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Volumetric abnormalities of thalamic subnuclei in medication-overuse headache

Volumetric abnormalities of thalamic subnuclei in medication-overuse headache Background: The thalamus exerts a pivotal role in pain processing and cortical excitability control and a previous voxel-based morphometry study confirmed increased volume in bilateral thalamus in medication-overuse headache (MOH). The aim of this study is to investigate altered thalamic subnuclei volume in MOH compared with normal controls, and to evaluate the relationship of each thalamic subnuclei volume with the clinical variables. Methods: High resolution three-dimensional T1-weighted fast spoiled gradient recalled echo MR images were obtained from 27 patients with MOH and 27 normal controls (NC). Thalamic subnuclei templates were created based on Talairach template with MNI space transformation, and the individual thalamic subnuclei templates were generated by applying the deformation field from structural image segment to the thalamic subnuclei templates, and then individual thalamci subnuclei volume were calculated. Results: The whole thalamus and each thalamic subnuclei presented increased volume compared with NC (P <0.05). The correlation analysis demonstrated that the whole thalamus volume and each thalamic subnuclei volume showed a negative relationship with HAMD scores(P < 0.05), and no any correlation with HAMA, VAS score and disease duration (P >0.05). Conclusion: Increased gray matter volume in the whole thalamus and all the thalamus subnuclei may reflect central sensitization and higher-order of pain alteration in MOH. These structural changes in the thalamus may also be influenced by mood disturbances related to the MOH. Keywords: Medication-overuse headache, Migraine, Thalamus, Magnetic resonance imaging Background primary headaches such as migraine are the most Medication-overuse headache (MOH) was defined as a important risk factors for the development of MOH, headache occurring on 15 or more days per month de- 50%–70% MOH have co-occurrence of migraine in veloping as a consequence of regular overuse of acute or population-based studies [6, 7]. Many psychosocial and symptomatic headache medication for more than socioeconomic factors which are prevailed in patients 3 months [1] . MOH has a prevalence of 0.6–2.0% in the with chronic forms of headache are also associated with general population [2, 3], and was associated with mood MOH. However, the mechanism behind how chronic ex- disorders in 27–85% and anxiety disorders in 61–83%. posure to abortive medication leads to MOH remains MOH patients experience reduced quality of life com- unclear. Alteration of cortical neuronal excitability, cen- pared with those who do not suffer from headaches [4]. tral sensitization involving the trigeminal nociceptive A pre-existing headache disorder seems to be required system have been suggested to play a part in the patho- to develop MOH [5]. It is well known that previous physiology of MOH [8]. The thalamus contains third-order trigeminovascular * Correspondence: cjr.malin@vip.163.com; yusy1963@126.com nociceptive neurons and exerts a pivotal role in pain Zhiye Chen and Zhihua Jia contributed equally to this work. processing and cortical excitability control [9, 10]. Lin Ma and Shengyuan Yu contributed equally to this work. Department of Radiology, Chinese PLA General Hospital, 28 Fuxing Road, Microstructural and functional alterations of the thal- Beijing 100853, China amus have been found in migraine patients [11, 12]. Sig- Department of Neurology, Chinese PLA General Hospital, 28 Fuxing Road, nificant volume reductions of the following thalamic Beijing 100853, China Full list of author information is available at the end of the article © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Chen et al. The Journal of Headache and Pain (2017) 18:82 Page 2 of 7 nuclei densely connected to the limbic system were ob- MOH patients. Headache information were registered and served in migraineurs: central nuclear complex, anterior evaluated in our headache database. All the patients were nucleus and lateral dorsal nucleus, supported that given with the Visual Analogue Scale (VAS) evaluation. higher-order integration systems are altered in migraine Additionally, we used the Hamilton Anxiety Scale [11]. Increased iron deposition and myelin content/ (HAMA) [19] scale to assess the anxiety, the Hamilton cellularity in the thalamus of migraine with aura pa- Depression Scale) [20] to assess the depression, and the tients compared with migraine without aura patients Mini-mental State Examination (MMSE) [21] to assess the and healthy controls were found, may underlie abnor- cognitive function of all the participants. MRI scans were mal cortical excitability control leading to cortical taken in the interictal stage at least three days after a mi- spreading depression and visual aura [13]. A voxel- graine attack for MOH patients. Alcohol, nicotine, caf- based morphometry (VBM) study identified increased feine, and other substances were avoided for at least 12 h gray matter volume