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Schaare D, Lusk L, Karlin A, Kaufman MC, Magielski J, Sarasua SM, Allison K, Boccuto L, Helbig I. A Longitudinal Exploration of CACNA1A -related Hemiplegic Migraine in Children. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.06.14.24308953. [PMID: 38946946 PMCID: PMC11213092 DOI: 10.1101/2024.06.14.24308953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
Introduction Since the initial description of CACNA1A- related hemiplegic migraine (HM), the phenotypic spectrum has expanded from mild episodes in neurotypical individuals to potentially life-threatening events frequently seen in individuals with developmental and epileptic encephalopathies. However, the overall longitudinal course throughout childhood remains unknown. Methods We analyzed HM and seizure history in individuals with CACNA1A -related HM, delineating frequency and severity of events in monthly increments through a standardized approach. Combining these data with medication prescription information, we assessed the response of HM to different agents. Results Our cohort involved 15 individuals between 3 and 29 years (163 patient years) and included 11 unique and two recurrent variants (p.R1349Q and p.V1393M; both n= 2). The age of first confirmed HM ranged from 14 months to 13 years (average 3 years). 25% of all HM events were severe (lasting >3 days) and 73% of individuals had at least 1 severe occurrence. Spacing of HM events ranged from 1 month to 14 years and changes in HM severity over time of showed increases or decreases of >2 severity levels in 12/122 events. Eight individuals had epilepsy, but severity of epilepsy did not correlate with frequency and severity of HM events. While levetiracetam ( n= 6) and acetazolamide ( n= 5) were the most frequently used medications, they did not show efficacy in HM prevention or HM severity reduction. However, verapamil ( n= 3) showed efficacy in preventing HM episodes (OR 2.68, CI 1.39-5.67). Significance The longitudinal course of CACNA1A -related HM lacks recognizable patterns for timing and severity of HM events or correlation with seizure patterns. Our data underscores the unpredictability of CACNA1A -related HM, highlighting the need for close surveillance for reoccurring HM events even in individuals with symptom-free periods. Key points 24% of hemiplegic migraines (HM) in CACNA1A- related disorders are severe, involving cerebral edema and greater than 4 days to recover Timing and severity of HM are unpredictable, with large changes in severity between events, and age of onset ranging from 1-13 yearsEpilepsy occurred in 53% of individuals, with neither the timing nor severity of seizures correlated with HM.
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Allam S, Levenson-Palmer R, Chia Chang Z, Kaur S, Cernuda B, Raman A, Booth A, Dobbins S, Suppa G, Yang J, Buraei Z. Inactivation influences the extent of inhibition of voltage-gated Ca +2 channels by Gem-implications for channelopathies. Front Physiol 2023; 14:1155976. [PMID: 37654674 PMCID: PMC10466392 DOI: 10.3389/fphys.2023.1155976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 07/21/2023] [Indexed: 09/02/2023] Open
Abstract
Voltage-gated Ca2+ channels (VGCC) directly control muscle contraction and neurotransmitter release, and slower processes such as cell differentiation, migration, and death. They are potently inhibited by RGK GTP-ases (Rem, Rem2, Rad, and Gem/Kir), which decrease Ca2+ channel membrane expression, as well as directly inhibit membrane-resident channels. The mechanisms of membrane-resident channel inhibition are difficult to study because RGK-overexpression causes complete or near complete channel inhibition. Using titrated levels of Gem expression in Xenopus oocytes to inhibit WT P/Q-type calcium channels by ∼50%, we show that inhibition is dependent on channel inactivation. Interestingly, fast-inactivating channels, including Familial Hemiplegic Migraine mutants, are more potently inhibited than WT channels, while slow-inactivating channels, such as those expressed with the Cavβ2a auxiliary subunit, are spared. We found similar results in L-type channels, and, remarkably, Timothy Syndrome mutant channels were insensitive to Gem inhibition. Further results suggest that RGKs slow channel recovery from inactivation and further implicate RGKs as likely modulating factors in channelopathies.
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Affiliation(s)
- Salma Allam
- Department of Biology, Pace University, New York, NY, United States
| | - Rose Levenson-Palmer
- Department of Biological Sciences, Columbia University, New York, NY, United States
| | | | - Sukhjinder Kaur
- Department of Biology, Pace University, New York, NY, United States
| | - Bryan Cernuda
- Department of Biology, Pace University, New York, NY, United States
| | - Ananya Raman
- Department of Biology, Pace University, New York, NY, United States
| | - Audrey Booth
- Department of Biology, Pace University, New York, NY, United States
| | - Scott Dobbins
- Department of Biological Sciences, Columbia University, New York, NY, United States
| | - Gabrielle Suppa
- Department of Biology, Pace University, New York, NY, United States
| | - Jian Yang
- Department of Biological Sciences, Columbia University, New York, NY, United States
| | - Zafir Buraei
- Department of Biology, Pace University, New York, NY, United States
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Xiang Y, Li F, Song Z, Yi Z, Yang C, Xue J, Zhang Y. Two pediatric patients with hemiplegic migraine presenting as acute encephalopathy: case reports and a literature review. Front Pediatr 2023; 11:1214837. [PMID: 37576133 PMCID: PMC10419215 DOI: 10.3389/fped.2023.1214837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 07/10/2023] [Indexed: 08/15/2023] Open
Abstract
Introduction Hemiplegic migraine (HM) is a rare subtype of migraine. HM in children may be atypical in the initial stage of the disease, which could easily lead to misdiagnosis. Methods We report two cases of atypical hemiplegic migraine that onset as an acute encephalopathy. And a comprehensive search was performed using PubMed, Web of Science, and Scopus. We selected only papers that reported complete clinical information about the patients with CACNA1A or ATP1A2 gene mutation. Results Patient #1 showed a de novo mutation, c.674C>A (p. Pro225His), in exon 5 of the CACNA1A gene. And patient #2 showed a missense mutation (c.2143G>A, p. Gly715Arg) in exon 16 of the ATP1A2. Together with our two cases, a total of 160 patients (73 CACNA1A and 87 ATP1A2) were collected and summarized finally. Discussion Acute encephalopathy is the main manifestation of severe attacks of HM in children, which adds to the difficulty of diagnosis. Physicians should consider HM in the differential diagnosis of patients presenting with somnolence, coma, or convulsion without structural, epileptic, infectious, or inflammatory explanation. When similar clinical cases appear, gene detection is particularly important, which is conducive to early diagnosis and treatment. Early recognition and treatment of the disease can help improve the prognosis.
