Jou nal o
Clinical Medicine
A icle
Pen axin 3 (PTX3): A Molecula Ma ke o
Endo helial Dys unc ion in Ch onic Mig aine
Cla a Domínguez-Vi e o 1,†, Yago Lei a 2,3,†, Ana López-Fe ei o 1, Ma a Saa ed a 1,
Xiana Rod íguez-Oso io 1, Tomás Sob ino 4, F ancisco Campos 4, JoséCas illo 4and
Rogelio Lei a 1,4,*
1Headache Uni , Depa men o Neu ology, Uni e si y Clinical Hospi al, Uni e sidade de San iago de
Compos ela, 15706 San iago de Compos ela, Spain; [email p o ec ed]g (C.D.-V.);
[email p o ec ed] (A.L.-F.); ma a.saa ed a.pinei [email p o ec ed] (M.S.); [email p o ec ed] (X.R.-O.)
2UCL Eas man Den al Ins i u e and NIHR UCLH Biomedical Resea ch Cen e, Uni e si y College London,
London WC1X 8LD, UK; y[email p o ec ed]
3Medical-Su gical Den is y (OMEQUI) Resea ch G oup, Heal h Resea ch Ins i u e o San iago de
Compos ela, 15782 San iago de Compos ela, Spain
4Clinical Neu osciences Resea ch Labo a o y, Heal h Resea ch Ins i u e o San iago de Compos ela,
15706 San iago de Compos ela, Spain; omas.sob ino.mo ei as@se gas.es (T.S.);
ancisco.campos.pe ez@se gas.es (F.C.); jose.cas illo.sanchez@se gas.es (J.C.)
*Co espondence: [email p o ec ed]; Tel.: Phone: +34-9-8195-1342; Fax: +34-9-8195-1098
†These wo au ho s con ibu ed equally o he manusc ip .
Recei ed: 20 Feb ua y 2020; Accep ed: 18 Ma ch 2020; Published: 20 Ma ch 2020
Abs ac :
E en hough endo helial dys unc ion is known o play a ole in mig aine pa hophysiology,
s udies ega ding le els o endo helial bioma ke s in mig aine ha e con o e sial esul s. Ou aim
was o e alua e he ole o pen axin 3 (PTX3) and soluble umou nec osis ac o -like weak induce o
apop osis (sTWEAK) as po en ial bioma ke s o endo helial dys unc ion in ch onic mig aine (CM). We
pe o med a case-con ol s udy including 102 CM pa ien s and 28 con ol subjec s and measu ed se um
le els o ma ke s o endo helial dys unc ion (PTX3 and sTWEAK) and in lamma ion [high-sensi i i y
C- eac i e p o ein (hs-CRP)] as well as b achial a e y low-media ed dila ion (FMD) du ing in e ic al
pe iods. In e ic al se um le els o PTX3 and sTWEAK we e highe in CM pa ien s han in con ols
(1350.6
±
54.8 e sus 476.1
±
49.4 pg/mL, p<0.001 and 255.7
±
21.1 e sus
26.4 ±2.6 pg/mL, p<0.0001;
espec i ely). FMD was diminished in CM pa ien s compa ed o con ols
(9.6 ±0.6
e sus
15.2 ±0.9%,
p<0.001). Bo h PTX3 and sTWEAK we e nega i ely co ela ed wi h FMD
( =−0.508,
p<0.001 and
=
−
0.188, p=0.033; espec i ely). A e adjus men o con ounde s, PTX3 emained signi ican ly
co ela ed o FMD ( =
−
0.250, p=0.013). Diagnosis o CM was 68.4 imes mo e likely in an indi idual
wi h le els o PTX3
≥
832.5 pg/mL, sugges ing ha PTX3 could be a no el bioma ke o endo helial
dys unc ion in CM.
Keywo ds: PTX3; sTWEAK; endo helial dys unc ion; ch onic mig aine; FMD
1. In oduc ion
Mig aine is a neu ological diso de ha in ol es ascula and neu al mechanisms in i s
pa hophysiology. I is gene ally ecognized ha he de elopmen o a mig aine headache depends on
he ac i a ion o senso y a e en ibe s o he igeminal ne e, al hough he mechanisms leading o his
ac i a ion a e s ill unclea [1]. T igeminal ac i a ion esul s in he elease o in lamma o y asoac i e
pep ides ha p omo e asodila ion o he meningeal essels and modula e endo helial unc ion. The
in lamma o y esponse ep esen s he key piece o e idence behind he ole o endo helial dys unc ion
in he pa hophysiology o mig aine [2].
J. Clin. Med. 2020,9, 849; doi:10.3390/jcm9030849 www.mdpi.com/jou nal/jcm
J. Clin. Med. 2020,9, 849 2 o 11
Abulko e idencepoin s oanassocia ionbe weenmig aineandendo helialdys unc ion. Whe he
his associa ion is causal o on he con a y— ha endo helial dys unc ion appea s as a consequence o
he disease— emains unclea [
3
]. The possible associa ion be ween s oke o some non-a he oscle o ic
ascula condi ions and mig aine suppo s a ole o endo helium in he e iopa hogenesis o mig aine.
A sys ema ic e iew [
4
] has ecen ly analysed he ela ionship be ween se e al ascula bioma ke s and
mig aine, concluding ha he e a e no clea changes in hei le els in pa ien s. P omising bioma ke s
demand u he in es iga ion in he mig aine popula ion, o ins ance, b achial a e y low-media ed
dila ion (FMD). This echnique has eme ged as he mos widely used non-in asi e ool o assess
endo helial unc ion [
5
]. P e ious FMD s udies in mig aineu s du ing in e ic al and ic al pe iods ha e
shown con adic o y esul s [
6
–
8
]. A s udy pe o med speci ically in pa ien s wi h ch onic mig aine
(CM) showed diminished FMD [9].
In o ma ion ega ding he associa ion be ween CM and molecula bioma ke s o ascula
in lamma ion is limi ed. Inc eased plasma le els o ib inogen and CRP we e obse ed in pa ien s
wi h CM [
9
]. Pen axin 3 (PTX3) is a membe o he long pen axin amily ha ac s as an acu e phase
in lamma o y glycop o ein [
10
]. Two s udies ha e demons a ed highe plasma le els o PTX3 in
mig aine pa ien s du ing a acks when compa ed o in e ic al pe iods [
11
] o heal hy con ols [
12
].
