraine diagnosis were based on subjective criteria was an important limitation. The single center included and rela- tively low number of participants was another limitation. Further- more, it was not possible to evaluate the effects of drugs previously used by the patients that may have affected PTX-3 levels. Another important limitation was that the PTX-3 level of each patient who presented to the ED for an acute migraine was determined based on a single blood sample.

Conclusion

This is the first study to investigate plasma levels of PTX3 in patients with acute migraine. Our results suggest that high levels may be helpful in the differential diagnosis of acute migraine and may also be associated with vascular deterioration. The high levels observed in this study suggest that endothelial dysfunction plays a role in the pathogenesis of acute migraine. PTX3 as a biomarker may be used as an additional examination to the current subjective criteria to support the diagnosis of patients presenting to the ED with an acute migraine attack. However, further extensive studies are needed to support this assessment.

Acknowledgements

We would like to thank to Harran University Project Support (HUBAK) for sport the funding of this article.

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