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Affiliation(s)
| | | | | | | | | | | | - Ying Zhang
- Department of Pediatric Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
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Gu L, Shu H, Wang Y. Functional brain alterations in migraine patients: an activation likelihood estimation study. Neurol Res 2023:1-8. [PMID: 37019685 DOI: 10.1080/01616412.2023.2199377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
BACKGROUND Previous functional magnetic resonance imaging (fMRI) studies reported inconsistent results for comparison in brain activation between migraine patients and healthy controls (HC). Thus, activation likelihood estimation (ALE) method, a powerful voxel-based technique, was used to explore the concordant functional brain changes in migraine patients. METHODS Studies published before October 2022 were searched in the following databases (PubMed, Web of Science and Google Scholar). RESULTS Migraine without aura (MWoA) patients showed reduced amplitude of low-frequency fluctuations (ALFF) in right lingual gyrus, the left posterior cingulate and the right precuneus (PCUN), compared to HC. Migraine patients showed increased ALFF in the right claustrum, the left caudate, the left insula and the right parahippocampal gyrus, compared to HC. MWoA patients showed reduced regional homogeneity (ReHo) in the right culmen, compared to HC. In addition, migraine patients showed increased ReHo in the bilateral thalamus, compared to HC. MWoA patients showed reduced whole-brain functional connectivity (FC) in the left middle occipital gyrus and the right superior parietal lobule, compared to HC. In addition, migraine patients showed increased whole-brain FC in the left middle temporal gyrus (MTG), the right inferior frontal gyrus, the right superior temporal gyrus (STG) and the left inferior temporal gyrus, compared to HC. CONCLUSIONS ALE analysis identified consistent functional changes in widespread regions, especially in cingulate gyrus, basal ganglia region and frontal cortex in migraine. These regions involve in pain processing, cognitive dysfunction and emotional problems. These results may provide important clues for clarifying the pathophysiology of migraine.
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Affiliation(s)
- Lihua Gu
- Department of Neurology, Tianjin Huanhu Hospital, Tianjin, China
| | - Hao Shu
- Department of Neurology, the Fourth Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu, China
| | - Yanjuan Wang
- Department of Neurology, Affiliated ZhongDa Hospital, School of Medicine, Southeast University, Nanjing, Jiangsu, China
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Schaare D, Sarasua SM, Lusk L, Parthasarathy S, Wang L, Helbig I, Boccuto L. Concomitant Calcium Channelopathies Involving CACNA1A and CACNA1F: A Case Report and Review of the Literature. Genes (Basel) 2023; 14:400. [PMID: 36833327 PMCID: PMC9956337 DOI: 10.3390/genes14020400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Revised: 01/30/2023] [Accepted: 01/30/2023] [Indexed: 02/05/2023] Open
Abstract
Calcium channels are an integral component in maintaining cellular function. Alterations may lead to channelopathies, primarily manifested in the central nervous system. This study describes the clinical and genetic features of a unique 12-year-old boy harboring two congenital calcium channelopathies, involving the CACNA1A and CACNA1F genes, and provides an unadulterated view of the natural history of sporadic hemiplegic migraine type 1 (SHM1) due to the patient's inability to tolerate any preventative medication. The patient presents with episodes of vomiting, hemiplegia, cerebral edema, seizure, fever, transient blindness, and encephalopathy. He is nonverbal, nonambulatory, and forced to have a very limited diet due to abnormal immune responses. The SHM1 manifestations apparent in the subject are consistent with the phenotype described in the 48 patients identified as part of a systematic literature review. The ocular symptoms of CACNA1F align with the family history of the subject. The presence of multiple pathogenic variants make it difficult to identify a clear phenotype-genotype correlation in the present case. Moreover, the detailed case description and natural history along with the comprehensive review of the literature contribute to the understanding of this complex disorder and point to the need for comprehensive clinical assessments of SHM1.
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Affiliation(s)
- Donna Schaare
- Ph.D. Program in Healthcare Genetics and Genomics, School of Nursing, College of Behavioral, Social and Health Sciences, Clemson University, Clemson, SC 29634, USA
| | - Sara M. Sarasua
- Ph.D. Program in Healthcare Genetics and Genomics, School of Nursing, College of Behavioral, Social and Health Sciences, Clemson University, Clemson, SC 29634, USA
| | - Laina Lusk
- Division of Neurology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | | | - Liangjiang Wang
- Department of Genetics and Biochemistry, College of Science, Clemson University, Clemson, SC 29634, USA
| | - Ingo Helbig
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Luigi Boccuto
- Ph.D. Program in Healthcare Genetics and Genomics, School of Nursing, College of Behavioral, Social and Health Sciences, Clemson University, Clemson, SC 29634, USA
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Mizuguchi M, Shibata A, Kasai M, Hoshino A. Genetic and environmental risk factors of acute infection-triggered encephalopathy. Front Neurosci 2023; 17:1119708. [PMID: 36761411 PMCID: PMC9902370 DOI: 10.3389/fnins.2023.1119708] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 01/09/2023] [Indexed: 01/25/2023] Open
Abstract
Acute encephalopathy is a constellation of syndromes in which immune response, metabolism and neuronal excitation are affected in a variable fashion. Most of the syndromes are complex disorders, caused or aggravated by multiple, genetic and environmental risk factors. Environmental factors include pathogenic microorganisms of the antecedent infection such as influenza virus, human herpesvirus-6 and enterohemorrhagic Escherichia coli, and drugs such as non-steroidal anti-inflammatory drugs, valproate and theophylline. Genetic factors include mutations such as rare variants of the SCN1A and RANBP2 genes, and polymorphisms such as thermolabile CPT2 variants and HLA genotypes. By altering immune response, metabolism or neuronal excitation, these factors complicate the pathologic process. On the other hand, some of them could provide promising targets to prevent or treat acute encephalopathy.
