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Heterogeneity in migraine: many genes for many phenotypes?

Migraine, both with (MA) and without aura (MOA), is well recognized as being recurrent in families, although the exact mode of inheritance is unclear. There are abundant examples of migraine families whose pattern of affliction suggests a simple “monogenic” or mendelian genetic disorder (1). However, the vast majority of “sporadic” migraineurs cannot be consistently categorized by segregation analysis (2,3) and instead present with the multigenic, multifactorial features of complex diseases. Similarly, while twin studies indicate the possible role of a genetic component, concordance rates suggest the influence of other, probably environmental factors. An early family study highlighted a 2.5 times greater tendency for maternal transmission of migraine, which is compatible with cytoplasmic inheritance. A rare form of migraine, familial hemiplegic migraine (FHM), is a subtype of MA that is autosomal dominant and highly penetrant, and thus the only migraine type with a definite mendelian inheritance pattern (4). Some FHM families were found to have missense mutations in a brain P/Q voltage gated calcium channel (CACNL1A4) located on chromosome 19 (locus FHM1). The re-