Reversible MRI abnormalities in a patient with recurrent status migrainosus

Genetic analyses identify pleiotropy and causality for blood proteins and highlight Wnt/β-catenin signalling in migraine

Migraine is a common complex disorder with a significant polygenic SNP heritability (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$${h}_{{SNP}}^{2}$$\end{document}hSNP2). Here we utilise genome-wide association study (GWAS) summary statistics to study pleiotropy between blood proteins and migraine under the polygenic model. We estimate \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$${h}_{{SNP}}^{2}$$\end{document}hSNP2 for 4625 blood protein GWASs and identify 325 unique proteins with a significant \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$${h}_{{SNP}}^{2}$$\end{document}hSNP2 for use in subsequent genetic analyses. Pleiotropy analyses link 58 blood proteins to migraine risk at genome-wide, gene and/or single-nucleotide polymorphism levels—suggesting shared genetic influences or causal relationships. Notably, the identified proteins are largely distinct from migraine GWAS loci. We show that higher levels of DKK1 and PDGFB, and lower levels of FARS2, GSTA4 and CHIC2 proteins have a significant causal effect on migraine. The risk-increasing effect of DKK1 is particularly interesting—indicating a role for downregulation of β-catenin-dependent Wnt signalling in migraine risk, suggesting Wnt activators that restore Wnt/β-catenin signalling in brain could represent therapeutic tools against migraine.

Understanding of the causes and treatment of migraine is incomplete. Here, the authors detect pleiotropic genetic effects and causal relationships between migraine and 58 proteins that are largely distinct from migraine-associated loci identified by GWAS.

Functional NHE1 expression is critical to blood brain barrier integrity and sumatriptan blood to brain uptake

Disruption of blood-brain barrier integrity and dramatic failure of brain ion homeostasis including fluctuations of pH occurs during cortical spreading depression (CSD) events associated with several neurological disorders, including migraine with aura, traumatic brain injury and stroke. NHE1 is the primary regulator of pH in the central nervous system. The goal of the current study was to investigate the role of sodium-hydrogen exchanger type 1 (NHE1) in blood brain barrier (BBB) integrity during CSD events and the contributions of this antiporter on xenobiotic uptake. Using immortalized cell lines, pharmacologic inhibition and genetic knockdown of NHE1 mitigated the paracellular uptake of radiolabeled sucrose implicating functional NHE1 in BBB maintenance. In contrast, loss of functional NHE1 in endothelial cells facilitated uptake of the anti-migraine therapeutic, sumatriptan. In female rats, cortical KCl but not aCSF selectively reduced total expression of NHE1 in cortex and PAG but increased expression in trigeminal ganglia; no changes were seen in trigeminal nucleus caudalis. Thus, in vitro observations may have a significance in vivo to increase brain sumatriptan levels. Pharmacological inhibition of NHE1 prior to cortical manipulations enhanced the efficacy of sumatriptan at early time-points but induced facial sensitivity alone. Overall, our results suggest that dysregulation of NHE1 contributes to breaches in BBB integrity, drug penetrance, and the behavioral sensitivity to the antimigraine agent, sumatriptan.

Treatment of status migrainosus by general anesthesia: a case report

BACKGROUND AND OBJECTIVES

The status migrainosus is a complication of migraine characterized by severe headache for more than 72h that did not respond to treatment, with risk of stroke and suicide. Researches on treatment are directed to drugs that stimulate GABA receptors; propofol and isoflurane act on sub-GABAa receptors and theoretically could be interesting. The first has been the subject of research in severe migraine. Opioids are employed in pain, and its use in chronic headache is debatable, but these agents are employed in acute cases. The goal is to present a case of refractory status migrainosus in that we decided to break the pain cycle by general anesthesia.

CASE REPORT

Female patient, aged 50 years, with status migrainosus, in the last five days with visits to the emergency department, medicated parenterally with various agents without result. Without comorbidities, dehydrated, described her pain as "well over 10" in Visual Numeric Scale (VNS). After consulting the literature, and given the apparent severity of the condition, we opted for a general anesthesia: induction with fentanyl, propofol, and vecuronium and maintenance with isoflurane and propofol for two hours. Following the treatment, in the postanesthetic recuperation (PAR), the patient related her pain as VNS 3, and was released after five hours with VNS 2. Subsequently, her preventive treatment was resumed.