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Affiliation(s)
- Masashi Mizuguchi
- Department of Developmental Medical Sciences, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan,Department of Pediatrics, National Rehabilitation Center for Children With Disabilities, Tokyo, Japan,*Correspondence: Masashi Mizuguchi,
| | - Akiko Shibata
- Department of Developmental Medical Sciences, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan,Laboratory for Brain Development and Disorders, RIKEN Center for Brain Science, Tokyo, Japan
| | - Mariko Kasai
- Department of Developmental Medical Sciences, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan,Department of Pediatrics, Saitama Citizens Medical Center, Saitama, Japan
| | - Ai Hoshino
- Department of Developmental Medical Sciences, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan,Department of Neuropediatrics, Tokyo Metropolitan Neurological Hospital, Fuchu, Japan
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Zhang D, Huang X, Mao C, Chen Y, Miao Z, Liu C, Xu C, Wu X, Yin X. Assessment of normalized cerebral blood flow and its connectivity with migraines without aura during interictal periods by arterial spin labeling. J Headache Pain 2021; 22:72. [PMID: 34261444 PMCID: PMC8278584 DOI: 10.1186/s10194-021-01282-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 06/24/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Migraine constitutes a global health burden, and its pathophysiology is not well-understood; research evaluating cerebral perfusion and altered blood flow between brain areas using non-invasive imaging techniques, such as arterial spin labeling, have been scarce. This study aimed to assess cerebral blood flow (CBF) and its connectivity of migraine. METHODS This study enrolled 40 patients with episodic migraine without aura (MwoA), as well as 42 healthy patients as control (HC). Two groups of normalized CBF and CBF connectivity were compared, and the relationship between CBF variation and clinical scale assessment was further evaluated. RESULTS In comparison to HC subjects, MwoA patients exhibited higher CBF in the right middle frontal orbital gyrus (ORBmid.R) and the right middle frontal gyrus, while that in Vermis_6 declined. The increased CBF of ORBmid.R was positively correlated with both the Visual Light Sensitivity Questionnaire-8 (VLSQ-8) and the monthly attack frequency score. In MwoA, significantly decreased CBF connectivity was detected between ORBmid.R and the left superior frontal gyrus, the right putamen, the right caudate, as well as the right angular gyrus. In addition, increased CBF connectivity was observed between the left calcarine cortex and ORBmid.R. CONCLUSIONS Our results indicate that migraine patients exhibit abnormalities in regional CBF and feature CBF connection defects at the resting state. The affected areas involve information perception, information integration, and emotional, pain and visual processing. Our findings might provide important clues for the pathophysiology of migraine.
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Affiliation(s)
- Di Zhang
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, No.68, Changle Road, Nanjing, 210006, Jiangsu, China
| | - Xiaobin Huang
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, No.68, Changle Road, Nanjing, 210006, Jiangsu, China
| | - Cunnan Mao
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, No.68, Changle Road, Nanjing, 210006, Jiangsu, China
| | - Yuchen Chen
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, No.68, Changle Road, Nanjing, 210006, Jiangsu, China
| | - Zhengfei Miao
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, No.68, Changle Road, Nanjing, 210006, Jiangsu, China
| | - Chunmei Liu
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, No.68, Changle Road, Nanjing, 210006, Jiangsu, China
| | - Chenjie Xu
- Department of Pain Treatment, Nanjing First Hospital, Nanjing Medical University, No.68, Changle Road, Nanjing, 210006, Jiangsu, China
| | - Xinying Wu
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, No.68, Changle Road, Nanjing, 210006, Jiangsu, China.
| | - Xindao Yin
- Department of Radiology, Nanjing First Hospital, Nanjing Medical University, No.68, Changle Road, Nanjing, 210006, Jiangsu, China.
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Moya-Mendez ME, Mueller DM, Pratt M, Bonner M, Elliott C, Hunanyan A, Kucera G, Bock C, Prange L, Jasien J, Keough K, Shashi V, McDonald M, Mikati MA. Early onset severe ATP1A2 epileptic encephalopathy: Clinical characteristics and underlying mutations. Epilepsy Behav 2021; 116:107732. [PMID: 33493807 PMCID: PMC7940561 DOI: 10.1016/j.yebeh.2020.107732] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 11/09/2020] [Accepted: 12/20/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND ATP1A2 mutations cause hemiplegic migraine with or without epilepsy or acute reversible encephalopathy. Typical onset is in adulthood or older childhood without subsequent severe long-term developmental impairments. AIM We aimed to describe the manifestations of early onset severe ATP1A2-related epileptic encephalopathy and its underlying mutations in a cohort of seven patients. METHODS A retrospective chart review of a cohort of seven patients was conducted. Response to open-label memantine therapy, used off-label due to its NMDA receptor antagonist effects, was assessed by the Global Rating Scale of Change (GRSC) and Clinical Global Impression Scale of Improvement (CGI-I) methodologies. Molecular modeling was performed using PyMol program. RESULTS Patients (age 2.5-20 years) had symptom onset at an early age (6 days-1 year). Seizures were either focal or generalized. Common features were: drug resistance, recurrent status epilepticus, etc., severe developmental delay with episodes of acute severe encephalopathy often with headaches, dystonias, hemiplegias, seizures, and developmental regression. All had variants predicted to be disease causing (p.Ile293Met, p.Glu1000Lys, c.1017+5G>A, p.Leu809Arg, and 3 patients with p.Met813Lys). Modeling revealed that mutations interfered with ATP1A2 ion binding and translocation sites. Memantine, given to five, was tolerated in all (mean treatment: 2.3 years, range 6 weeks-4.8 years) with some improvements reported in all five. CONCLUSIONS Our observations describe a distinctive clinical profile of seven unrelated probands with early onset severe ATP1A2-related epileptic encephalopathy, provide insights into structure-function relationships of ATP1A2 mutations, and support further studies of NMDAR antagonist therapy in ATP1A2-encephalopathy.