in bilateral thalamus in MOH pa- before MRI examination. tients [14]. Although it was demonstrated that peria- queductal gray (PAG) volume gain [15] and altered MRI acquisition intrinsic functional connectivity architecture [16] were MRI data were obtained by a conventional eight-channel confirmed in MOH patients in our previous study, quadrature head coil from a GE 3.0 T MR system however, it was not known that how the thalamic (DISCOVERY MR750, GE Healthcare, Milwaukee, WI, subfields volume changed in MOH up to now. USA). All subjects were instructed to lie in a supine pos- Up to now, several documents had recognized that ition, and formed padding was used to limit head move- thalamic subnuclei were segmented based on diffusion ment. An axial three-dimensional T1-weighted fast tensor imaging [17, 18], and thalamic nuclei densely spoiled gradient recalled echo (3D T1-FSPGR) sequence connected to the limbic system were observed in migrai- was performed to acquire the brain structure images. neurs [11]. Therefore, morphology analysis of thalamic The 3D T1-FSPGR parameters were listed as follows: subnuclei would provide more information in the under- TR (repetition time) = 6.3 ms, TE (echo time) = 2.8 ms, standing of neuromechanism of MOH. flip angle = 15o, FOV (field of view) = 25.6 cm × 25.6 cm, The main objective of the current study was to investi- Matrix = 256 × 256, NEX (number of acquisition) = 1]. gate the altered thalamic subnuclei volume in MOH All the subjects were performed the same imaging pro- compared with normal controls, and to further evaluate tocols, and the subjects with structural damage would be the relationship of each thalamic subnuclei volume with excluded. the clinical variables. Image processing Methods Image processing mainly included the following steps: Subjects (1) Convert Talairach template [22] into MNI space, and This study was approved by the ethics committee of the the thalamic subnuclei templates were created using rest Chinese PLA General Hospital, and written informed software [23]. The thalamic subnuclei [11] included fol- consent was obtained from the subjects according to the lowing subregions: left/right ventral posterior lateral nu- Declaration of Helsinki. Twenty-seven MOH patients cleus (L_VPL/R_VPL), left/right ventral posterior medial were consecutively recruited from the headache center, nucleus (L_VPM/R_VPM), left/right dorsomedial nu- Chinese PLA General Hospital. The included criteria of cleus (L_DM/R_DM), left/right ventral lateral nucleus MOH included as follows: (1) All patients with both, (L_VL/R_VL), left/right ventral anterior nucleus (L_VA/ MOH and migraine; (2) The diagnosis of 8.2 MOH, 1.1 R_VA), and left/right anterior nucleus (L_AN/R_AN). and 1.2 migraine based on the International Classification (Fig. 1). (2) The individual structural images were seg- of Headache Disorders, third Edition (beta version) mented by the new segment tool embedded in SPM 12 (ICHD-III beta); (3) Without migraine preventive medica- software (http://www.fil.ion.ucl.ac.uk/spm), and the in- tion in the past 3 months. The excluded criteria included verse deformation field was generated (iy_subjectID.nii). as follows: (1) With chronic disorders, including Then, the standard thalamic subnuclei were applied with hypertension, diabetes mellitus, cardiovascular diseases, the inverse deformation with pullback strategy, which etc.; (2) With cranium trauma, psychotic disorder, and would generate the individual thalamic subnuclei masks regular use of a psychoactive or hormone medication. [15] (Fig. 2). Each individual thalamic subnucleus seg- Part of MOH patients were overlapping with our pre- mentations were visually inspected to confirm anatom- vious studies [15, 16]. Twenty-seven normal controls ical accuracy by one experienced radiologist. (3) The (NCs) were recruited, who should never have any pri- volume of individual thalamic subnuclei were measured mary headache disorders or other types of headache in by ITK-SNAP (V3.6.0) software (http://www.itksnap.org/ the past year, and had the same exclusion criteria with pmwiki/pmwiki.php). Chen et al. The Journal of Headache and Pain (2017) 18:82 Page 3 of 7 MOH group and NC group. The Pearson’s correlation analysis was applied between thalamic volume and the clinical variables (including disease duration, VAS) in MOH. Significant difference was set at a P value of <0.05. Results Comparison of clinical characteristics between MOH and NC The current study included 27 MOH patients (F/ M = 20/7) and 27 normal controls (F/M = 19/8). The age, sex and MMSE showed no significant difference be- tween MOH and NC (P > 0.05). There was a significant HAMD and HAMA between MOH (20.85 ± 12.67 and 17.70 ± 8.63) and NC (7.32 ± 4.26 and 9.78 ± 2.91) (P < 0.05)(Table 1). Comparison of thalamic subnuclei volume between MOH Fig. 1 The standard thalamic subnuclei templates were created and NC according to Talairach template. AN, anterior nucleus; DM, Table 2 demonstrated that all the thalamic subnuclei doromedial nucleus; VA, ventral anterior nucleus; VL, ventral lateral nucleus; VPL, ventral posterior lateral