Anti-inflammatory plasma cytokines in children and adolescents with migraine headaches

Transcription

1 Pharmacological Reports 2010, 62, ISSN Copyright 2010 by Institute of Pharmacology Polish Academy of Sciences Anti-inflammatory plasma cytokines in children and adolescents with migraine headaches Leszek Boækowski 1, Joanna Œmigielska-Kuzia 1, Wojciech Sobaniec 1, Beata elazowska-rutkowska 2, Wojciech Ku³ak 3, Krzysztof Sendrowski 1 Department of Pediatric Neurology and Rehabilitation, Department of Pediatric Laboratory Diagnostics,! Department of Pediatric Rehabilitation, Medical University of Bia³ystok, Waszyngtona 17, PL Bia³ystok, Poland Correspondence: Leszek Boækowski, bockow@kki.pl Abstract: Studies have shown fluctuations of cytokine levels in patients with migraine headaches; however, further studies are needed to verify these results. Our previous studies suggest increased levels of pro-inflammatory cytokines, such as IL-1, stnf-ri and TNF-,in children with migraine headaches. In this study, we analyzed anti-inflammatory cytokines interleukin-4 (IL-4), interleukin-10 (IL-10) and interleukin-13 (IL-13) in plasma from children and adolescents with migraine and tension-type headaches during the interictal period. The study group consisted of 35 children and adolescents between 8 18 years old, suffering from migraine headaches with or without aura. The control group consisted of 33 patients suffering from episodic tension-type headaches. IL-4 was detected in 17.1% of patients with migraine headaches and in 28.6% of patients with tension-type headaches. IL-13 was detected in 17.1% of patients with migraine headaches and in 15.2% of patients with tension-type headaches. IL-10 was only detected in 3 of 68 (4.4%) patients. Any significant correlations between measurable cytokine levels and age, gender, aura, duration of disease, frequency and severity of headaches were determined. Any significant fluctuations of selected anti-inflammatory cytokines during the headachefree period in children with migraine and tension-type headaches have been found, immune dysfunction in migraineurs could not be excluded. Key words: migraine, cytokines, children, interleukin-4, interleukin-10, interleukin-13 Introduction Based on clinical history, an allergic mechanism has been hypothesized to be involved in migraine pathophysiology [9, 14]. High comorbidity between migraine headaches and atopic diseases, such as eczema and asthma [12, 18], is an important argument for a suspected immune system dysfunction in migraineurs, however, migraine headaches have also been associated with infection. Migraineurs reported that not only do infections precipitate migraine attacks, they also increase the headache intensity [3]. Elevated frequencies of sub-clinical and clinical infections have been found in patients with migraines [4, 11], which provides indirect evidence that supports the involvement of the immune system in migraine precipitation. Several other studies also support the involvement of the immune system in migraine headache precipitation [3, 4, 11, 12, 18]. Changes in serum levels of complement, immunoglobulin, histamine Pharmacological Reports, 2010, 62,

2 and immune cells in migraine patients have been found in some studies, but conflicting results have been reported on the mechanisms involved [9, 16]. The interaction between immune cells is regulated by several mechanisms, including cytokines, which play a crucial role in modulating the quality and intensity of immune responses. Cytokines are small proteins produced by most cells in the body and possess multiple biologic activities that promote cell-cell interaction. Despite a growing interest in the contribution of the immune system in causing migraine headaches, the role of cytokines in migraine pathophysiology remains unclear. Cytokines have been shown to induce headaches but these studies are controversial [9]. Studies on cytokines in patients with migraine headaches have shown fluctuations in cytokine levels. [6, 13, 15, 16]. Some authors reported increased levels of tumor necrosis factor (TNF- ) [5], interleukin-5 and interleukin-4 in patients suffering from migraine headaches [15], whereas others found no changes in plasma levels of TNF-, interleukin-1 (IL-1 ) or interleukin-1 during migraine attacks [19]. These data are generally interpreted as a possible immune dysfunction [16]. In our previous study, we focused on pro-inflammatory cytokines in children with migraine headaches [2] and found that plasma IL-1 was undetectable in 19 controls with tension-type headache; however, IL-1 was detected in 16 patients with migraine headaches. These results suggest that IL-1 levels were higher in patients with migraine headaches than in the control group. Soluble receptor for tumor necrosis factor in the migraine group was significantly higher than in the tensiontype headache group. Migraine patients tended to have increased IL-1 levels than