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Affiliation(s)
- Mary E. Moya-Mendez
- Department of Pediatrics, Division of Pediatric Neurology and Developmental Medicine, Duke University, Durham, NC, United States
| | - David M. Mueller
- Center for Genetic Diseases, The Chicago Medical School, Rosalind Franklin University of Medicine and Science, Chicago, IL, United States
| | - Milton Pratt
- Department of Pediatrics, Division of Pediatric Neurology and Developmental Medicine, Duke University, Durham, NC, United States
| | - Melanie Bonner
- Department of Psychiatry, Duke University, Durham, NC, United States
| | - Courtney Elliott
- Department of Pediatrics, Division of Pediatric Neurology and Developmental Medicine, Duke University, Durham, NC, United States
| | - Arsen Hunanyan
- Department of Pediatrics, Division of Pediatric Neurology and Developmental Medicine, Duke University, Durham, NC, United States
| | - Gary Kucera
- Duke Cancer Institute Rodent Cancer Models Shared Resource, Duke University Medical Center, Durham, NC, United States
| | - Cheryl Bock
- Duke Cancer Institute Rodent Cancer Models Shared Resource, Duke University Medical Center, Durham, NC, United States
| | - Lyndsey Prange
- Department of Pediatrics, Division of Pediatric Neurology and Developmental Medicine, Duke University, Durham, NC, United States
| | - Joan Jasien
- Department of Pediatrics, Division of Pediatric Neurology and Developmental Medicine, Duke University, Durham, NC, United States
| | - Karen Keough
- Dell Medical School at the University of Texas, Austin TX, United States
| | - Vandana Shashi
- Dell Medical School at the University of Texas, Austin TX, United States
| | - Marie McDonald
- Dell Medical School at the University of Texas, Austin TX, United States
| | - Mohamad A. Mikati
- Department of Pediatrics, Division of Pediatric Neurology and Developmental Medicine, Duke University, Durham, NC, United States,Department of Neurobiology, Duke University, Durham, NC, United States,Corresponding Author: Mohamad Mikati, MD, Children Health Center, T913J, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, Phone: 919-668-4073, Fax: 919-681-8943,
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Indelicato E, Unterberger I, Nachbauer W, Eigentler A, Amprosi M, Zeiner F, Haberlandt E, Kaml M, Gizewski E, Boesch S. The electrophysiological footprint of CACNA1A disorders. J Neurol 2021; 268:2493-2505. [PMID: 33544220 PMCID: PMC8217028 DOI: 10.1007/s00415-021-10415-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 01/16/2021] [Accepted: 01/17/2021] [Indexed: 12/14/2022]
Abstract
Objectives CACNA1A variants underlie three neurological disorders: familial hemiplegic migraine type 1 (FHM1), episodic ataxia type 2 (EA2) and spinocerebellar ataxia type 6 (SCA6). EEG is applied to study their episodic manifestations, but findings in the intervals did not gain attention up to date. Methods We analyzed repeated EEG recordings performed between 1994 and 2019 in a large cohort of genetically confirmed CACNA1A patients. EEG findings were compared with those of CACNA1A-negative phenocopies. A review of the related literature was performed. Results 85 EEG recordings from 38 patients (19 EA2, 14 FHM1, 5 SCA6) were analyzed. Baseline EEG was abnormal in 55% of cases (12 EA2, 9 FHM1). The most common finding was a lateralized intermittent slowing, mainly affecting the temporal region. Slowing was more pronounced after a recent attack but was consistently detected in the majority of patients also during the follow-up. Interictal epileptic discharges (IEDs) were detected in eight patients (7 EA2,1 FHM1). EEG abnormalities and especially IEDs were significantly associated with younger age at examination (16 ± 9 vs 43 ± 21 years in those without epileptic changes, p = 0.003) and with earlier onset of disease (1 (1–2) vs 12 (5–45) years, p = 0.0009). EEG findings in CACNA1A-negative phenocopies (n = 15) were largely unremarkable (p = 0.03 in the comparison with CACNA1A patients). Conclusions EEG abnormalities between attacks are highly prevalent in episodic CACNA1A disorders and especially associated with younger age at examination and earlier disease onset. Our findings underpin an age-dependent effect of CACNA1A variants, with a more severe impairment when P/Q channel dysfunction manifests early in life.