nucleus; VPM, ventral posterior presented increased volume in MOH compared with NC medial nucleus (P < 0.05). Bilateral whole thalamus also showed in- creased volume in MOH (L_T, 3.365 ± 0.291 ml, R_T,3.312 ± 0.288 ml) compared with NC (L_T, Statistical analysis 3.237 ± 0.249 ml, R_T, 3.190 ± 0.241 ml) (P < 0.05) The statistical analysis was performed by using PASW (Fig. 3). Statistics 18.0. The age, MMSE, HAMD,and HAMA were performed with independent samples T test, and Correlation analysis between thalamic subnuclei volume sex was performed with Chi-Square test. The signifi- and the clinical variable cance differences of whole thalamus and thalamic sub- Figure 4 demonstrated that all the thalamic subnuclei nuclei volume were computed using analysis of volume were significantly negatively related with HAMD covariance with the age and sex as covariates between score (P < 0.05), and there were not significant relation- ship between all the thalamic subnuclei and the other clinical variables including HAMA, VAS and disease duration (P > 0.05) (Table 3). Discussion Our study aimed to identify morphological changes of thalamic subnuclei in MOH and try to reveal more Table 1 The clinical characteristics of the subjects MOH NC T value P value Num(F/M) 27(20/7) 27(19/8) 0.092 0.761 Age 39.93 ± 9.75 43.04 ± 10.82 2.007 0.272 MMSE 27.41 ± 3.74 28.19 ± 1.00 2.007 0.302 HAMD 20.85 ± 12.67 7.32 ± 4.26 2.008 0.000 HAMA 17.70 ± 8.63 9.78 ± 2.91 2.007 0.000 DD 18.07 ± 9.85 NA NA NA Fig. 2 The individual thalamic nuclei were generated by applying VAS 8.26 ± 1.46 NA NA NA the inverse deformation with pullback strategy to the standard thalamic subnuclei. AN, anterior nucleus; DM, doromedial nucleus; Chi-square test. MOH medication-overuse headache, NC normal control, DD disease duration, VAS Visual Analogue Scale, HAMA Hamilton Anxiety Scale, VA, ventral anterior nucleus; VL, ventral lateral nucleus; VPL, ventral HAMD Hamilton Depression Scale, MMSE Mini-mental State Examination, NA posterior lateral nucleus; VPM, ventral posterior medial nucleus not available Chen et al. The Journal of Headache and Pain (2017) 18:82 Page 4 of 7 Table 2 The volume comparison of thalamic subnuclei(ml) factors for MOH among people with chronic headache, between MOH and NC including increased Hospital Anxiety and Depression MOH NC F value P value Scale score [27]. However, depression and anxiety disor- ders are associated with both migraine and non- L_AN 0.195 ± 0.017 0.187 ± 0.015 6.788 0.012 migrainous headache, and this was related to the head- L_DM 1.164 ± 0.106 1.123 ± 0.093 4.627 0.036 ache frequency rather than headache diagnosis in an- L_VA 0.324 ± 0.027 0.311 ± 0.023 6.974 0.011 other research, so the relationship between psychiatric L_VL 1.056 ± 0.090 1.014 ± 0.076 7.570 0.008 disorders and MOH may be comobidity [28]. The cause- L_VPL 0.375 ± 0.033 0.360 ± 0.027 7.546 0.008 effect relationship needs further longitudinal study. L_VPM 0.253 ± 0.022 0.243 ± 0.018 7.087 0.010 Consistent with the previous study [14], we found in- creased whole thalamus volume bilaterally in the MOH. L_T 3.365 ± 0.291 3.237 ± 0.249 6.474 0.014 An increase in GMV may reflect structural brain plasti- R_AN 0.182 ± 0.016 0.175 ± 0.013 6.657 0.013 city as a result of exercise and learning [29]. Gray matter R_DM 1.845 ± 0.112 1.143 ± 0.095 4.529 0.038 volume increase in the thalamus has also been found in R_VA 0.319 ± 0.027 0.306 ± 0.022 8.365 0.006 chronic pain conditions such as back pain [30] and R_VL 0.997 ± 0.083 0.958 ± 0.069 7.607 0.008 chronic post-traumatic headache [31]. Increased GMV R_VPL 0.393 ± 0.034 0.379 ± 0.028 6.059 0.017 in the thalamus might reflect central sensitization in chronic pain states. However, studies about the thalamic R_VPM 0.236 ± 0.021 0.229 ± 0.017 4.937 0.031 subnuclei volume in these chronic pain conditions have R_T 3.312 ± 0.288 3.190 ± 0.241 6.210 0.016 not been found. If the morphological abnormalities of L left, R right, AN anterior nucleus, DM dorsomedial nucleus, VA ventral thalamic subnuclei are specific to MOH or if the mor- anterior nucleus, VL ventral lateral nucleus, VPL ventral posterior lateral nucleus, VPM ventral posterior medial nucleus, T thalamus phological abnormalities of thalamic can be normalized as cephalic, extra-cephalic pressure-pain thresholds and information about the neuromechanism of MOH. In our pain-related cortical potentials in MOH patients after study, psychiatric evaluation revealed that the majority withdrawal of the overused medication needs further of patients had comorbid psychiatric conditions, con- study [31, 32]. Unlike the specific thalamic subnuclei de- taining both anxiety and depressive disorders, which is creases observed in migraineurs [11], all the thalamic accordant with epidemiologic studies [24, 25]. A previ- subnuclei presented increased volume in MOH. Each ous study showed MOH patients have a greater risk of thalamus is divided into the following subnuclei accord- suffering from anxiety and depression than episodic mi- ing to the inner medullary plate (including plate core): graine, and psychiatric disorders occurred significantly anterior nucleus (AN), dorsomedial nucleus (DM), ven- more often before the transformation from migraine into tral anterior nucleus (VA), ventral lateral nucleus (VL), MOH than after [26]. It deduced that these disorders ventral posterior lateral nucleus (VPL) and ventral pos- may be a risk factor for the evolution of migraine into terior medial nucleus (VPM). AN of the thalamus is a MOH. Another follow-up study identified several risk key component of the hippocampal system for episodic memory. Via its connections with the anterior cingulate and orbitomedial prefrontal cortex, the AN may also in- volve in emotional and executive functions [33]. Affective and anxiety disorders prevailed in patients with chronic forms or transform of headache and substance use than in patients with migraine alone [34]. Decreased AN volume in migraineurs may be related to the psychi- atric disorders in migraine patients and suggest that the central reorganization after repeated, long-term nocicep- tive signaling. Increased volume of AN in our study may suggest pre-existed morphological abnormalities in MOH. Somatosensory-related thalamic structures can be broadly divided into lateral and medial subdivisions (VPL and VPM), which receive sensory inputs from the spinal cord or medulla to the thalamus directly through Fig. 3 The mean volume of thalamic subnuclei in MOH and NC. L, the spinothalamic tract or trigeminothalamic tract [35]. left; R, right; AN, anterior nucleus; DM, doromedial nucleus; VA, VPL and VPM then project to the dorsal part of thal- ventral anterior nucleus; VL, ventral lateral nucleus; VPL, ventral amus and then sends axon projections to the cerebral posterior lateral nucleus; VPM, ventral posterior medial nucleus cortex for a complete sensory transmission [36]. Chen et al. The Journal of Headache and Pain (2017) 18:82 Page 5 of 7 Fig. 4 The scatter plot between thalamic subnuclei volume and the HAMD score (a and b, left thalamic subnuclei; c and d, right thalamic subnuclei). L, left; R, right; AN, anterior nucleus; DM, doromedial nucleus; VA, ventral anterior nucleus; VL, ventral lateral nucleus; VPL, ventral posterior lateral nucleus; VPM, ventral posterior medial nucleus; T, thalamus; HAMD, Hamilton Depression Scale Increased gray matter volume in DM, VPL and VPM increased gray matter volume in thalamus may relate to may indicate higher-order of pain are altered in MOH. the genetic background of patients with MOH. We ob- In our study, we did not find a relation between the served negative associations between HAMD scores and volumes of thalamic nuclei and clinical features, such as gray matter volume in all the thalamus subnuclei in pa- VAS or the duration of the disorder. It suggests that tients, suggesting that these structural changes may also Table 3 The correlation of thalamic subnuclei volume with the clinical variables HAMD HAMA VAS DD r P value r P value r P value r P value L_AN −0.469 0.016 −0.159 0.439 0.002 0.991 −0.018 0.929 L_DM −0.466 0.017 −0.171 0.404 0.025 0.902 0.071 0.724 L_VA −0.467 0.016 −0.192 0.347 −0.073 0.718 −0.009 0.966 L_VL −0.468 0.016 −0.186 0.363 −0.069 0.733 −0.005 0.981 L_VPL −0.460 0.018 −0.178 0.384 −0.099 0.623 0.026 0.897 L_VPM −0.453 0.020 −0.161 0.434 −0.087 0.668 0.035 0.863 L_T −0.471 0.015 −0.180 0.380 −0.037 0.856 0.028 0.889 R_AN −0.491 0.011 −0.165 0.420 0.027 0.892 −0.013 0.948 R_DM −0.502 0.009 −0.205 0.316 0.014 0.946 0.077 0.701 R_VA −0.512 0.008 −0.229 0.261 −0.058 0.775 0.018 0.931 R_VL −0.514 0.007 −0.217 0.288 −0.064 0.753 0.037 0.853 R_VPL −0.506 0.008 −0.215 0.292 −0.109 0.589 0.052 0.796 R_VPM −0.494 0.010 −0.200 0.329 −0.108 0.592 0.055 0.786 R_T −0.513 0.007 −0.213 0.297 −0.037 0.853 0.052 0.798 L left, R right, AN anterior nucleus, DM dorsomedial nucleus, VA ventral anterior nucleus, VL ventral lateral nucleus, VPL ventral posterior lateral nucleus, VPM ventral posterior medial nucleus, T thalamus Chen et al. The Journal of Headache and Pain (2017) 18:82 Page 6 of 7 be influenced by mood disturbances related to the dis- 8. Bongsebandhu-phubhakdi S, Srikiatkhachorn A (2012) Pathophysiology of medication-overuse headache: implications from animal studies. Curr Pain order [37]. Headache Rep 16:110–115 9. Borsook D (2012) Neurological diseases and pain. Brain 135:320–344 10. Poulet JF, Fernandez LM, Crochet S, Petersen CC (2012) Thalamic control of Conclusions cortical states. Nat Neurosci 15:370–372 In conclusion, increased gray matter volume in the 11. Magon S, May A, Stankewitz A, Goadsby PJ, Tso AR, Ashina M et al (2015) whole thalamus and all the thalamus subnuclei may re- Morphological abnormalities of thalamic subnuclei in migraine: a multicenter MRI study at 3 tesla. J Neurosci 35:13800–13806 flect central sensitization and higher-order of pain alter- 12. Afridi SK, Giffin NJ, Kaube H, Friston KJ, Ward NS, Frackowiak RS, Goadsby PJ ation in MOH. 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Volumetric abnormalities of thalamic subnuclei in medication-overuse headache

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Springer Journals
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Copyright © 2017 by The Author(s).