controls. IL-1 levels were significantly higher in migraine patients with aura than in migraine patients without aura. TNF- and soluble receptor for tumor necrosis factor levels were also increased (non-significantly) in the migraine patients with aura subgroup. Our results suggest that pro-inflammatory cytokines may be involved in the pathogenesis of migraine attacks, but cytokine level fluctuations in children could be different than in adults [2]. To understand the possible role of anti-inflammatory cytokines in migraine headaches, we analyzed interleukin-4 (IL-4), interleukin-10 (IL-10) and interleukin-13 (IL- 13) levels in plasma from children and adolescents with migraine headaches. Materials and Methods The study protocol was approved by the ethics committee of the Medical University in Bia³ystok. The study group consisted of 68 children and adolescents 8 18 years old who were hospitalized in the Department of Pediatric Neurology and Rehabilitation at the Medical University in Bia³ystok because of headaches. Thirty-five of the 68 suffered from migraine headaches with or without aura and were years old (the mean ± SD: ± 2.29 years). There were 15 girls and 20 boys in the group. Migraine headaches were diagnosed based on the criteria of the second edition of International Headache Classification [7]. Twenty-one patients (9 females and 12 males) suffered from migraine headaches without aura, and fourteen patients (6 females and 8 males) suffered from migraine headaches with aura. The control group consisted of 33 subjects (22 female and 11 male) who were 8 17 years old (mean age ± 3.46) suffering from episodic tension-type headaches. Diagnoses were made using the criteria of the 2nd edition of International Headache Classification [7]. Patients in both groups underwent detailed pediatric and neurological examinations to exclude pre-existing inflammation. All of the children had basic laboratory tests and neuroimaging procedures. All patients affected by allergic, inflammatory, infectious or immune disorders that could interfere with the study were excluded. Patients taking prophylactic medication, and those with drug overuse were also excluded. The levels of inflammatory indices were all within the normal ranges, therefore, all subjects were generally asymptomatic except for headaches. Plasma for analysis of cytokines was obtained simultaneously with routine laboratory tests. The period of the study was 12 months. Blood samples were obtained under fasting and rest conditions in the morning, during headache-free intervals and at least 2 days after the last attack. Symptomatic drugs were not taken for at least 2 days before the blood samples were obtained, and all patients were free from prophylactic medications for at least 2 weeks. Blood was drawn from the antecubital vein, centrifuged, frozen and stored at 20 C until assayed. Immunoassay kits from BioSource (BioSource International Inc. 542 Flynn Road, Camarillo, California 93012, USA) were used. Levels of interleukin-4 (IL-4), interleukin-10 (IL-10) and human interleukin- 13 (IL-13) in plasma samples were determined by spe- 288 Pharmacological Reports, 2010, 62,

3 Anti-inflammatory cytokines in migraine headaches Leszek Boækowski et al. Tab. 1. Selected data of plasma cytokines in children and adolescents with headaches Number of measurable amounts (mean ± SD) Migraine with aura (n = 14) Migraine without aura (n = 21) Migraine total (n = 35) Tension-type headache (n = 33) Il-4, pg/ml 2 of % (1.98 ± 1.33) Il-13, pg/ml 2 of % (1.25 ± 0.29) Il -10, pg/ml 0 of 14 0% 4of % (2.07 ± 0.84) 4of % (3.11 ± 2.98) 1of21 4.7% 6of % (2.04 ± 0.89) 6of % (2.49 ± 2.50) 1of35 2.8% 10 of 33 28,6% (3.39 ± 1.44) 5of % (1.78 ± 0.79) 2of33 6.1% cific enzyme-linked immunosorbent assay (ELISA) techniques according to the manufacturer s instructions (Cat. no.: KAP1281, KAP1321, KPMS113). The minimum detectable concentration of the assay was 1.2 pg/ml for IL-4, 0.2 pg/ml for IL-10 and 0.73 pg/ml for IL-13. To define the specificity of these ELISA assays, several proteins were tested for cross-reactivity. These tests showed that the assay KAP1281 is specific for natural human and recombinant IL-4, and the assay KAP1321 is specific for natural human and recombinant IL-10. A very low level (0.2%) of crossreaction was observed with BRCF1 (viral IL-10) at a concentration of 70,000 pg/ml. BRCF1 gave a signal corresponding to 134 pg/ml of IL-10. The assay KPMS113 recognizes both natural and recombinant human IL-13. Reproducibility within the assay was evaluated in three independent experiments. Each assay was carried out with 6 replicates of serum samples containing different concentration of interleukins, and the laboratory staff was blind to the clinical data. out of 35 subjects with only migraine headaches (10.25 pg/ml) and 2 out of 33 subjects with tensiontype headaches (24.24 pg/ml and pg/ml). Cytokine plasma levels are presented in Table 1. The number of