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Affiliation(s)
- Elisabetta Indelicato
- Center for Rare Movement Disorders Innsbruck, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Iris Unterberger
- Epileptology Division, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Wolfgang Nachbauer
- Center for Rare Movement Disorders Innsbruck, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Andreas Eigentler
- Center for Rare Movement Disorders Innsbruck, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Matthias Amprosi
- Center for Rare Movement Disorders Innsbruck, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Fiona Zeiner
- Department of Pediatrics I, Medical University of Innsbruck, Innsbruck, Austria
| | - Edda Haberlandt
- Department of Pediatrics I, Medical University of Innsbruck, Innsbruck, Austria
- Department of Pediatrics, City Hospital, Dornbirn, Austria
| | - Manuela Kaml
- Epileptology Division, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Elke Gizewski
- Department of Neuroradiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Sylvia Boesch
- Center for Rare Movement Disorders Innsbruck, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
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Di Stefano V, Rispoli MG, Pellegrino N, Graziosi A, Rotondo E, Napoli C, Pietrobon D, Brighina F, Parisi P. Diagnostic and therapeutic aspects of hemiplegic migraine. J Neurol Neurosurg Psychiatry 2020; 91:764-771. [PMID: 32430436 PMCID: PMC7361005 DOI: 10.1136/jnnp-2020-322850] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 04/22/2020] [Accepted: 04/24/2020] [Indexed: 01/25/2023]
Abstract
Hemiplegic migraine (HM) is a clinically and genetically heterogeneous condition with attacks of headache and motor weakness which may be associated with impaired consciousness, cerebellar ataxia and intellectual disability. Motor symptoms usually last <72 hours and are associated with visual or sensory manifestations, speech impairment or brainstem aura. HM can occur as a sporadic HM or familiar HM with an autosomal dominant mode of inheritance. Mutations in CACNA1A, ATP1A2 and SCN1A encoding proteins involved in ion transport are implicated. The pathophysiology of HM is close to the process of typical migraine with aura, but appearing with a lower threshold and more severity. We reviewed epidemiology, clinical presentation, diagnostic assessment, differential diagnosis and treatment of HM to offer the best evidence of this rare condition. The differential diagnosis of HM is broad, including other types of migraine and any condition that can cause transitory neurological signs and symptoms. Neuroimaging, cerebrospinal fluid analysis and electroencephalography are useful, but the diagnosis is clinical with a genetic confirmation. The management relies on the control of triggering factors and even hospitalisation in case of long-lasting auras. As HM is a rare condition, there are no randomised controlled trials, but the evidence for the treatment comes from small studies.
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Affiliation(s)
- Vincenzo Di Stefano
- Department of Biomedicine, Neuroscience and Advanced Diagnostic (BIND), University of Palermo, Palermo, Sicilia, Italy
| | - Marianna Gabriella Rispoli
- Department of Neuroscience Imaging and Clinical Sciences, 'G. d'Annunzio' University, Universita degli Studi Gabriele d'Annunzio Chieti e Pescara, Chieti Scalo, Chieti, Italy
| | - Noemi Pellegrino
- Pediatrics, University Gabriele d'Annunzio of Chieti Pescara Department of Medicine and Aging Science, Chieti, Abruzzo, Italy
| | - Alessandro Graziosi
- Pediatrics, University Gabriele d'Annunzio of Chieti Pescara Department of Medicine and Aging Science, Chieti, Abruzzo, Italy
| | - Eleonora Rotondo
- Pediatrics, University Gabriele d'Annunzio of Chieti Pescara Department of Medicine and Aging Science, Chieti, Abruzzo, Italy
| | - Christian Napoli
- Department of Medical Surgical Sciences and Translational Medicine, Sapienza University of Rome, Roma, Lazio, Italy
| | - Daniela Pietrobon
- Department of Biomedical Sciences & Padova Neuroscience Center, University of Padova, Padova, Italy.,CNR Neuroscience Institute, Padova, Italy
| | - Filippo Brighina
- Department of Biomedicine, Neuroscience and Advanced Diagnostic (BIND), University of Palermo, Palermo, Sicilia, Italy
| | - Pasquale Parisi
- Dipartimento di Neuroscienze Salute Mentale e Organi di Senso (NESMOS), University of Rome La Sapienza Faculty of Medicine and Psychology, Roma, Lazio, Italy
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Zhang L, Wen Y, Zhang Q, Chen Y, Wang J, Shi K, Du L, Bao X. CACNA1A Gene Variants in Eight Chinese Patients With a Wide Range of Phenotypes. Front Pediatr 2020; 8:577544. [PMID: 33425808 PMCID: PMC7793878 DOI: 10.3389/fped.2020.577544] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 10/20/2020] [Indexed: 11/13/2022] Open
Abstract
Background: The CACNA1A gene encodes the voltage-dependent P/Q-type calcium channel subunit alpha-1A, which is widely expressed throughout the CNS. The biological roles of the P/Q channel are diverse and the phenotypic spectrum caused by CACNA1A mutations is wide. The aim of this study is to demonstrate its phenotypic diversity and analyze the genotype-phenotype correlations in a cohort of Chinese patients. Methods: Patients with hemiplegic migraine, cerebellar ataxia, developmental delay, or epilepsy without known causes were tested by trios whole-exome sequencing. Patients with pathogenic CACNA1A gene variants were recruited. The clinical information of the patients was collected, and the association between the genotype and the phenotype was investigated. Results: In total, eight patients (six females and two males) were found to have CACNA1A gene variants. All the variants were de novo including six missense variants and one frameshift variant. Four de novo missense variants were found in five patients located in the S4, S5, or S6 transmembrane segments of Domain II and III (p.R1352Q, p.G701V, p.A713T, p.V1393M). All of them were correlated with severe phenotypes, including three with sporadic hemiplegic migraine type 1 and epilepsy, and two with developmental and epileptic encephalopathy. The other two missense variants, p.Y62C and p.F1814L, located in the cytoplasmic side of the N-terminus and C-terminus, respectively. The variant p.Y62C was associated with severe hemiconvulsion-hemiplegia-epilepsy syndrome, and p.F1814L was associated with relatively mild phenotypes. All the missense variants were speculated as gain-of-function (GOF) mutations. The only frameshift variant, p.Q681Rfs*100, a lose-of-function (LOF) mutation, was found in a patient with episodic ataxia type 2. Meanwhile, all the patients had developmental delay ranging from mild to severe, as well as cerebellar ataxia including one with congenital ataxia, one with episodic ataxia, and six with non-progressive ataxia. Conclusions: CACNA1A variants could lead to a wide spectrum of neurological disorders including epileptic or non-epileptic paroxysmal events, cerebellar ataxia, and developmental delay. The variants could be both GOF and LOF mutations. There appeared to be some correlations between genotypes and phenotypes.