Subject
Medicine & Public Health; Pain Medicine; Internal Medicine; Neurology
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1129-2369
eISSN
1129-2377
DOI
10.1186/s10194-017-0791-5
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28808921
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Abstract

Background: The thalamus exerts a pivotal role in pain processing and cortical excitability control and a previous voxel-based morphometry study confirmed increased volume in bilateral thalamus in medication-overuse headache (MOH). The aim of this study is to investigate altered thalamic subnuclei volume in MOH compared with normal controls, and to evaluate the relationship of each thalamic subnuclei volume with the clinical variables. Methods: High resolution three-dimensional T1-weighted fast spoiled gradient recalled echo MR images were obtained from 27 patients with MOH and 27 normal controls (NC). Thalamic subnuclei templates were created based on Talairach template with MNI space transformation, and the individual thalamic subnuclei templates were generated by applying the deformation field from structural image segment to the thalamic subnuclei templates, and then individual thalamci subnuclei volume were calculated. Results: The whole thalamus and each thalamic subnuclei presented increased volume compared with NC (P <0.05). The correlation analysis demonstrated that the whole thalamus volume and each thalamic subnuclei volume showed a negative relationship with HAMD scores(P < 0.05), and no any correlation with HAMA, VAS score and disease duration (P >0.05). Conclusion: Increased gray matter volume in the whole thalamus and all the thalamus subnuclei may reflect central sensitization and higher-order of pain alteration in MOH. These structural changes in the thalamus may also be influenced by mood disturbances related to the MOH. Keywords: Medication-overuse headache, Migraine, Thalamus, Magnetic resonance imaging Background primary headaches such as migraine are the most Medication-overuse headache (MOH) was defined as a important risk factors for the development of MOH, headache occurring on 15 or more days per month de- 50%–70% MOH have co-occurrence of migraine in veloping as a consequence of regular overuse of acute or population-based studies [6, 7]. Many psychosocial and symptomatic headache medication for more than socioeconomic factors which are prevailed in patients 3 months [1] . MOH has a prevalence of 0.6–2.0% in the with chronic forms of headache are also associated with general population [2, 3], and was associated with mood MOH. However, the mechanism behind how chronic ex- disorders in 27–85% and anxiety disorders in 61–83%. posure to abortive medication leads to MOH remains MOH patients experience reduced quality of life com- unclear. Alteration of cortical neuronal excitability, cen- pared with those who do not suffer from headaches [4]. tral sensitization involving the trigeminal nociceptive A pre-existing headache disorder seems to be required system have been suggested to play a part in the patho- to develop MOH [5]. It is well known that previous physiology of MOH [8]. The thalamus contains third-order trigeminovascular * Correspondence: cjr.malin@vip.163.com; yusy1963@126.com nociceptive neurons and exerts a pivotal role in pain Zhiye Chen and Zhihua Jia contributed equally to this work. processing and cortical excitability control [9, 10]. Lin Ma and Shengyuan Yu contributed equally to this work. Department of Radiology, Chinese PLA General Hospital, 28 Fuxing Road, Microstructural and functional alterations of the thal- Beijing 100853, China amus have been found in migraine patients [11, 12]. Sig- Department of Neurology, Chinese PLA General Hospital, 28 Fuxing Road, nificant volume reductions of the following thalamic Beijing 100853, China Full list of author information is available at the end of the article © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Chen et al. The Journal of Headache and Pain (2017) 18:82 Page 2 of 7 nuclei densely connected to the limbic system were ob- MOH patients. Headache information were registered and served in migraineurs: central nuclear complex, anterior evaluated in our headache database. All the patients were nucleus and lateral dorsal nucleus, supported that given with the Visual Analogue Scale (VAS) evaluation. higher-order integration systems are altered in migraine Additionally, we used the Hamilton Anxiety Scale [11]. Increased iron deposition and myelin content/ (HAMA) [19] scale to assess the anxiety, the Hamilton cellularity in the thalamus of migraine with aura pa- Depression Scale) [20] to assess the depression, and the tients compared with migraine without aura patients Mini-mental State Examination (MMSE) [21] to assess the and healthy controls were found, may underlie abnor- cognitive function of all the