CONCLUSION

Status migrainosus is a rare disabling complication and anesthetics have been the subject of research in its treatment; the option for general anesthesia with agents that stimulate GABA receptors, propofol and isoflurane, in association with fentanyl, proved effective and should encourage new research.

Recurrent steroid-responsive cerebral vasogenic edema in status migrainosus and persistent aura

Background

Status migrainosus (SM) and persistent aura (PA) without infarction are complications of migraine. Although several patients have been reported to have reversible brain lesions associated with complications of migraine, their nature and pathophysiology remain unclear.

Case

We report on a 38-year-old male who presented with nine episodes of SM and PA over eight years. Serial neuroimaging studies including brain magnetic resonance imaging (MRI), blood flow single photon emission tomography (SPECT),18 F-fluorodeoxyglucose positron emission tomography (FDG-PET) and11 C-flumazenil PET (FMZ-PET) demonstrated cerebral vasogenic edema (CVE) with hypoperfusion and hypometabolism in the area, anatomically corresponding to the area with PA. SM and PA were effectively controlled by corticosteroid therapy. Follow-up MRI revealed complete reversibility of the CVE, which was supported by normal FMZ-PET and FDG-PET findings.

Conclusion

We have described a patient with transient brain lesions associated with complications of migraine who was diagnosed with fully reversible and steroid responsive CVE.

MRI white matter lesions in pediatric migraine

OBJECTIVES

Studies have reported an association between migraine and white matter hyperintensities on T2-weighted brain magnetic resonance imaging (MRI) in adults. The aim of the present study was to evaluate white matter MRI brain findings in pediatric patients with migraine.

METHODS

The medical files and imaging scans of all 194 patients who underwent brain MRI at the headache clinic of a tertiary medical center in 2008-2011 were reviewed.

RESULTS

Mean age was 10.9 ± 3.5 years. Migraine was diagnosed in 131 patients and other disorders in 63. In the migraine group, findings on physical and laboratory examinations were within normal range. White matter lesions were identified on MRI scan in 14 children with migraine (10.6%) and none of the children with other disorders ( P  = 0.006). In 13/14 patients, the lesions were focal with a variable distribution; in the remaining patient, confluent periventricular hyperintensities were documented.

CONCLUSIONS

In a headache clinic of a tertiary pediatric medical center, white matter lesions are found in about 10% of pediatric patients with migraine.

Variable manifestations of familial hemiplegic migraine associated with reversible cerebral edema in children

Three children with familial hemiplegic migraine presented with right-sided weakness, speech difficulty, altered mental status, and gait abnormalities. These persistent aura signs were accompanied by left-sided slowing and cerebral dysfunction, documented by electroencephalograms. Cranial magnetic resonance imaging revealed cortical edema restricted to the left cerebral hemisphere. Follow-up electroencephalogram and imaging studies produced normal results 1-4 months afterward. However, cognitive changes persisted. Genetic testing demonstrated variable results: one child manifested a CACNA1A mutation compatible with familial hemiplegic migraine type 1, whereas another demonstrated an ATP1A2 sequence alteration. No known mutations were evident in the third child, with minor head trauma thought to precipitate the familial hemiplegic migraine. These findings demonstrate the variable clinical and genetic heterogeneity of childhood familial hemiplegic migraine.

Transient complete homonymous hemianopia associated with migraine

INTRODUCTION

Because of the transient and rare nature, objective visual and neuroimaging evaluation during an acute, spontaneous attack of a migrainous aura causing a complete homonymous hemianopia has not been reported.

CASE REPORT

A healthy 27-year-old white woman with a history of typical aura with migraine presented during an episode of no light perception in the right hemifield of both eyes. Ophthalmic testing and neuroimaging were unremarkable. The visual field defect started to resolve 1 hour after initial symptoms, and significant improvement was seen after 4 hours. One year later, the patient had no visual field defects and had not experienced another episode of homonymous hemianopia.

DISCUSSION

More than one third of migrainous patients experience visual symptoms. Typical aura with migraine is diagnosed usually by history. Laboratory testing and neuroimaging are necessary if an alternative cause is suspected, i.e., the aura begins after age 40 years, negative features are predominant, or the aura is very short or prolonged. Correct diagnosis is critical, because conditions that mimic migrainous aura have potentially devastating consequences. Migraine with aura patients may have persistent visual field defects and are at an increased risk for stroke compared with nonmigraine patients. This case improves our knowledge of the nature of a transient homonymous hemianopia associated with migraine.