Plasma le els o soluble umou nec osis ac o -like weak induce o apop osis (sTWEAK) ha e
been analysed as po en ial bioma ke s o ca dio ascula disease and endo helial dys unc ion in
ascula [
13
–
15
] and non- ascula diseases [
16
]. Ou g oup demons a ed highe le els o PTX3 and
sTWEAK in pa ien s wi h se e e pe iodon i is and CM [
17
]. Fu he mo e, we demons a ed ha PTX3
and sTWEAK a e ele a ed in CM pa ien s and ha high plasma le els o PTX3 can p edic a good
esponse o Onabo ulinum oxinA (Onabo A), which is widely used o he ea men o CM [18].
The aim o his s udy, he e o e, was o in es iga e he ela ionship be ween le els o PTX3 and
sTWEAK and FMD in o de o elucida e hei po en ial ole as ma ke s o endo helial dys unc ion in
CM pa ien s du ing in e ic al pe iods.
2. Expe imen al Sec ion
Subjec s we e ec ui ed p ospec i ely om he ou pa ien Headache Clinic o Depa men
o Neu ology a he Clinical Uni e si y Hospi al o San iago de Compos ela. One hund ed and
wo indi iduals diagnosed o CM acco ding o In e na ional Classi ica ion o Headache Diso de s,
3 d edi ion c i e ia [
19
], we e selec ed. P e en i e ea men use was allowed. Twen y-eigh heal hy
subjec s wi hou his o y o mig aine o o he ype o headache we e en olled as a con ol g oup.
Con ol subjec s we e ec ui ed om he hospi al and uni e si y s a , s uden s, and gene al popula ion.
All subjec s we e olde han 18 yea s old. Clinical a iables we e eco ded, and selec ed molecula
make s we e de e mined in pe iphe al blood.
Exclusion c i e ia included he ollowing: 1) high blood p essu e (known high blood p essu e
o >2 measu emen s g ea e han 140/90 mm Hg); 2) co ona y disease (co ona y lesions >50%
de e mined by angiog aphy, myoca dial in a c ion, angina pec o is, o co ona y ecanaliza ion);
3) diabe es melli us (known diabe es melli us o >2 as ing se um glucose de e mina ions >
126 mg/dL);
4) hype choles e olemia (pha macologically ea ed o as ing se um choles e ol >
200 mg/dL); 5) in ec ious diseases; 6) ch onic in lamma o y condi ions; 7) se e e sys emic diseases;
8) oligomeno hea, polymeno hea, o polycys ic o a ian synd ome; 9) p egnancy o lac a ion;
10) obesi y (body mass index >30 kg/m2); 11) smoking habi (wi hin he p e ious 12 mon hs); 12) ecen
o ch onic consump ion o asoac i e d ugs (>4 imes he medium hal -li e o he ac i e subs ance),
including angio ensin-con e ing enzyme inhibi o s and angio ensin ecep o blocke s. No pa ien
was ecei ing p e en i e ea men o any o hese condi ions.
W i en in o med consen was ob ained om each subjec included in he s udy. The Resea ch
E hics Commi ee o he Clinical Uni e si y Hospi al o San iago de Compos ela (Spain) app o ed he
s udy (ID NO.: 2016/085). All p ocedu es pe o med in he s udy we e in acco dance wi h he 1964
Helsinki decla a ion and i s la e amendmen s o compa able e hical s anda ds.
J. Clin. Med. 2020,9, 849 3 o 11
All subjec s illed a comple e medical eco d including demog aphic da a (age, gende ) and
pe sonal and amily his o y. Physical examina ion and clinical esul s we e eco ded. Fo mig aineu s,
ype o mig aine (wi h o wi hou au a), ime o e olu ion o he mig aine (measu ed in yea s), in ensi y
o headaches (measu ed by he isual analogic scale [VAS]), du a ion o a acks (quan i ied in hou s),
equency o headaches (numbe o days wi h pain pe mon h) as well as allodynia (>2 poin s on he
12 i em allodynia symp om sco e, ASC-12) we e egis e ed. Clinical pa ame e s we e conside ed as
an a e age o he pa ien ’s episodes in he p e ious h ee mon hs. We eco ded possible como bid
condi ions associa ed wi h mig aine as well as symp oma ic and p e en i e ea men s o mig aine.
A e a sc eening isi , eligible subjec s we e in i ed o pe o m an ul asonog aphic examina ion
and blood sample ex ac ion. Pa ien s we e headache- ee om he p e ious 24 h o he isi . I a
mig aine occu ed wi hin he ollowing 24 h, measu emen s we e epea ed in ano he headache- ee
pe iod. Subjec s had no p e iously consumed an i-in lamma o y o analgesic medica ion in he
p e ious 24 h o he blood sample ex ac ion. T ea men wi h p ophylac ic d ugs, when i exis ed, was
no in e up ed o pe o m he s udy. Measu emen s o con ol subjec s and pa ien s we e pe o med
be ween 10:00 and 11:00 am in a quie , empe a u e-con olled oom (22–24
◦
C) by a single obse e .
Subjec s we e a es in he supine posi ion o he p e ious 10 min.
A blood sample was ex ac ed om he non-dominan o ea m. Blood samples we e collec ed
in chemis y es ubes, cen i uged a 3000
×
g o 15 min, and immedia ely ozen and s o ed a
−
80
◦
C. Se um le els o PTX3 and sTWEAK (Assay Bio ech, Sunny ale, CA, USA) we e measu ed
using comme cial ELISA ki s ollowing manu ac u e ins uc ions. High sensi i i y C- eac i e p o ein
(hs-CRP) was measu ed wi h an immunodiagnos ic IMMULITE 1000 Sys em (Siemens Heal hca e
Global, Los Angeles). The in a-assay and in e -assay coe icien s o a ia ion o all molecula ma ke s
we e <8%. De e mina ions we e pe o med in a labo a o y blinded o clinical da a.
A e blood collec ion, he ul asonog aphic s udy was comple ed in he dominan o ea m. FMD
o he b achial a e y was assessed in all pa ien s by he same esea che (A.L.-F.). The esea che was
blinded o biochemical and molecula de e mina ions and unde wen p e ious echnical aining and
alida ion o da a (compa ed wi h medical s a skilled in neu osonology). We used a high- esolu ion
B-mode ul asound de ice (Aplio 50 Toshiba SSA-700) wi h a 7.5-MHz linea a ay ansduce . FMD
e alua ions we e pe o med acco ding o he In e na ional B achial A e y Reac i i y Task Fo ce and
he Wo king G oup o he Eu opean Socie y o Hype ension guidelines [
20
]. The dominan b achial
a e y was imaged 3–5 cm p oximal o he an ecubi al ossa in a longi udinal plane, pe pendicula o he
ul asound beam. Baseline measu emen s we e i s pe o med (d1, as he mean o 5 a e y diame e
de e mina ions du ing sys ole) and loca ion ma ked, ollowed by a apid in la ion o a cu placed
a ound he p oximal o ea m o 300 mm Hg o 4 min. Then a new de e mina ion was pe o med (d2,
as he mean o new 5 de e mina ions o he a e y diame e du ing sys ole) 45–60 s a e cu elease
causing a eac i e hype emia. B achial a e y diame e s we e ob ained om he nea - o- a blood
wall in ima-media in e aces. FMD was exp essed as he pe cen age o inc ease in he diame e om
baseline (d2-d1/d1 ×100).