participants. MRI scans were mal cortical excitability control leading to cortical taken in the interictal stage at least three days after a mi- spreading depression and visual aura [13]. A voxel- graine attack for MOH patients. Alcohol, nicotine, caf- based morphometry (VBM) study identified increased feine, and other substances were avoided for at least 12 h gray matter volume in bilateral thalamus in MOH pa- before MRI examination. tients [14]. Although it was demonstrated that peria- queductal gray (PAG) volume gain [15] and altered MRI acquisition intrinsic functional connectivity architecture [16] were MRI data were obtained by a conventional eight-channel confirmed in MOH patients in our previous study, quadrature head coil from a GE 3.0 T MR system however, it was not known that how the thalamic (DISCOVERY MR750, GE Healthcare, Milwaukee, WI, subfields volume changed in MOH up to now. USA). All subjects were instructed to lie in a supine pos- Up to now, several documents had recognized that ition, and formed padding was used to limit head move- thalamic subnuclei were segmented based on diffusion ment. An axial three-dimensional T1-weighted fast tensor imaging [17, 18], and thalamic nuclei densely spoiled gradient recalled echo (3D T1-FSPGR) sequence connected to the limbic system were observed in migrai- was performed to acquire the brain structure images. neurs [11]. Therefore, morphology analysis of thalamic The 3D T1-FSPGR parameters were listed as follows: subnuclei would provide more information in the under- TR (repetition time) = 6.3 ms, TE (echo time) = 2.8 ms, standing of neuromechanism of MOH. flip angle = 15o, FOV (field of view) = 25.6 cm × 25.6 cm, The main objective of the current study was to investi- Matrix = 256 × 256, NEX (number of acquisition) = 1]. gate the altered thalamic subnuclei volume in MOH All the subjects were performed the same imaging pro- compared with normal controls, and to further evaluate tocols, and the subjects with structural damage would be the relationship of each thalamic subnuclei volume with excluded. the clinical variables. Image processing Methods Image processing mainly included the following steps: Subjects (1) Convert Talairach template [22] into MNI space, and This study was approved by the ethics committee of the the thalamic subnuclei templates were created using rest Chinese PLA General Hospital, and written informed software [23]. The thalamic subnuclei [11] included fol- consent was obtained from the subjects according to the lowing subregions: left/right ventral posterior lateral nu- Declaration of Helsinki. Twenty-seven MOH patients cleus (L_VPL/R_VPL), left/right ventral posterior medial were consecutively recruited from the headache center, nucleus (L_VPM/R_VPM), left/right dorsomedial nu- Chinese PLA General Hospital. The included criteria of cleus (L_DM/R_DM), left/right ventral lateral nucleus MOH included as follows: (1) All patients with both, (L_VL/R_VL), left/right ventral anterior nucleus (L_VA/ MOH and migraine; (2) The diagnosis of 8.2 MOH, 1.1 R_VA), and left/right anterior nucleus (L_AN/R_AN). and 1.2 migraine based on the International Classification (Fig. 1). (2) The individual structural images were seg- of Headache Disorders, third Edition (beta version) mented by the new segment tool embedded in SPM 12 (ICHD-III beta); (3) Without migraine preventive medica- software (http://www.fil.ion.ucl.ac.uk/spm), and the in- tion in the past 3 months. The excluded criteria included verse deformation field was generated (iy_subjectID.nii). as follows: (1) With chronic disorders, including Then, the standard thalamic subnuclei were applied with hypertension, diabetes mellitus, cardiovascular diseases, the inverse deformation with pullback strategy, which etc.; (2) With cranium trauma, psychotic disorder, and would generate the individual thalamic subnuclei masks regular use of a psychoactive or hormone medication. [15] (Fig. 2). Each individual thalamic subnucleus seg- Part of MOH patients were overlapping with our pre- mentations were visually inspected to confirm anatom- vious studies [15, 16]. Twenty-seven normal controls ical accuracy by one experienced radiologist. (3) The (NCs) were recruited, who should never have any pri- volume of individual thalamic subnuclei were measured mary headache disorders or other types of headache in by ITK-SNAP (V3.6.0) software (http://www.itksnap.org/ the past year, and had the same exclusion criteria with pmwiki/pmwiki.php). Chen et al. The Journal of Headache and Pain (2017) 18:82 Page 3 of 7 MOH group and NC group. The Pearson’s correlation analysis was applied between thalamic volume and the clinical variables (including disease duration, VAS) in MOH. Significant difference was set at a P value of <0.05. Results Comparison of clinical characteristics between MOH and NC The current study included 