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Affiliation(s)
- Linxia Zhang
- Department of Pediatric, Peking University First Hospital, Beijing, China.,Department of Neurology, Children's Hospital of Shanxi, Taiyuan, China
| | - Yongxin Wen
- Department of Pediatric, Peking University First Hospital, Beijing, China
| | - Qingping Zhang
- Department of Pediatric, Peking University First Hospital, Beijing, China
| | - Yan Chen
- Department of Pediatric, Peking University First Hospital, Beijing, China
| | - Jiaping Wang
- Department of Pediatric, Peking University First Hospital, Beijing, China
| | - Kaili Shi
- Department of Neurology, Children's Hospital of Shanxi, Taiyuan, China
| | - Lijun Du
- Department of Neurology, Children's Hospital of Shanxi, Taiyuan, China
| | - Xinhua Bao
- Department of Pediatric, Peking University First Hospital, Beijing, China
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12
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Li M, Zheng X, Zhong R, Zhao Q, Lu Y, Wang Z, Lin W. Familial Hemiplegic Migraine With Progressive Cerebellar Ataxia Caused by a p.Thr666Met CACNA1A Gene Mutation in a Chinese Family. Front Neurol 2019; 10:1221. [PMID: 31824404 PMCID: PMC6882281 DOI: 10.3389/fneur.2019.01221] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 11/01/2019] [Indexed: 11/13/2022] Open
Abstract
Here, we describe the first case of familial hemiplegic migraine type 1 (FHM1) resulting from a T666M mutation in the CACNA1A gene of a Chinese individual. A 54-year-old female patient demonstrated extensive clinical manifestations, including transient paropsia, hemianesthesia, logaphasia, hemiplegia, migraine, fever, impaired consciousness, and progressive cerebellar ataxia. At admission, neurological examination showed a fever of 38.6°C, coma, bilateral pupillary constriction, left-sided deviation of both eyes, meningeal irritation, and bilateral positive Chaddock's sign. Brain magnetic resonance imaging (MRI) displayed only cerebellar atrophy. The pressure and white blood cells of the cerebrospinal fluid (CSF) were elevated. Her nine relatives also had similar clinical spectra. To further clarify the diagnosis, we conducted a genetic analysis on the family. The results of genetic testing showed that all seven living affected members carried the T666M mutation in the CACNA1A gene. This case report indicates that the diagnosis of FHM should be taken into account when a patient manifests migraine accompanied with hemiplegia, acute encephalopathy, and abnormal CSF. In addition, genetic testing is indispensable for the identification of some atypical attacks of hemiplegic migraine.
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Affiliation(s)
- Mengmeng Li
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Xiangyu Zheng
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Rui Zhong
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Qian Zhao
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Yingxue Lu
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Zan Wang
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Weihong Lin
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
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13
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Rispoli MG, Di Stefano V, Mantuano E, De Angelis MV. Novel missense mutation in the ATP1A2 gene associated with atypical sporapedic hemiplegic migraine. BMJ Case Rep 2019; 12:12/10/e231129. [PMID: 31586957 DOI: 10.1136/bcr-2019-231129] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Hemiplegic migraine (HM) is a rare subtype of migraine with aura in which attacks include transient motor weakness or hemiparesis that can last several days. HM is linked to mutations in three different genes, CACNA1A, ATP1A2 and SCN1A, which encode for ion transporters. The clinical spectrum includes atypical symptoms such as impaired consciousness, epileptic seizures, permanent cerebellar ataxia or mental retardation. We describe a novel mutation found in the ATP1A2 gene in a patient with late-onset HM. His attacks were characterised by motor weakness associated with altered mental status, diplopia and ataxia. He also showed up MRI abnormalities and incomplete response to prophylactic therapy with verapamil. Late-onset HM should be considered among the possible causes of focal neurological deficits even in older patients with cerebrovascular risk factors when a stroke appears to be more likely.
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Affiliation(s)
| | - Vincenzo Di Stefano
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d' annunzio" University, Chieti, Italy
| | - Elide Mantuano
- Institute of Translational Pharmacology, National Research Council of Italy, Rome, Italy
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14
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Nagarajan E, Bollu PC, Manjamalai S, Yelam A, Qureshi AI. White Matter Hyperintensities in Patients with Sporadic Hemiplegic Migraine. J Neuroimaging 2019; 29:730-736. [PMID: 31304994 DOI: 10.1111/jon.12656] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 06/26/2019] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND AND PURPOSE To identify the differences in overall occurrence, location, and disease burden of white matter hyperintensities (WMH) in patients with sporadic hemiplegic migraine (SHM) and patients with migraine headaches. METHODS We included patients who met diagnostic criteria proposed by the third International Classification of Headache Disorders (ICHD-3) for SHM and migraine headache. WMHs were identified using T2 fluid-attenuated inversion recovery axial sequence and classified based upon the location. The disease burden was assessed using Scheltens visual rating scale. RESULTS Fifty patients met the diagnostic criteria for SHM and 100 patients for migraine headache. Patients in the study group were similar to the control group in terms of age (47.7 ± 12.2 years vs. 48.17 ± 9.7 years; P = .814) and gender (M: F; 14:36 vs. M: F 25:75; P = .693). WMH were found in 28 (56%) patients with SHM and 44 (44%) in patients with migraine headache. The proportion of patients with WMH was not different between the two groups (P = .166). On univariate analysis, the proportion of patients with WMH in parietal, occipital, and infratentorial regions was higher in patients with SHM. White matter burden determined by visual rating scale and proportion of patients with lesions ≥5 mm in diameter was also significantly higher in patients with SHM. On multivariate analysis, the WMH occurrence in the parietal lobe (P = .043) was found to be significantly higher in SHM. CONCLUSIONS The WMH occurrence in patients with SHM is significantly more in the parietal lobe when compared to those with migraine headaches. WMH burden was also higher in patients with SHM, and larger white matter lesions occurred more frequently in these patients with SHM (compared to ordinary migraineurs).