A o mal sample size calcula ion was no done. Howe e , conside ing a minimum expec ed e ec
size o 874.5
±
108.0 pg/mL and including 102 CM cases and 28 con ols, a pos hoc powe analysis
calcula ion using he Mac o !NSize o PASW S a is ics (h p://www.me odo.uab.ca /mac os.h m.) was
ca ied ou , showing ha ou s udy had a powe o 96% wi h an alpha isk o 5% o demons a e
signi ican di e ences be ween ch onic mig aineu s and heal hy con ols ega ding he p ima y
ou come o he s udy (i.e., PTX3 se um le els). Mean alues
±
s anda d e o (SE) and median (P
25
,
P
75
) we e calcula ed o no mally and non-no mally dis ibu ed con inuous a iables, espec i ely.
S a is ical es s used o compa e con inuous da a we e he independen - es o Mann-Whi ney U es .
Ca ego ical a iables we e epo ed as pe cen ages and compa ed by chi-squa e es . Analysis o
co a iance (ANCOVA) was used o c ea e adjus ed models using age, gende and BMI as co a ia es
o compa e mean alues o FMD and bioma ke s be ween cases and con ols. Non-pa ame ic
co ela ion analysis be ween FMD, bioma ke s and clinical a iables was pe o med using Spea man’s
ank co ela ion coe icien . In addi ion, pa ial co ela ions adjus ed o same common con ounde s
J. Clin. Med. 2020,9, 849 4 o 11
we e also pe o med o FMD and signi ican bioma ke s. The a ea unde he Recei e Ope a ing
Cha ac e is ic (ROC) cu e was pe o med o calcula e a cu -o poin o PTX3 in o de o disc imina e
pa icipan s wi h and wi hou CM. Logis ic eg ession analysis was conduc ed o es he associa ion
be ween PTX3 (ca ego ized acco ding o calcula ed cu -o poin ) and diagnosis o CM adjus ed o
po en ial con ounde s (age, gende and BMI). All es s we e ca ied ou a a signi icance le el o
α=0.05 using IBM SPSS S a is ics ( e sion 24.0, IBM Co p., A monk, NY, USA).
3. Resul s
Baseline cha ac e is ics o he s udy popula ion a e shown in Table 1. No signi ican di e ences
we e ound be ween CM pa ien s and con ols in e ms o age, sex o BMI. Rega ding mig aine- ela ed
a iables, almos hal o CM pa ien s p esen ed au a. Allodynia was p esen in 32.4% o subjec s. The
a e age numbe o headache days in CM pa ien s was 17.5 days pe mon h wi h a mean du a ion o
21 h o each mig aine a ack. In ensi y was ecalled as high o mos a acks. The numbe o yea s
since i s mig aine symp oms was on a e age 16.
Table 1. Baseline cha ac e is ics o he s udy popula ion.
Va iables Con ols (N =28) CM (N =102) p-Value
Age (yea s) 37.3 ±1.6 39.5 ±1.2 0.382
Gende , Females, n(%) 26 (92.9) 96 (94.1) 0.682
BMI (kg/m2) 24.3 (22.6, 25.9) 24.8 (22.3, 28.0) 0.474
F equency o a acks (days/mon h) 17.5 ±0.8
In ensi y o mig aine a acks (VAS) 9.0 (8.0, 10.0)
Du a ion o mig aine a acks (hou s) 21.3 ±3.8
Time o e olu ion o mig aine (yea s) 15.9 ±1.2
Au a, n(%) 45 (44.1)
Allodynia, n(%) 33 (32.4)
CM: ch onic mig aine; BMI: body mass index; VAS: isual analogue scale.
FMD was signi ican ly diminished in pa ien s wi h CM compa ed o con ols (9.6
±
0.6 e sus
15.2
±
0.9, p<0.001) (Figu e 1A). Highe ci cula ing le els o PTX3 and sTWEAK we e ound in CM
compa ed o hose wi hou CM (1350.6
±
54.8 e sus 476.1
±
49.4 pg/mL, p<0.001 and 255.7
±
21.1
e sus 26.4
±
2.6 pg/mL, p<0.001; espec i ely) (Figu es 1B and 1C). These di e ences we e con i med
in he mul i a ia e model a e adjus ing o age, gende and BMI. No signi ican di e ences we e
obse ed o hs-CRP be ween g oups (0.1
±
0.03 mg/dL e sus 0.3
±
0.05 mg/dL, p=0.178) (Figu e 1D).
J. Clin. Med. 2020, 9, x FOR PEER REVIEW 4 o 11
addi ion, pa ial co ela ions adjus ed o same common con ounde s we e also pe o med o FMD
and signi ican bioma ke s. The a ea unde he Recei e Ope a ing Cha ac e is ic (ROC) cu e was
pe o med o calcula e a cu -o poin o PTX3 in o de o disc imina e pa icipan s wi h and
wi hou CM. Logis ic eg ession analysis was conduc ed o es he associa ion be ween PTX3
(ca ego ized acco ding o calcula ed cu -o poin ) and diagnosis o CM adjus ed o po en ial
con ounde s (age, gende and BMI). All es s we e ca ied ou a a signi icance le el o α = 0.05 using
IBM SPSS S a is ics ( e sion 24.0, IBM Co p., A monk, NY, USA).
3. Resul s
Baseline cha ac e is ics o he s udy popula ion a e shown in Table 1. No signi ican di e ences
we e ound be ween CM pa ien s and con ols in e ms o age, sex o BMI. Rega ding
mig aine- ela ed a iables, almos hal o CM pa ien s p esen ed au a. Allodynia was p esen in
32.4% o subjec s. The a e age numbe o headache days in CM pa ien s was 17.5 days pe mon h
wi h a mean du a ion o 21 h o each mig aine a ack. In ensi y was ecalled as high o mos
a acks. The numbe o yea s since i s mig aine symp oms was on a e age 16.
Table 1. Baseline cha ac e is ics o he s udy popula ion.