27 MOH patients (F/ M = 20/7) and 27 normal controls (F/M = 19/8). The age, sex and MMSE showed no significant difference be- tween MOH and NC (P > 0.05). There was a significant HAMD and HAMA between MOH (20.85 ± 12.67 and 17.70 ± 8.63) and NC (7.32 ± 4.26 and 9.78 ± 2.91) (P < 0.05)(Table 1). Comparison of thalamic subnuclei volume between MOH Fig. 1 The standard thalamic subnuclei templates were created and NC according to Talairach template. AN, anterior nucleus; DM, Table 2 demonstrated that all the thalamic subnuclei doromedial nucleus; VA, ventral anterior nucleus; VL, ventral lateral nucleus; VPL, ventral posterior lateral nucleus; VPM, ventral posterior presented increased volume in MOH compared with NC medial nucleus (P < 0.05). Bilateral whole thalamus also showed in- creased volume in MOH (L_T, 3.365 ± 0.291 ml, R_T,3.312 ± 0.288 ml) compared with NC (L_T, Statistical analysis 3.237 ± 0.249 ml, R_T, 3.190 ± 0.241 ml) (P < 0.05) The statistical analysis was performed by using PASW (Fig. 3). Statistics 18.0. The age, MMSE, HAMD,and HAMA were performed with independent samples T test, and Correlation analysis between thalamic subnuclei volume sex was performed with Chi-Square test. The signifi- and the clinical variable cance differences of whole thalamus and thalamic sub- Figure 4 demonstrated that all the thalamic subnuclei nuclei volume were computed using analysis of volume were significantly negatively related with HAMD covariance with the age and sex as covariates between score (P < 0.05), and there were not significant relation- ship between all the thalamic subnuclei and the other clinical variables including HAMA, VAS and disease duration (P > 0.05) (Table 3). Discussion Our study aimed to identify morphological changes of thalamic subnuclei in MOH and try to reveal more Table 1 The clinical characteristics of the subjects MOH NC T value P value Num(F/M) 27(20/7) 27(19/8) 0.092 0.761 Age 39.93 ± 9.75 43.04 ± 10.82 2.007 0.272 MMSE 27.41 ± 3.74 28.19 ± 1.00 2.007 0.302 HAMD 20.85 ± 12.67 7.32 ± 4.26 2.008 0.000 HAMA 17.70 ± 8.63 9.78 ± 2.91 2.007 0.000 DD 18.07 ± 9.85 NA NA NA Fig. 2 The individual thalamic nuclei were generated by applying VAS 8.26 ± 1.46 NA NA NA the inverse deformation with pullback strategy to the standard thalamic subnuclei. AN, anterior nucleus; DM, doromedial nucleus; Chi-square test. MOH medication-overuse headache, NC normal control, DD disease duration, VAS Visual Analogue Scale, HAMA Hamilton Anxiety Scale, VA, ventral anterior nucleus; VL, ventral lateral nucleus; VPL, ventral HAMD Hamilton Depression Scale, MMSE Mini-mental State Examination, NA posterior lateral nucleus; VPM, ventral posterior medial nucleus not available Chen et al. The Journal of Headache and Pain (2017) 18:82 Page 4 of 7 Table 2 The volume comparison of thalamic subnuclei(ml) factors for MOH among people with chronic headache, between MOH and NC including increased Hospital Anxiety and Depression MOH NC F value P value Scale score [27]. However, depression and anxiety disor- ders are associated with both migraine and non- L_AN 0.195 ± 0.017 0.187 ± 0.015 6.788 0.012 migrainous headache, and this was related to the head- L_DM 1.164 ± 0.106 1.123 ± 0.093 4.627 0.036 ache frequency rather than headache diagnosis in an- L_VA 0.324 ± 0.027 0.311 ± 0.023 6.974 0.011 other research, so the relationship between psychiatric L_VL 1.056 ± 0.090 1.014 ± 0.076 7.570 0.008 disorders and MOH may be comobidity [28]. The cause- L_VPL 0.375 ± 0.033 0.360 ± 0.027 7.546 0.008 effect relationship needs further longitudinal study. L_VPM 0.253 ± 0.022 0.243 ± 0.018 7.087 0.010 Consistent with the previous study [14], we found in- creased whole thalamus volume bilaterally in the MOH. L_T 3.365 ± 0.291 3.237 ± 0.249 6.474 0.014 An increase in GMV may reflect structural brain plasti- R_AN 0.182 ± 0.016 0.175 ± 0.013 6.657 0.013 city as a result of exercise and learning [29]. Gray matter R_DM 1.845 ± 0.112 1.143 ± 0.095 4.529 0.038 volume increase in the thalamus has also been found in R_VA 0.319 ± 0.027 0.306 ± 0.022 8.365 0.006 chronic pain conditions such as back pain [30] and R_VL 0.997 ± 0.083 0.958 ± 0.069 7.607 0.008 chronic post-traumatic headache [31]. Increased GMV R_VPL 0.393 ± 0.034 0.379 ± 0.028 6.059 0.017 in the thalamus might reflect central sensitization in chronic pain states. However, studies about the thalamic R_VPM 0.236 ± 0.021 0.229 ± 0.017 4.937 0.031 subnuclei volume in these chronic pain conditions have R_T 3.312 ± 0.288 3.190 ± 0.241 6.210 0.016 not been found. If the morphological abnormalities of L left, R right, AN anterior nucleus, DM dorsomedial nucleus, VA ventral thalamic subnuclei are specific to MOH or if the mor- anterior nucleus, VL ventral lateral nucleus, VPL ventral posterior lateral nucleus, VPM ventral posterior medial nucleus, T thalamus phological abnormalities of thalamic