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Affiliation(s)
| | - Pradeep C Bollu
- Department of Neurology, University of Missouri, Columbia, Missouri
| | | | - Anudeep Yelam
- Department of Neurology, University of Missouri, Columbia, Missouri
| | - Adnan I Qureshi
- Department of Neurology, University of Missouri, Columbia, Missouri.,Zeenat Qureshi Stroke Institute, St. Cloud, Minnesota
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15
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Indelicato E, Nachbauer W, Karner E, Eigentler A, Wagner M, Unterberger I, Poewe W, Delazer M, Boesch S. The neuropsychiatric phenotype in CACNA1A mutations: a retrospective single center study and review of the literature. Eur J Neurol 2018; 26:66-e7. [PMID: 30063100 DOI: 10.1111/ene.13765] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 07/24/2018] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND PURPOSE CACNA1A encodes the α1 subunit of the neuronal calcium channel P/Q. CACNA1A mutations underlie three allelic disorders: familial hemiplegic migraine type 1 (FHM1), episodic ataxia type 2 (EA2) and spinocerebellar ataxia type 6 (SCA6). A clear-cut genotype-phenotype correlation is often lacking since clinical manifestations may overlap. Several case reports have described cognitive and behavioral features in CACNA1A disorders, but studies in larger case series are lacking. METHODS Genetically confirmed CACNA1A cases were retrieved from the database of the ataxia outpatient clinic of the Department of Neurology at Innsbruck Medical University. Clinical charts and neuropsychological test results were retrospectively analyzed. In addition, a review of the literature including only genetically confirmed cases was performed. RESULTS Forty-four CACNA1A cases were identified in our database. Delayed psychomotor milestones and poor school performance were described in seven (four FHM1, three EA2) and eight (three FHM1, five EA2) patients, respectively. Psychiatric comorbidities were diagnosed in eight patients (two FHM1, six EA2). Neuropsychological testing was available for 23 patients (11 FHM1, 10 EA2, two SCA6). Various cognitive deficits were documented in 21 cases (all patients except one SCA6). Impairments were predominantly seen in figural memory, visuoconstructive abilities and verbal fluency. In the literature, an early psychomotor delay is described in several children with EA2 and FHM1, whilst reports of cognitive and psychiatric findings from adult cases are scarce. CONCLUSIONS Neuropsychiatric manifestations are common in episodic CACNA1A disorders. In the case of otherwise unexplained developmental delay and a positive family history, CACNA1A mutations should be considered in the differential diagnosis.
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Affiliation(s)
- E Indelicato
- Department of Neurology, Innsbruck Medical University, Innsbruck, Austria
| | - W Nachbauer
- Department of Neurology, Innsbruck Medical University, Innsbruck, Austria
| | - E Karner
- Department of Neurology, Innsbruck Medical University, Innsbruck, Austria
| | - A Eigentler
- Department of Neurology, Innsbruck Medical University, Innsbruck, Austria
| | - M Wagner
- Department of Neuroradiology, Innsbruck Medical University, Innsbruck, Austria
| | - I Unterberger
- Department of Neurology, Innsbruck Medical University, Innsbruck, Austria
| | - W Poewe
- Department of Neurology, Innsbruck Medical University, Innsbruck, Austria
| | - M Delazer
- Department of Neurology, Innsbruck Medical University, Innsbruck, Austria
| | - S Boesch
- Department of Neurology, Innsbruck Medical University, Innsbruck, Austria
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16
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Multimodal imaging findings during severe attacks of familial hemiplegic migraine type 2. J Neurol Sci 2018; 392:22-27. [DOI: 10.1016/j.jns.2018.06.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 06/09/2018] [Accepted: 06/23/2018] [Indexed: 11/24/2022]
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17
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Saleh C, Pierquin G, Beyenburg S. Hemiplegic Migraine Presenting with Prolonged Somnolence: A Case Report. Case Rep Neurol 2016; 8:204-210. [PMID: 27790126 PMCID: PMC5075733 DOI: 10.1159/000448473] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Hemiplegic migraine is a rare and complex disease, characterized by migraine with a reversible motor aura. Hemiplegic migraine can be easily misdiagnosed at its first presentation with an atypical severe form of migraine, a stroke, multiple sclerosis, metabolic disorders, conversion disorder or an epilepsy. We present the case of a young 24-year-old male patient, who since the age of 4 years had been having multiple episodes of migraine associated with hemiparesis, paraesthesia, prolonged somnolence, aphasia and confusion. We review the literature and discuss important diagnostic findings in hemiplegic migraine to help establishing a prompt diagnosis.