Va iables Con ols (N = 28) CM (N = 102) p-Value
Age (yea s) 37.3 ± 1.6 39.5 ± 1.2 0.382
Gende , Females, n (%) 26 (92.9) 96 (94.1) 0.682
BMI (kg/m
2
) 24.3 (22.6, 25.9) 24.8 (22.3, 28.0) 0.474
F equency o a acks (days/mon h) 17.5 ± 0.8
In ensi y o mig aine a acks (VAS) 9.0 (8.0, 10.0)
Du a ion o mig aine a acks (hou s) 21.3 ± 3.8
Time o e olu ion o mig aine (yea s) 15.9 ± 1.2
Au a, n (%) 45 (44.1)
Allodynia, n (%) 33 (32.4)
CM: ch onic mig aine; BMI: body mass index; VAS: isual analogue scale.
FMD was signi ican ly diminished in pa ien s wi h CM compa ed o con ols (9.6 ± 0.6 e sus
15.2 ± 0.9, p < 0.001) (Figu e 1A). Highe ci cula ing le els o PTX3 and sTWEAK we e ound in CM
compa ed o hose wi hou CM (1350.6 ± 54.8 e sus 476.1 ± 49.4 pg/mL, p < 0.001 and 255.7 ± 21.1
e sus 26.4 ± 2.6 pg/mL, p < 0.001; espec i ely) (Figu e 1B and Figu e 1C). These di e ences we e
con i med in he mul i a ia e model a e adjus ing o age, gende and BMI. No signi ican
di e ences we e obse ed o hs-CRP be ween g oups (0.1 ± 0.03 mg/dL e sus 0.3 ± 0.05 mg/dL, p =
0.178) (Figu e 1D).
Figu e 1. Compa isons be ween cases and con ols o : (A) low-media ed dila ion (FMD) (%); (B)
Se um le els o Pen axin 3 (PTX3) (pg/mL); (C) Se um le els o soluble umou nec osis ac o -like
Figu e 1.
Compa isons be ween cases and con ols o : (
A
) low-media ed dila ion (FMD) (%);
(
B
) Se um le els o Pen axin 3 (PTX3) (pg/mL); (
C
) Se um le els o soluble umou nec osis ac o -like
weak induce o apop osis (sTWEAK) (pg/mL); (
D
) Se um le els o high sensi i i y C- eac i e p o ein
hs-CRP (mg/dL). * p<0.001.
J. Clin. Med. 2020,9, 849 5 o 11
Bo h PTX3 and sTWEAK we e nega i ely co ela ed wi h FMD ( =
−
0.508, p<0.001 and
=−0.188,
p=0.033;
espec i ely) (Figu e 2A,B). No signi ican co ela ions we e ound be ween FMD, PTX3,
sTWEAK and clinical o biochemical pa ame e s (Table 2). A e adjus men o con ounde s, PTX3
emained signi ican ly co ela ed o FMD ( =
−
0.250, p=0.013) while adjus ed co ela ion be ween
sTWEAK and FMD was a enua ed, losing s a is ical signi icance ( =0.005, p=0.962).
J. Clin. Med. 2020, 9, x FOR PEER REVIEW 5 o 11
weak induce o apop osis (sTWEAK) (pg/mL); (D) Se um le els o high sensi i i y C- eac i e
p o ein hs-CRP (mg/dL). * p < 0.001.
Bo h PTX3 and sTWEAK we e nega i ely co ela ed wi h FMD ( = −0.508, p < 0.001 and =
−0.188, p = 0.033; espec i ely) (Figu e 2A,B). No signi ican co ela ions we e ound be ween FMD,
PTX3, sTWEAK and clinical o biochemical pa ame e s (Table 2). A e adjus men o con ounde s,
PTX3 emained signi ican ly co ela ed o FMD ( = −0.250, p = 0.013) while adjus ed co ela ion
be ween sTWEAK and FMD was a enua ed, losing s a is ical signi icance ( = 0.005, p = 0.962).
Figu e 2. Sca e plo s showing co ela ions be ween low-media ed dila ion (FMD) (%) and: (A)
pen axin 3 (PTX3) (pg/mL); (B) soluble umou nec osis ac o -like weak induce o apop osis
(sTWEAK) (pg/mL).
Table 2. Co ela ions be ween low-media ed dila ion, clinical and labo a o y pa ame e s.
Age
BMI
(kg/m
2
) F equency In ensi y Du a ion Time o
E olu ion
hs-CRP
(mg/dL)
FMD (%) 0.032 0.166 0.014 0.176 0.121 −0.048 0.156
p- alue 0.722 0.059 0.890 0.076 0.225 0.634 0.078
PTX3
(pg/mL) −0.205 −0.096 0.29 −0.065 −0.125 −0.171 0.037
p- alue 0.190 0.276 0.771 0.516 0.211 0.085 0.676
sTWEAK
(pg/mL) −0.157 0.025 −0.118 −0.078 −0.118 −0.124 0.095
p- alue 0.075 0.779 0.236 0.437 0.236 0.216 0.283
BMI: body mass index; FMD: low-media ed dila ion; PTX3: pen axin 3; sTWEAK: soluble agmen
o umo nec osis ac o -like weak induce o apop osis; hs-CRP: high sensi i i y C- eac i e p o ein.
The ROC ( ecei e ope a ing cha ac e is ic) analysis o PTX3 had an a ea unde he cu e o
0.928 (95% CI: 0.884–0.971, p < 0.001), which sugges s ha his app oach could disc imina e be ween
hose pa ien s wi h and wi hou CM. The cu poin o 832.5 pg/mL o PTX3 p oduced he op imal
sensi i i y and speci ici y o 83% and 85%, espec i ely and 86.9% o he pa icipan s we e co ec ly
assigned o e all wi h an OR
adjus ed
o 68.4 (which means ha CM is 68.4 imes mo e likely in an
indi idual wi h se um le els o PTX3 ≥ 832.5 pg/mL).
4. Discussion
In he p esen s udy, CM pa ien s showed al e ed FMD (a di ec measu e o endo helial
unc ion) compa ed o heal hy con ols. Le els o PTX3 and sTWEAK we e highe in CM pa ien s
and PTX3 le els we e nega i ely co ela ed wi h FMD, e en a e adjus men o po en ial
con ounde s. PTX3 se um le els ≥ 832.5 pg/mL independen ly p edic ed diagnosis o CM wi h a
sensi i i y o 83% and a speci ici y o 85%. Ou esul s sugges ha PTX3 could be a po en ial
bioma ke o endo helial dys unc ion in CM.
Figu e 2.
Sca e plo s showing co ela ions be ween low-media ed dila ion (FMD) (%) and:
(
A
) pen axin 3 (PTX3) (pg/mL); (
B
) soluble umou nec osis ac o -like weak induce o apop osis
(sTWEAK) (pg/mL).
