Lipopolysaccharide, VE-cadherin, HMGB1, and HIF-1α levels are elevated in the systemic circulation in chronic migraine patients with medication overuse headache: evidence of leaky gut and inflammation

Abstract

Objective: Medication overuse headache (MOH) was recently shown to be associated with leaky gut in rodents. We aimed to investigate whether chronic migraine (CM) patients with MOH have elevated lipopolysaccharide levels and inflammatory molecules in blood circulation.

Materials and methods: The study included women participants (40 CM patients with NSAID overuse headache, 35 episodic migraine (EM) patients, and 20 healthy non-headache sufferers). Migraine duration, monthly migraine headache days, MigSCog, HADS-D, HADS-A, and HIT-6 scores were recorded. Serum samples were collected to measure circulating LPS, LPS binding protein (LBP), tight junction protein occludin, adherens junction protein vascular endothelial cadherin (VE-cadherin), CGRP, HMGB1, HIF-1α, IL-6, and IL-17 levels.

Results: Serum LPS, VE-Cadherin, CGRP, HIF-1α, and IL-6 levels were significantly higher in the CM + MOH group compared to the EM group and healthy controls while serum LBP and HMGB1 were higher in the CM + MOH group compared to healthy controls. IL-17 and occludin levels were comparable between the three groups. Serum HMGB1 levels in EM patients were higher compared to the control group. Mig-SCog and HIT-6 scores were higher in the CM + MOH group compared to EM patients. HADS-A and HADS-D scores were significantly higher in the CM + MOH group compared to EM patients and healthy controls, and they were also higher in EM patients compared to healthy subjects. LPS levels were correlated with VE-cadherin and occludin levels. The number of monthly migraine headache days was positively correlated with serum LPS, HIF-1α, VE-cadherin, and IL-6 levels, HADS-A, HADS-D, HIT-6, and MigSCog scores.

Conclusion: We have evidence for the first time that CM + MOH is associated with elevated serum LPS and LBP levels suggestive of LPS leak into the systemic circulation. Higher levels of nociceptive and/or pro-inflammatory molecules such as HMGB1, HIF-1α, IL-6, and CGRP may play a role in trigeminal sensitization and neurobiology of MOH. Intestinal hyperpermeability and consequent inflammatory response should be considered as a potential contributory factor in patients with MOH.

Keywords: Chronic migraine; HIF-1α; HMGB1; Inflammation; Leaky gut; Lipopolysaccharide; Lipopolysaccharide-binding protein; Medication overuse headache; Occludin; VE-Cadherin.

Fig. 1

The flowchart of the study

Fig. 2

Data are shown as whisker-box plots (whisker: full range; line: median; cross: mean). a Serum LPS was higher in CM + MOH patients compared to EM patients (p < 0.0001) and healthy controls (p = 0.001), b serum LBP was higher in CM + MOH patients compared to healthy controls (p = 0.041), c serum HMGB1 was higher in CM + MOH patients (p = 0.0001) and EM patients (p = 0.014) compared to the healthy controls, d serum HIF-1α was higher in the CM + MOH patients compared to EM patients (p = 0.012) and healthy controls (p = 0.025), e serum IL-6 levels were higher in the CM + MOH patients compared to EM patients (p = 0.003) and healthy control (p = 0.005) and serum IL-17 levels were similar between the three groups (p = 0.101). Statistical analysis was performed with Kruskal-Wallis followed by post hoc Dunn’s multiple comparisons test for LPS, HIF-1α, and IL-6 data. Statistical analysis was performed with one way-ANOVA followed by post-hoc Šidák’s test for multiple comparisons when required for all other data. * p < 0.05

Fig. 3

Data are shown as whisker-box plots (whisker: full range; line: median; cross: mean). a Serum CGRP was higher in the CM + MOH patients compared to EM patients (p = 0.005) and healthy controls (p = 0.025), b serum VE-cadherin levels were higher in the CM + MOH patients compared to the EM patients (p < 0.0001) and healthy controls (p < 0.002) and (c) serum occludin levels were comparable between the groups (p = 0.47). Statistical analysis was performed with Kruskal-Wallis followed by post hoc Dunn’s multiple comparisons test. * p < 0.05

Fig. 4

Data are shown as whisker-box plots (whisker: full range; line: median; cross: mean). a CM + MOH patients had significantly higher HADS-A scores compared to EM patients (p = 0.002) and healthy controls (p < 0.0001) and HADS-A scores were also higher in EM patients compared to healthy controls (p < 0.0001), b CM + MOH patients had significantly higher HADS-D scores compared to EM patients (p = 0.007) and healthy controls (p < 0.0001) and HADS-D scores were also higher in EM patients compared to healthy controls (p = 0.001) (c) HIT-6 scores were significantly higher in the CM + MOH group compared to the EM group (p < 0.0001) and (d) MigSCog scores were significantly higher in the CM + MOH patients compared to EM patients (p < 0.0001). Statistical analysis was performed with one way-ANOVA followed by post-hoc Šidák’s test for multiple comparisons for HADS-A and HADS-D. Data analysis was performed with Mann-Whitney’s U test for HIT-6 scores and student t-test for MigSCog scores. * p < 0.05

Fig. 5

Data are shown as whisker-box plots (whisker: full range; line: median). CM + MOH patients with IBS had significantly higher serum VE-cadherin levels compared to CM + MOH patients without IBS (p = 0.045). Data analysis was performed with Mann-Whitney’s U test. * p < 0.05