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Affiliation(s)
- Christian Saleh
- Department of Neurology, Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
| | - Geneviève Pierquin
- Génétique et Cytogénétique (T3é1), Centre Hospitalier Universitaire de Liège (C.H.U.), Sart Tilman, Liège, Belgium; Department of Pediatrics, Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
| | - Stefan Beyenburg
- Department of Neurology, Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
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18
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Tantsis EM, Gill D, Griffiths L, Gupta S, Lawson J, Maksemous N, Ouvrier R, Riant F, Smith R, Troedson C, Webster R, Menezes MP. Eye movement disorders are an early manifestation of CACNA1A mutations in children. Dev Med Child Neurol 2016; 58:639-44. [PMID: 26814174 DOI: 10.1111/dmcn.13033] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/11/2015] [Indexed: 11/29/2022]
Abstract
AIM The alpha-1 isoform of the calcium channel gene is expressed abundantly in neuronal tissue, especially within the cerebellum. Mutations in this gene may manifest with hemiplegic migraine, spinocerebellar ataxia type 6 (SCA6) and episodic ataxia type 2 (EA2) in adults. There are reports of children with CACAN1A mutations presenting with paroxysmal tonic upgaze, abnormal saccades and congenital nystagmus as well as severe forms of hemiplegic migraine. The aim of this study was to review the clinical presentation and subsequent course of all children with a CACNA1A mutation who presented to a tertiary children's hospital. METHOD We reviewed retrospectively nine children with a proven CACNA1A mutation who presented to the Children's Hospital at Westmead between 2005-2015. The initial and subsequent clinical presentation, radiological features and molecular genetic profile of each child was reviewed. RESULTS Nine children presented to out institute over a 10 year period; six were female and three male. The median age of presentation was 1.2 years. Eye movement disorders were the presenting feature in eight children. Three of these children later presented with severe hemiplegic migraine episodes often requiring ICU care. Affected children also had developmental delay and developed classical hemiplegic migraine, episodic ataxia and seizures. Calcium channel blockers were used with some efficacy in preventing severe HM episodes. INTERPRETATION Eye movement disorders are an early manifestation of CACNA1A mutations in children. Improved recognition of the CACNA1A phenotype in childhood is important for early diagnosis, counselling and appropriate emergency management. There is some early evidence that calcium channel blockers may be an effective prophylactic agent for the severe hemiplegic migraine episodes.
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Affiliation(s)
- Esther M Tantsis
- TY Nelson Department of Neurology and Neurosurgery, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Deepak Gill
- TY Nelson Department of Neurology and Neurosurgery, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Lyn Griffiths
- Institute for Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Qld, Australia
| | - Sachin Gupta
- TY Nelson Department of Neurology and Neurosurgery, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - John Lawson
- Department of Neurology, Sydney Children's Hospital, Randwick, NSW, Australia
| | - Neven Maksemous
- Institute for Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Qld, Australia
| | - Robert Ouvrier
- TY Nelson Department of Neurology and Neurosurgery, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Florence Riant
- Ap-HP, Groupe Gospitalier Lariboisiere-Fernand Widal, Laboratoire de Genetique, Paris, France
| | - Robert Smith
- Institute for Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Qld, Australia
| | - Christopher Troedson
- TY Nelson Department of Neurology and Neurosurgery, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Richard Webster
- TY Nelson Department of Neurology and Neurosurgery, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Manoj P Menezes
- TY Nelson Department of Neurology and Neurosurgery, The Children's Hospital at Westmead, Westmead, NSW, Australia
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Pelzer N, Stam AH, Haan J, Ferrari MD, Terwindt GM. Familial and sporadic hemiplegic migraine: diagnosis and treatment. Curr Treat Options Neurol 2013. [PMID: 23203776 DOI: 10.1007/s11940-012-0208-3] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OPINION STATEMENT Hemiplegic migraine (HM) is a rare subtype of migraine with aura, characterized by transient hemiparesis during attacks. Diagnosis is based on the International Classification of Headache Disorders criteria (ICHD-II). Two types of HM are recognized: familial (FHM) and sporadic hemiplegic migraine (SHM). HM is genetically heterogeneous. Three genes have been identified (CACNA1A, ATP1A2, and SCN1A) but more, so far unknown genes, are involved. Clinically, attacks of the 3 subtypes cannot be distinguished. The diagnosis can be confirmed but not ruled out by genetic testing, because in some HM patients other, not yet identified, genes are involved. The presence of additional symptoms (such as chronic ataxia or epilepsy) may increase the likelihood of identifying a mutation. Additional diagnostics like imaging, CSF analysis, or an EEG are mainly performed to exclude other causes of focal neurological symptoms associated with headache. Conventional cerebral angiography is contraindicated in HM because this may provoke an attack. Because HM is a rare condition, no clinical treatment trials are available in this specific subgroup of migraine patients. Thus, the treatment of HM is based on empirical data, personal experience of the treating neurologist, and involves a trial-and-error strategy. Acetaminophen and NSAIDs often are the first choice in acute treatment. Although controversial in HM, triptans can be prescribed when headaches are not relieved sufficiently with common analgesics. An effective treatment for the severe and often prolonged aura symptoms is more warranted, but currently no such acute treatment is available. Prophylactic treatment can be considered when attack frequency exceeds 2 attacks per month, or when severe attacks pose a great burden that requires reduction of severity and frequency. In no strictly preferred order, flunarizine, sodium valproate, lamotrigine, verapamil, and acetazolamide can be tried. While less evidence is available for prophylactic treatment with topiramate, candesartan, and pizotifen, these drugs can also be considered. The use of propranolol in HM is more controversial, but evidence of adverse effects is insufficient to contraindicate beta-blockers.
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Affiliation(s)
- Nadine Pelzer
- Department of Neurology, Leiden University Medical Center, P.O. Box 9600, 2300, RC Leiden, The Netherlands
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20
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Millichap JG. Manifestations of Familial Hemiplegic Migraine. Pediatr Neurol Briefs 2012. [DOI: 10.15844/pedneurbriefs-26-10-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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