Table 2. Co ela ions be ween low-media ed dila ion, clinical and labo a o y pa ame e s.
Age BMI
(kg/m2)F equency In ensi y Du a ion Time o
E olu ion
hs-CRP
(mg/dL)
FMD (%) 0.032 0.166 0.014 0.176 0.121 −0.048 0.156
p- alue 0.722 0.059 0.890 0.076 0.225 0.634 0.078
PTX3 (pg/mL) −0.205 −0.096 0.29 −0.065 −0.125 −0.171 0.037
p- alue 0.190 0.276 0.771 0.516 0.211 0.085 0.676
sTWEAK (pg/mL) −0.157 0.025 −0.118 −0.078 −0.118 −0.124 0.095
p- alue 0.075 0.779 0.236 0.437 0.236 0.216 0.283
BMI: body mass index; FMD: low-media ed dila ion; PTX3: pen axin 3; sTWEAK: soluble agmen o umo
nec osis ac o -like weak induce o apop osis; hs-CRP: high sensi i i y C- eac i e p o ein.
The ROC ( ecei e ope a ing cha ac e is ic) analysis o PTX3 had an a ea unde he cu e o 0.928
(95% CI: 0.884–0.971, p<0.001), which sugges s ha his app oach could disc imina e be ween hose
pa ien s wi h and wi hou CM. The cu poin o 832.5 pg/mL o PTX3 p oduced he op imal sensi i i y
and speci ici y o 83% and 85%, espec i ely and 86.9% o he pa icipan s we e co ec ly assigned
o e all wi h an OR
adjus ed
o 68.4 (which means ha CM is 68.4 imes mo e likely in an indi idual wi h
se um le els o PTX3 ≥832.5 pg/mL).
4. Discussion
In he p esen s udy, CM pa ien s showed al e ed FMD (a di ec measu e o endo helial unc ion)
compa ed o heal hy con ols. Le els o PTX3 and sTWEAK we e highe in CM pa ien s and PTX3
le els we e nega i ely co ela ed wi h FMD, e en a e adjus men o po en ial con ounde s. PTX3
se um le els
≥
832.5 pg/mL independen ly p edic ed diagnosis o CM wi h a sensi i i y o 83% and
a speci ici y o 85%. Ou esul s sugges ha PTX3 could be a po en ial bioma ke o endo helial
dys unc ion in CM.
The ole o gende and sexual ho mones in mig aine and mig aine ch oni ica ion has been
ex ensi ely s udied [
21
]. Se e al s udies ha e also e alua ed he ela ionship be ween BMI and
mig aine. A highe isk o mig aine has been epo ed in obese subjec s and speci ically o ch onic
mig aine ei he in obese o p e-obese subjec s [
22
]. This associa ion is likely media ed by gende . In ou
s udy he e we e no di e ences among g oups ega ding sex o BMI, and di e ences obse ed in PTX3
le els su i ed mul i a ia e analysis conside ing hese ac o s.
J. Clin. Med. 2020,9, 849 6 o 11
To da e, se e al s udies ha e ocused on endo helial dys unc ion in mig aine, howe e , hei
indings a e con o e sial. Rela ed molecula ma ke s such as endo helin-1 (ET-1) o ni ic oxide
(NO) ha e been de e mined in mig aine [
23
,
24
]. A sys ema ic e iew has e alua ed mo e han 600
epo s measu ing le els o bioma ke s o in lamma ion, p o h ombo ic s a e, endo helial ac i a ion
and endo helial epai [
4
] in mig aine and concluded ha esul s a e con lic ing and he e a e no
de ini e ascula bioma ke s in mig aine pa ien s. In he ollowing yea s, no el po en ial ma ke s o
endo helial dys unc ion we e b ough up and e alua ed, such as endo helial mic opa icles (EMPs) [
25
],
asymme ic dime hyla ginine (ADMA) [
26
,
27
], and endo helial p ogeni o cells (EPCs) [
28
,
29
]. These
molecules and cells play a ole in endo helial egene a ion and epai o inju ed essels. Howe e ,
o da e, none o hese bioma ke s ha e been p o en o be associa ed wi h ascula endo helial
dys unc ion speci ically in mig aine pa ien s.
FMD is a ep oducible and non-in asi e ul asound assessmen o endo helial unc ion [
5
]. Many
s udies assessing endo helial unc ion in mig aineu s ha e used FMD, howe e , hei indings ha e
been inconsis en [
30
–
32
]. In a p e ious s udy pe o med by ou g oup, we did no ind signi ican
di e ences in FMD be ween con ol subjec s and pa ien s wi h episodic mig aine (EM) du ing in e ic al
and ic al pe iods. In he p esen s udy, howe e , we s udied FMD in CM and ound ha i was
signi ican ly diminished when compa ed o con ols, in ag eemen wi h a p e ious epo [
9
]. FMD
shows a high a iabili y, and single de e mina ions may e lec a ansi o y esponse o he endo helium
mo e han a long- e m p ocess o endo helial dys unc ion. Recu en mig aine a acks could in luence
pe sis en damage o he endo helium, explaining he di e en indings be ween CM and EM pa ien s.
PTXs, a supe amily o soluble, mul i ac o ial, pa e n ecogni ion p o eins [
33
,
34
], a e classical
media o s o in lamma ion and ma ke s o acu e-phase eac ion. PTXs a e an essen ial componen o
he humo al esponse in inna e immuni y. In addi ion o CRP, he PTX supe amily includes he long
PTX3, which is eme ging as a key playe in immuni y and in lamma ion [
35
]. Unlike CRP, which is
p ima ily syn hesized in he li e , PTX3 is eleased by ascula endo helial cells and mac ophages a e
s imula ion wi h in lamma o y cy okines (IL-1
β
, TNF-
α
), TLR agonis s and mic obial componen s.
The e o e, PTX3 le els a e belie ed o be a ue independen indica o o local in lamma ion and a e
hough o e lec endo helial dys unc ion mo e accu a ely han CPR [
12
]. I s concen a ion inc eases
apidly in a ious in ec ions and plays an impo an ole in he ea ly phase o in lamma ion. PTX-3
can be used as a p ognos ic bioma ke in sepsis and sep ic shock in adul s [
36
] and child en [
37
].
