We report a significant association between a common SNP (rs1801133) in the MTHFR gene and MA in a well-characterized sample of depressed cases compared to psychiatrically healthy controls. Previous reports have shown an association between this SNP and depression. In fact, the association between MTHFR polymorphism and MA remained significant after adjusting for depression suggesting that this association is unique to MA. No statistically significant association was seen between this SNP and depression or MO in this study. The association between MTHFR C677T polymorphism and MA was stronger in women, however remained significantly associated with MA after controlling for sex, age and depression. Several studies suggested an association between MTHFR C677T polymorphism and migraine as described earlier. Similarly, our meta-analysis of 15 case-control studies showed that the T allele is significantly associated with MA and total migraine, the association with total migraine is most likely accounted for by the presence of migraine with aura. Conversely other studies found the TT genotype protective for MA [26
]. A meta analysis [30
] pooled data from 2961 cases of migraine reported a significant association between TT genotype and MA only (OR 1.30, 95% CI 1.06-1.58). More recently, a meta-analysis of studies published up to March 2009, reported a significant association between migraine with aura and MTHFR C677T polymorphism (OR 1.48, 95% CI 1.02-2.13) that was mainly driven by non-Caucasian populations [31
]. Our meta-analysis included 2 additional studies and found that this genetic variant is associated with total migraine in non-Caucasian populations and with migraine with aura in Caucasians. Furthermore, it has been suggested that this polymorphism was also associated with depression [18
], we have reported previously that there was no significant association between depression and this SNP [19
] and we argue that the previous reports of MTHFR C677T association with depression can be explained by the high prevalence of migraine in depressed subjects included in these studies. None of the studies reported have screened subjects for migraine. Since migraine can be present in almost a third of participants [2
], it is likely that the association between MTHFR C677T and depression is actually an association with migraine.
In this depression case control study, we found migraine to be significantly associated with excess T allele and TT genotype of the MTHFR C677T polymorphism. This association was specific only to MA. Broad migraine (including MA, MO and PM) was not significantly different than non-migraine headaches in their T allele and TT genotype distribution. This trend was also shown in previous studies in different populations as described earlier. The results were not always consistent however and other studies reported negative findings. A relatively large study failed to show an association between migraine and MTHFR C677T polymorphism [17
]. Such contradictions can be explained in part by methods of identification of migraine, the different populations (clinical, epidemiological samples), age and sex of the study participants, ethnic variations and geographic sites included in these studies. Studies have shown that there are genetic variations across different populations and geographic locations; these variations may have a significant role in genetic studies findings when different populations were included. A small Japanese study (n = 22) was the first to report a significant association between MTHFR C677T and MA [12
] replicated by several other small studies (Korean n = 34 [36
], Spanish n = 60 [37
] and Italian n = 33 [38
]) while large German (n = 656) and Finish (n = 898) studies failed to show significant association between MA and this polymorphism [16
]. These observations were in parallel with our meta-analysis by subgroups, which showed a strong and significant association between TT genotype and migraine in non-Europeans, although we also observed a modest but significant association with MA among Caucasians. This ethnic specific association between a genetic variant and phenotype highlights the importance of ethnic variations in genetic studies and the need to expand studies beyond one ethnic group. In addition, ethnic variation may be a reflection of health behaviour and life style factors such as dietary habits and policies on folic acid fortification of diet and supplements. In addition to the different population studied, there is also a significant variation in migraine case identification that added further heterogeneity to the reported studies. The diagnosis of migraine, like depression, is mainly based on careful history taking of specific symptoms that show repeated patterns over time and lack of significant findings in physical examination. Objective measures to confirm or deny the diagnosis of migraine are not yet available and therefore the methods of identification of migraine cases are important sources of heterogeneity and conflicting results in the literature of migraine genetics. Our findings of significant association between MA and MTHFR C677T in a well characterised study of 1849 subjects (migraine cases = 447) replicates earlier studies of moderate size [13
] suggesting a role for the MTHFR gene in migraine especially MA. Further meta analysis of 13 studies reported a pooled OR = 1.48, 95% CI 1.02-2.13, for MA only [31
]. This may also indicate that the MTHFR gene effect is associated with aura symptoms specifically rather than migraine in general. It will be interesting to investigate homocysteine (a risk factor for stroke [40
]) and folate levels, low folate levels have been reported in depression [41
], in subjects with migraine with aura to confirm the association between MTHFR mutation and its function by measuring the end products of the enzyme. A small open label trial of folic acid administration in children with migraine, hyperhomocysteinaemia and MTHFR C677T polymorphism (TT genotype) reported a reduction in migraine symptoms in this population [42
]. In a study of 136 individuals with migraine with aura compared to controls, homocysteine level was higher in the migraine group [10
]. The homocysteine level was also higher in MA compared to MO [43
]. Randomized controlled trials are needed to confirm such findings, the results of which will be valuable for clinical practice in the management of migraine and depression.
Our results showed that excess T allele and homozygous TT genotype of the MTHFR gene C677T polymorphism is associated with increased risk for MA regardless of depression status. Our case control study showed that individuals carrying this genetic variant are 30% more likely to have migraine with aura and meta-analysis strengthened this observation and reported 42% increase in risk for such individuals, however it is important to keep in context that this 42% risk increase for MA is only in individuals carrying this genetic variant, the number of which is relatively small compared to the general population. The importance of our findings can be focused into 2 main areas:
1st studies of the MTHFR C677T variant are common especially in psychiatric and cardiovascular fields. These studies, we encourage, must take into consideration the common co occurrence of migraine in these disorders and the strong and reproducible association between this variant and migraine with aura. It is advisable therefore to screen and adjust for migraine in these studies to avoid spurious associations.
2nd individuals carrying this variant (although a small number of individuals are carrying the TT genotype variant) are at 42% increased risk for migraine with aura. In the light of increasing interests in personalised medicine, adding folate supplements to individuals at risk (a specifically targeted intervention for population at risk) may mitigate future development of migraine with aura.
The main strengths of our study are the use of validated diagnostic tool to identify migraine and the use of direct interviewing of all participants. Our study participants are also relatively homogenous (of Caucasian ethnicity, residing in the UK) thus reducing population stratification that can have a confounding effect. There are however certain weaknesses to our study. The study recruitment was designed to select depressed cases, which may have led to ascertainment bias. However migraine was systematically screened for in all participants and we have adjusted for depression status in our analysis. In addition our sample size did not allow for subgroup analysis of each headache type and therefore we are not able to report whether there is any association between this SNP and other types of primary headache disorders in addition to MA such as tension type headache.