measurable samples was too small for statistical analysis, and the data were not normally distributed; therefore, we did not find any significant differences or trends between groups. Because high cytokine levels were detected in some patients, we analyzed the demographic data and medical history of all patients. Any significant correlations between measurable cytokine levels and age, gender, type of headache (migraine with aura or without aura), duration of disease, frequency and severity of attacks, family history of migraine, infection or laboratory tests and EEG were determined. Discussion Results IL-4 was detected in 6 out of 35 (17.1%) subjects with migraine headaches (mean, 2.04 ± 0.89 pg/ml) and 10 out of 33 (28.6%) subjects with tension-type headaches (mean, 3.39 ± 1.44 pg/ml). IL-13 was detected in 6 out of 35 (17.1%) subjects with migraine headaches (mean, 2.49 ± 2.50 pg/ml) and 5 out of 33 (15.2%) subjects with tension-type headaches (mean, 1.78 ± 0.79 pg/ml). Interleukin-10 was detected in 1 In our study, we focused on anti-inflammatory cytokines in children with only migraine headaches because of the hypothesis that migraine headaches could be caused by an immune dysfunction. Our control group consisted of children with episodic tension-type headaches without inflammatory conditions. Episodic tension-type headaches have a functional pathomechanism, and these patients were accepted as control vs. migraine in our previously published studies [2]. The mechanism leading to migraine headaches is still not clearly understood. The activation of brainstem structures through trigeminal nociceptive fibers Pharmacological Reports, 2010, 62,

4 lasts longer than the pain experienced from migraine headaches [20] and therefore, cannot explain the length of individual migraine attacks. The hypothesis of cytokines as possible pain mediators offers a potential mechanism for the generation of pain from migraine headaches. Our previous results showed increased levels of pro-inflammatory cytokines IL-1, stnf-ri and TNF- in children with migraine headaches during interictal periods [2]. Moreover, concentrations of these cytokines, particularly IL-1, tend to be higher in patients suffering from migraine headaches with aura [2]. Thus, we could also expect fluctuations in anti-inflammatory cytokine levels. The anti-inflammatory cytokines IL-4 and IL-10 have been studied previously in adult migraineurs, and several reports indicate a reduced level of IL-4 during an attack [10, 15, 17], whereas IL-10 has been found to increase during an attack [15, 16]. However, very little has been reported in the literature concerning anti-inflammatory cytokines during the headachefree period. Compared to controls, significantly increased plasma levels of transforming growth factor (TGF)-1 have been found in patients with migraine headaches during the headache-free period but not in patients with tension-type headaches [8]. Plasma levels of cytokines IL-4, IL-5 and IL-10 were undetectable in all healthy controls [14, 15]. Cytokine levels below the detection limits were recorded as equal to the detection limits. IL-10 levels were undetectable in 30 of 32 (93.7%) adult patients with migraine headaches [14]. IL-4 levels were found to be higher in plasma from the same group in 12 (37.5%) patients with migraine headaches, and IL-5 levels in plasma from the same group were found to be higher in 27 (84.3%) patients with migraine headaches. However, critical analysis of these results suggests that IL-4 plasma levels were undetectable in 62.5% of patients with migraine headaches during pain-free periods. Moreover, plasma IL-4 and IL-5 levels were also undetectable in most patients during the attack of migraine headaches without aura [15]. Interestingly, in 12 out of 23 (52.2%) migraineurs from this same group, plasma IL-10 levels were significantly higher than in healthy controls [15]. However, our results clearly indicate that in 47.8% of migraineurs, plasma levels of IL-10 were undetectable. These data seem to be unclear and controversial. In our study, the number of undetectable and detectable cytokine levels in all groups was small and similar, and we could not draw any conclusions about differences between migraine and tension-type headaches. From a clinical point of view, there was no correlation between cytokine levels and clinical features, such as duration of illness, attack frequency and intensity, presence of aura, and age and gender of migraineurs. Other authors did not find any correlations between plasma cytokine levels and clinical features of headaches [14]. A possible explanation for the difference between our results and other studies is the different sensitivity of enzyme-linked immunosorbent assay techniques; the minimum detectable concentration of our assay was 1.2 pg/ml for IL-4, 0.2 pg/ml for IL-10 and 0.73 pg/ml for IL-13. In one cited study, the detection limit for IL-4, IL-5 and IL-10 was 6 pg/ml, 1 