PTX3 plasma le els a e also inc eased in some non-in ec ious condi ions ha in ol e in lamma ion
and endo helial damage, such as ascula a he oscle osis, in lamma ion o ascula damage [
38
–
41
],
especially a e myoca dial in a c ion [
42
], e lec ing he ex en o issue damage. PTX3 has been
associa ed wi h he incidence o co ona y a e y disease (CAD) and all-cause mo ali y in CAD
pa ien s [
43
]. Mo eo e , in pa ien s wi h co ona y a e y disease, plasma le els o PTX3 ha e been
co ela ed wi h endo helial unc ion assessed by FMD showing a s onge associa ion han he one
exis ing be ween CRP and endo helial unc ion [
10
], and i has been sugges ed ha i migh play a
p o ec i e ole in a he oscle osis [43].
Rega ding mig aine, only wo s udies ha e demons a ed highe plasma le els o PTX3 measu ed
du ing a acks and compa ed o in e ic al pe iods [
11
] and con ol subjec s [
12
]. To da e, no in o ma ion
is a ailable ega ding pe iphe al blood bioma ke s o ascula in lamma ion speci ically in CM. Ou
g oup has epo ed highe le els o PTX3 and sTWEAK in pa ien s wi h CM and concu en se e e
pe iodon i is [
17
] as well as highe le els o PTX3 and sTWEAK in CM pa ien s. On op o ha , we
ound ha PTX3 could be a p edic o o a good esponse o Onabo A, which is widely used o he
ea men o CM [
18
]. The p esen s udy ollows his line o esea ch and shows ha plasma PTX3 is
signi ican ly co ela ed wi h endo helial unc ion assessed by FMD in pa ien s wi h CM, poin ing o
his as he mos p obable unde lying mechanism. Fu he mo e, PTX le els
≥
832.5 pg/mL p edic ed
diagnosis o CM, hus indica ing he po en ial ole o PTX3 as a po en ial bioma ke o endo helial
dys unc ion in CM.
J. Clin. Med. 2020,9, 849 7 o 11
TWEAK is a membe o he TNF supe amily o cy okines ha is syn hesized as a ype-II
ansmemb ane p o ein om which a soluble o m wi h biological ac i i y can be eleased
(i.e., sTWEAK) [
44
]. TWEAK mRNA is exp essed in a a ie y o issues and cells, including b ain, hea ,
and lung, as well as human endo helial and smoo h muscle cells [
45
]. TWEAK binds o Fn14, a highly
inducible cell-su ace ecep o ha is linked o se e al in acellula signalling pa hways, including
he nuclea ac o -
κ
B (NF-
κ
B) pa hway [
46
]. TWEAK is a mul i ace ed cy okine whose e ec s a e cell
ype and en i onmen -dependen [
47
]. I may induce a ious cellula esponses
in i o
including cell
p oli e a ion [
48
], mig a ion, di e en ia ion [
49
], angiogenesis [
48
], and exp ession o p o-in lamma o y
molecules such as IL-8, MPC-1, ICAM-1, and E-selec in in human umbilical endo helial cells [
50
], and
IL-6, IL-8, and ICAM-1 in as ocy es [
51
]. Plasma le els o sTWEAK ha e been e alua ed as po en ial
bioma ke s o ca dio ascula disease and endo helial dys unc ion wi hin se e al diseases. Low plasma
le els o sTWEAK we e associa ed wi h ch onic ascula damage in ca o id s enosis [
13
], co ona y
a e y disease [
52
], pe iphe al a e y disease [
15
], hea ailu e [
14
], and ch onic kidney disease [
45
],
and in pa ien s wi h ascula isk ac o s such as diabe es [
16
], o hype ension [
53
]. In con as ,
high plasma le els o sTWEAK ha e been desc ibed in pa ien s a e myoca dial in a c ion [
54
] and
s oke [
55
]. FMD has been associa ed wi h sTWEAK concen a ion in pa ien s wi h ch onic kidney
disease [
45
]. The associa ion o sTWEAK wi h FMD sugges s ha his p o ein could also be a bioma ke
o endo helial dys unc ion.
In ou s udy, we hypo hesized ha pa ien s wi h mig aine show inc eased le els o PTX3 and
sTWEAK as a esul o al e ed endo helial unc ion, e en in he absence o ascula isk ac o s. A ecen
e iew has ound da a suppo ing a ela ion be ween hype ension, ansien ischemic a ack (TIA),
s oke, hype choles e olemia and mig aine, he e o e we excluded subjec s wi h he mos p e alen
ascula isk ac o s and o he a iables ha may in luence endo helium in eg i y and s ill ound highe
le els o PTX3 and sTWEAK in CM pa ien s. Rega ding sys emic disease and i s in luence on CM, some
ch onic in lamma o y condi ions ha e been linked o mig aine, such as endome iosis o gas oin es inal
diso de s. Sys emic au oimmune diseases such as lupus, an iphospholipid synd ome and sys emic
scle osis a e mo e equen in pa ien s su e ing om mig aine, and endo helial dys unc ion is he
only al e a ion ha is common among all hese diso de s. Conside ing ha ou exclusion c i e ia
elimina ed hese con ounde s, i is emp ing o pos ula e ha high le els o PTX3 and sTWEAK a e
a esul o pa hophysiologic mechanisms ela ed o mig aine a he han a consequence o o he
condi ions associa ed wi h endo helial dys unc ion. These indings sugges a s ong link be ween
mig aine, in lamma ion and endo helial dys unc ion. Fu he mo e, no co ela ion was ound be ween
plasma le els o PTX3 and sTWEAK egis e ed du ing in e ic al pe iod and clinical pa ame e s
(in ensi y, du a ion o he headaches, ime o e olu ion o mig aine). These indings sugges ha
endo helial dys unc ion could be a phenomenon ela ed wi h he speci ic mechanisms unde lying CM
pa hophysiology and no wi h he clinical a iabili y o i s mani es a ions.
This s udy has se e al limi a ions. Fi s , he sample size was ela i ely small, pa icula ly in
he con ol g oup, and a la ge popula ion could ha e powe ed ou esul s. FMD was s udied only
once in each subjec when i is known o be a iable be ween di e en measu es, and he examine
who assessed FMD was no blinded o clinical da a. The s age o he mens ual cycle was no aken
in o accoun and i has been p o en o ha e an in luence in endo helial unc ion. Al hough ou
exclusion c i e ia suppo a ela ionship be ween endo helial dys unc ion and mig aine independen ly
o ca dio ascula co ounde s, i also may limi he ex e nal alidi y o ou indings.
5. Conclusions
In conclusion, pa ien s wi h CM had inc eased ci cula ing le els o PTX3 and sTWEAK as well
as diminished FMD compa ed o subjec s wi hou mig aine. PTX3 concen a ions a e nega i ely
co ela ed wi h FMD. A alue o PTX3
≥
832.5 pg/mL independen ly p edic ed he p esence o CM.
Hence, PTX3 could be conside ed as a po en ial bioma ke o ascula endo helial dys unc ion in CM.