can be normalized as cephalic, extra-cephalic pressure-pain thresholds and information about the neuromechanism of MOH. In our pain-related cortical potentials in MOH patients after study, psychiatric evaluation revealed that the majority withdrawal of the overused medication needs further of patients had comorbid psychiatric conditions, con- study [31, 32]. Unlike the specific thalamic subnuclei de- taining both anxiety and depressive disorders, which is creases observed in migraineurs [11], all the thalamic accordant with epidemiologic studies [24, 25]. A previ- subnuclei presented increased volume in MOH. Each ous study showed MOH patients have a greater risk of thalamus is divided into the following subnuclei accord- suffering from anxiety and depression than episodic mi- ing to the inner medullary plate (including plate core): graine, and psychiatric disorders occurred significantly anterior nucleus (AN), dorsomedial nucleus (DM), ven- more often before the transformation from migraine into tral anterior nucleus (VA), ventral lateral nucleus (VL), MOH than after [26]. It deduced that these disorders ventral posterior lateral nucleus (VPL) and ventral pos- may be a risk factor for the evolution of migraine into terior medial nucleus (VPM). AN of the thalamus is a MOH. Another follow-up study identified several risk key component of the hippocampal system for episodic memory. Via its connections with the anterior cingulate and orbitomedial prefrontal cortex, the AN may also in- volve in emotional and executive functions [33]. Affective and anxiety disorders prevailed in patients with chronic forms or transform of headache and substance use than in patients with migraine alone [34]. Decreased AN volume in migraineurs may be related to the psychi- atric disorders in migraine patients and suggest that the central reorganization after repeated, long-term nocicep- tive signaling. Increased volume of AN in our study may suggest pre-existed morphological abnormalities in MOH. Somatosensory-related thalamic structures can be broadly divided into lateral and medial subdivisions (VPL and VPM), which receive sensory inputs from the spinal cord or medulla to the thalamus directly through Fig. 3 The mean volume of thalamic subnuclei in MOH and NC. L, the spinothalamic tract or trigeminothalamic tract [35]. left; R, right; AN, anterior nucleus; DM, doromedial nucleus; VA, VPL and VPM then project to the dorsal part of thal- ventral anterior nucleus; VL, ventral lateral nucleus; VPL, ventral amus and then sends axon projections to the cerebral posterior lateral nucleus; VPM, ventral posterior medial nucleus cortex for a complete sensory transmission [36]. Chen et al. The Journal of Headache and Pain (2017) 18:82 Page 5 of 7 Fig. 4 The scatter plot between thalamic subnuclei volume and the HAMD score (a and b, left thalamic subnuclei; c and d, right thalamic subnuclei). L, left; R, right; AN, anterior nucleus; DM, doromedial nucleus; VA, ventral anterior nucleus; VL, ventral lateral nucleus; VPL, ventral posterior lateral nucleus; VPM, ventral posterior medial nucleus; T, thalamus; HAMD, Hamilton Depression Scale Increased gray matter volume in DM, VPL and VPM increased gray matter volume in thalamus may relate to may indicate higher-order of pain are altered in MOH. the genetic background of patients with MOH. We ob- In our study, we did not find a relation between the served negative associations between HAMD scores and volumes of thalamic nuclei and clinical features, such as gray matter volume in all the thalamus subnuclei in pa- VAS or the duration of the disorder. It suggests that tients, suggesting that these structural changes may also Table 3 The correlation of thalamic subnuclei volume with the clinical variables HAMD HAMA VAS DD r P value r P value r P value r P value L_AN −0.469 0.016 −0.159 0.439 0.002 0.991 −0.018 0.929 L_DM −0.466 0.017 −0.171 0.404 0.025 0.902 0.071 0.724 L_VA −0.467 0.016 −0.192 0.347 −0.073 0.718 −0.009 0.966 L_VL −0.468 0.016 −0.186 0.363 −0.069 0.733 −0.005 0.981 L_VPL −0.460 0.018 −0.178 0.384 −0.099 0.623 0.026 0.897 L_VPM −0.453 0.020 −0.161 0.434 −0.087 0.668 0.035 0.863 L_T −0.471 0.015 −0.180 0.380 −0.037 0.856 0.028 0.889 R_AN −0.491 0.011 −0.165 0.420 0.027 0.892 −0.013 0.948 R_DM −0.502 0.009 −0.205 0.316 0.014 0.946 0.077 0.701 R_VA −0.512 0.008 −0.229 0.261 −0.058 0.775 0.018 0.931 R_VL −0.514 0.007 −0.217 0.288 −0.064 0.753 0.037 0.853 R_VPL −0.506 0.008 −0.215 0.292 −0.109 0.589 0.052 0.796 R_VPM −0.494 0.010 −0.200 0.329 −0.108 0.592 0.055 0.786 R_T −0.513 0.007 −0.213 0.297 −0.037 0.853 0.052 0.798 L left, R right, AN anterior nucleus, DM dorsomedial nucleus, VA ventral anterior nucleus, VL ventral lateral nucleus, VPL ventral posterior lateral nucleus, VPM ventral posterior medial nucleus, T thalamus Chen et al. 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