pg/ml and 5 pg/ml, respectively [14], whereas in another cited study, the detection limit for IL-4, IL-5 and IL-10 was 2 pg/ml, 2 pg/ml and 1.5 pg/ml, respectively [15]. There are no previous reports addressing the plasma levels of IL-13 in patients with migraine headaches. It is worth noting that in the present study, the plasma level of IL-13 was measurable in 3 out of 68 (4.4%) patients with headache only. In the last published comparative study of cerebrospinal fluid (CSF) cytokine levels from headache patients during attacks, measurable amounts of only IL-1ra, MCP-1 and TGF-1 were found in all patients [1]. IL-10 was detected in most patients, but there was only a difference between groups with migraine with aura or without aura, episodic tension-type headache and cervicogenic headaches. However, measurable amounts of IL-4 were not found in CSF samples in any group [1]. Further studies should include more sensitive immunoassay techniques. In the present study, any significant fluctuations of the selected anti-inflammatory cytokines IL-4, IL-10 and IL-13 during the headache-free period in children with migraine and tension-type headaches have been found, but immune dysfunction in migraineurs could not be totally excluded. References: 1. Bo S, Davidsen E, Gulbrandsen P, Dietrichs E, Bovim G, Stovner L, White L: Cerebrospinal fluid cytokine levels in migraine, tension-type headache and cervicogenic headache. Cephalalgia, 2009, 29, Pharmacological Reports, 2010, 62,

5 Anti-inflammatory cytokines in migraine headaches Leszek Boækowski et al. 2. Boækowski L, Sobaniec W, elazowska-rutkowska B: Proinflammatory plasma cytokines In children with migraine. Pediatr Neurol, 2009, 41, Chabriat H, Danchot J, Michel P, Joire JE, Henry P: Precipitating factors in migraneurs: a reappraisal in a national control matched survey. Cephalalgia, 1997, 17, Covelli V, Massari F, Conrotto F, D Andrea L, Maffione AB, Jirrillo E, Buscaino GA: Demonstration of an elevated frequency of infectious events in patients with migraine without aura: a correlation with their altered immune status. J Immunol Immunopharmacol, 1993, 13, Covelli V, Munno I, Pellegrino MN, Altamura M, Decandia P, Marcuccio C, Di Venere A, Jirillo E: Are TNF-alpha and IL-1 beta relevant in the pathogenesis of migraine without aura? Acta Neurol, 1991, 13, Empl M, Sostak P, Riedel M: Decreased stnf-r1 in migraine patients? Cephalalgia, 2003, 23, Headache Classification Commitee of the International Headache Society. Classification and diagnostic criteria for headache disorders, cranial neuralgias and facial pain. 2nd edn. Cephalalgia, 2004, Suppl 1, Ishizaki K, Takeshima T, Fukuhara Y, Araki H, Nakaso K, Kusumi M, Nakashima K: Increased plasma transforming growth factor- 1 in migraine. Headache, 2005, 45, Kemper RHA, Meijler WJ, Korf J, Ter Horst GJ: Migraine and function of the immune system: a metaanalysis of clinical literature published between 1966 and Cephalalgia, 2001, 21, Martelletti P, Stirparo G, Morrone S, Rinaldi C, Giacovacco M: Inhibition of intracellular adhesion molecule-1 (ICAM-1), soluble ICAM-1 and interleukin-4 by nitric oxide expression in migraine patients. J Mol Med, 1997, 75, Mavromichalis I, Zaramboukas T, Giala MM: Migraine of gastrointestinal origin. Eur J Pediatr, 1995, 154, Mortimer MJ, Kay J, Gawkrodger DJ, Jaron A, Barker DC: The prevalence of migraine in atopic children: an epidemiological study in general practice. Headache, 1993, 33, Mueller L, Gupta AK, Stein TP: Deficiency of tumor necrosis factor in subclass of menstrual migraneurs. Headache, 2001, 41, Munno I, Centonze V, Marinaro M, Bassi A, Lacedra G, Causarano V, Nardelli P et al.: Cytokines and migraine: increase of IL-5 and IL-4 plasma levels. Headache, 1998, 38, Munno I, Marinaro M, Bassi A, Cassiano MA, Causarano V, Centoze V: Immunological aspects in migraine: increase of IL-10 plasma levels during attack. Headache, 2001, 41, Perini F, D Andrea G, Galloni E, Pignatelli F, Billo G, Alba S, Bussone G, Toso V: Plasma cytokine levels in migraneurs and controls. Headache, 2005, 45, Sarchielli P, Alberti A, Baldi A, Coppola F, Rossi C, Pierguidi L: Proinflammatory cytokines, adhesion molecules, and lymphocyte integrin expression in the internal jugular blood of migraine patients without aura assessed ictally. Headache, 2006, 46, Terwindt GM, Ferraro MD, Tijhuis M, Groenen SM, Picavet HS, Lanner LJ: The impact of migraine on quality of life in the general population: the GEM study. Neurology, 2000, 55, Van Hilten JJ, Ferrari MD, van der Meer JW, Gijsman HJ, Loji BJ Jr: Plasma interleukin-1, tumor necrosis factor and hypothalamic-pituitary-adrenal axis responses during migraine attacks. Cephalalgia, 1991, 11, Weiller C, May A, Limmroth V, Juptner M, Kaube H, Schayck, Coenen HH, Diener HC: Brain stem activation in spontaneous human migraine attacks. Nat Med, 1995, 1, Received: August 2, 2009; in revised form: February 3, Pharmacological Reports, 2010, 62,