Fu he longi udinal s udies a e needed o con i m ou p elimina y esul s. In e en ion s udies a e
J. Clin. Med. 2020,9, 849 8 o 11
wa an ed o in es iga e whe he a educ ion in his bioma ke could be ansla ed in o a bene icial
clinical e ec in ch onic mig aineu s.
Au ho Con ibu ions:
Concep ualiza ion: C.D.-V., A.L.-F., J.C., R.L.; da a cu a ion: C.D.-V., A.L.-F., M.S., X.R.-O.,
F.C.; o mal analysis: C.D.-V., Y.L., A.L.-F., in es iga ion: C.D.-V., A.L.-F., T.S., F.C., R.L.; me hodology: C.D.-V.,
Y.L., T.S., J.C., R.L.; w i ing-o iginal d a : C.D.-V., R.L.; w i ing- e iew & edi ing: Y.L., M.S., X.R.-O., T.S., F.C., J.C.,
R.L. All au ho s ha e ead and ag eed o he published e sion o he manusc ip .
Funding:
This esea ch was unded by Spanish Minis y o Economy and Compe i i eness—Ins i u e o Heal h
Ca los III, G an /Awa d Numbe s: PI15/01578.
Acknowledgmen s:
Y.L. holds a Senio Clinical Resea ch Fellowship suppo ed by he UCL Biomedical Resea ch
Cen e who ecei es unding om he NIHR.
Con lic s o In e es :
R.L. has se ed on ad iso y boa ds and/o has consul ed o Alle gan
™
, No a is, Eli Lilly
and Te a. He has also ecei ed hono a ia om hose companies om pa icipa ing as a speake and p ecep o in
sponso ed educa ional p og ams. O he au ho s epo no disclosu e. The au ho s decla e no con lic o in e es .
Re e ences
1.
Goadsby, P.J.; Lip on, R.B.; Fe a i, M.D. Mig aine-cu en unde s anding and ea men . N. Eng. J. Med.
2002,346, 257–270. [C ossRe ]
2.
Du ham, P.; Papape opoulos, S. Bioma ke s associa ed wi h mig aine and hei po en ial ole in mig aine
managemen . Headache 2013,53, 1262–1277. [C ossRe ]
3.
Ku h, T.; Gaziano, J.M.; Cook, N.R.; Log oscino, G.; Diene , H.C.; Bu ing, J.E. Mig aine and isk o
ca dio ascula disease in women. JAMA 2006,296, 283–291. [C ossRe ]
4. Tie jen, G.E.; Khubchandani, J. Vascula bioma ke s in mig aine. Cephalalgia 2015,35, 95–117. [C ossRe ]
5.
Flamme , A.J.; Ande son, T.; Cele maje , D.S.; C eage , M.A.; Dean ield, J.; Ganz, P.; Hambu g, N.M.;
Lüsche , T.F.; Shech e , M.; Taddei, M.; e al. The assessmen o endo helial unc ion: F om esea ch in o
clinical p ac ice. Ci cula ion 2012,126, 753–767. [C ossRe ]
6.
Pe ko, D.; P e na -Oblak, J.; Sabo ic, M.; Z an, B.; Zale el, M. Endo helium-dependen asodila a ion in
mig aine pa ien s. Cephalalgia 2011,31, 654–660. [C ossRe ]
7.
Sil a, F.A.; Rueda-Clausen, C.F.; Sil a, S.Y.; Za uk, J.G.; Guzm
á
n, J.C.; Mo illo, C.A.; FRCPC; FACC; Vesag, B.;
P adilla, G.; e al. Endo helial unc ion in pa ien s wi h mig aine du ing he in e ic al pe iod. Headache
2007
,
47, 45–51. [C ossRe ]
8.
Ve nie i, F.; Mo o, L.; Al amu a, C.; Palazzo, P.; Incalzi, R.A.; Rossini, P.M.; Pedone, C. Pa ien s wi h mig aine
wi h au a ha e inc eased low-media ed dila ion. BMC Neu ol. 2010,10, 18. [C ossRe ]
9.
Gonzalez-Quin anilla, V.; To iello, M.; Palacio, E.; Gonzalez-Gay, M.A.; Cas illo, J.; Mon es, S.;
Ma
í
nez-Nie o, R.; Fe nandez, J.; Rojo, A.; Gu i
é
ez, S.; e al. Sys emic and ce eb al endo helial dys unc ion
in ch onic mig aine. A case-con ol s udy wi h an ac i e compa a o . Cephalalgia
2016
,36, 552–560. [C ossRe ]
10.
Inoue, K.; Kodama, T.; Daida, H. Pen axin 3: A no el bioma ke o in lamma o y ca dio ascula disease.
In . J. Vasc. Med. 2012,2012, 657025. [C ossRe ]
11.
Gokdemi , M.T.; Nas, C.; Gokdemi , G.S. Pen axin 3 le el in acu e mig aine a ack wi h au a: Pa ien
managemen in he eme gency depa men . Am. J. Eme g. Med. 2020,30, 38–42. [C ossRe ]
12.
Ceylan, M.; Bay ak u an, O.F.; Becel, S.; A is, Ö.; Yalcin, A.; Ko an, D. Se um le els o pen axin-3 and
o he in lamma o y bioma ke s in mig aine: Associa ion wi h mig aine cha ac e is ics. Cephalagia
2016
,36,
518–525. [C ossRe ]
13.
Blanco-Colio, L.M.; Ma
í
n-Ven u a, J.L.; Muñoz-Ga c
í
a, B.; O be, J.; P
á
amo, J.A.; Michel, J.B.; O iz, A.;
Meilhac, O.; Egido, J. Iden i ica ion o soluble umo nec osis ac o -like weak induce o apop osis (sTWEAK)
as a possible bioma ke o subclinical a he oscle osis. A e ioscle . Th omb. Vasc. Biol.
2007
,27, 916–922.
[C ossRe ]
14.
Cho ianopoulos, E.; Rosenbe g, M.; Zugck, C.; Wol , J.; Ka us, H.A.; F ey, N. Dec eased soluble TWEAK
le els p edic an ad e se p ognosis in pa ien s wi h ch onic s able hea ailu e. Eu . J. Hea Fail.
2009
,11,
1050–1056. [C ossRe ]
15.
Mo eno, J.A.; Dejou encel, T.; Lab euche, J.; Smadja, D.M.; Dussio , M.; Ma in-Ven u a, J.L.; Egido, J.;
Gaussem, P.; Emme ich, J.; Michel, J.-B.; e al. Pe iphe al a e y disease is associa ed wi h a high
CD163/TWEAK plasma a io. A e ioscle . Th omb. Vasc. Biol. 2010,30, 1253–1262. [C ossRe ]
J. Clin. Med. 2020,9, 849 9 o 11
16.
K alisch, S.; Ziegelmeie , M.; Bachmann, A.; Seege , J.; Lössne , U.; Blühe , M.; S um oll, M.; Fasshaue , M.
Se um le els o he a he oscle osis bioma ke sTWEAK a e dec eased in ype 2 diabe es and end-s age enal
disease. A he oscle osis 2008,199, 440–444. [C ossRe ]
17.
Lei a, Y.; Ameijei a, P.; Dominguez, C.; Lopez-A ias, E.; A ila-Gomez, P.; P
é
ez-Ma o, M.; Sob ino, T.;
Campos, F.; D’Aiu o, F.; Lei a, R.; e al. Se e e pe iodon i is is linked wi h inc eased pe iphe al le els o
sTWEAK and PTX3 in ch onic mig aineu s. Clin. O al. In es ig. 2019,24, 597–606. [C ossRe ]
18.
Dominguez, C.; Viei es-P ado, A.; Pe ez-Ma o, M.; Sob ino, T.; Rod iguez-Oso io, X.; L
ó
pez, A.; F ancisco
Campos, F.; Ma
í
nez, F.; Cas illo, J.; Lei a, R.; e al. CGRP and PTX3 as p edic o s o e icacy o
Onabo ulinum oxin ype A in ch onic mig aine: An obse a ional s udy. Headache
2018
,58, 78–87. [C ossRe ]
19.
Headache Classi ica ion Commi ee o he In e na ional Headache Socie y (IHS). The In e na ional
Classi ica ion o Headache Diso de s, 3 d edi ion (be a e sion). Cephalalgia 2013,33, 629–808. [C ossRe ]
20.
Co e i, M.C.; Ande son, T.J.; Benjamin, E.J.; Cele maje , D.; Cha bonneau, F.; C eage , M.A.; Dean ield, J.;
D exle , H.; Ge ha d-He man, M.; He ing on, D.; e al. In e na ional B achial A e y Reac i i y Task Fo ce.
Guidelines o he ul asound assessmen o endo helial-dependen low-media ed asodila ion o he
b achial a e y: A epo o he In e na ional B achial A e y Reac i i y Task Fo ce. J. Am. Coll. Ca diol.
2002
,
39, 257–265. [C ossRe ]
21.
Sch oede , R.A.; B andes, J.; Buse, D.C.; Calhoun, A.; Eike mann-Ha e e , K.; Golden, K.; Halke , R.;
Kempne , J.; Maleki, N.; Mo ia y, M.; e al. Sex and gende di e ences in mig aine-e alua ing knowledge
gaps. J. Women’s Heal h 2018,27, 965–973. [C ossRe ]
22.
O nello, R.; Ripa, P.; Pis oia, F.; Degan, D.; Tiseo, C.; Ca olei, A.; Sacco, S. Mig aine and body mass index
ca ego ies: A sys ema ic e iew and me a-analysis o obse a ional s udies. J. Headache Pain
2015
,16, 27.
[C ossRe ]
23.
Gallai, V.; Sa chielli, P.; Fi enze, C.; T equa ini, A.; Pacia oni, M.; Usai, F.; Palumbo, R. Endo helin 1 in
mig aine and ension- ype headache. Ac a Neu ol. Scand. 1994,89, 47–55. [C ossRe ]
24.
Na e o, G.; Mengozzi, G.; Inconis, T.; Pa adisi, L. Ni ic oxide, endo helin-1, and ansc anial Dopple
in mig aine. Findings in in e ic al condi ions and du ing mig aine a ack. Headache
1996
,36, 307–311.
[C ossRe ]
25.
Liman, T.G.; Bachelie -Walen a, K.; Neeb, L.; Rosinski, J.; Reu e , U.; Böhm, M.; End es, M. Ci cula ing
endo helial mic opa icles in emale mig aineu s wi h au a. Cephalalgia 2015,35, 88–94. [C ossRe ]
26.
Guldiken, B.; Demi , M.; Guldiken, S.; Tu gu , N.; Ozkan, H.; Kabayel, L.; Tug ul, A. Asymme ic
dime hyla ginine and ni ic oxide le els in mig aine du ing he in e ic al pe iod. J. Clin. Neu osci.
2009
,16,
672–674. [C ossRe ]
27.
Uza , E.; E liyaoglu, O.; Top ak, G.; Aca , A.; Yucel, Y.; Calisi , T.; Ce ik, M.U.; Tasdemi , N. Inc eased
asymme ic dime hyla ginine and ni ic oxide le els in pa ien s wi h mig aine. J. Headache Pain
2011
,12,
239–243. [C ossRe ]
28.
Rod
í
guez-Oso io, X.; Sob ino, T.; B ea, D.; Ma
í
nez, F.; Cas illo, J.; Lei a, R. Endo helial p ogeni o cells:
A new key o endo helial dys unc ion in mig aine. Neu ology 2012,79, 474–479. [C ossRe ]
29.
O e ino, A.; To iello, M.; Palacio, E.; Quin anilla, V.G.; Ruiz-La illa, N.; Mon es, S.; de la Vega, M.L.;
Ma inez-Nie o, R.; Cas illo, J.; Pascual, J. Analysis o endo helial p ecu so cells in ch onic mig aine:
A case-con ol s udy. Cephalalgia 2013,33, 236–244. [C ossRe ]
30.
Vanmolko , F.H.; Van Bo el, L.M.; de Hoon, J.N. Al e ed a e ial unc ion in mig aine o ecen onse .
Neu ology 2007,68, 1563–1570. [C ossRe ]
31.
Bu , J.H.; F anzmann, U.; K uuse, C. Endo helial unc ion in mig aine wi h au a–A sys ema ic e iew.
Headache 2015,55, 35–54. [C ossRe ] [PubMed]
32.
Sacco, S.; Ripa, P.; G assi, D.; Pis oia, F.; O nello, R.; Ca olei, A.; Ku h, T. Pe iphe al ascula dys unc ion in
mig aine: A e iew. J. Headache Pain 2013,14, 80. [C ossRe ]
33.
Du Clos, T.W. Pen anxins: S uc u e, unc ion and ole in in lamma ion. ISRN In lamm.
2013
,2013, 379040.
[C ossRe ]
34.
Ga landa, C.; Bo azzi, B.; Bas one, A.; Man o ani, A. Pen anxins and he c oss oads be ween inna e
immuni y, in lamma ion, ma ix deposi ion, and emale e ili y. Annu. Re . Immunol.
2005
,23, 337–366.
[C ossRe ]
