Abdominal migraine associated with ecchymosis of the legs and buttocks: does the symptom imply an unknown mechanism of migraine?

Gi-protein-coupled 5-HT1B/D receptor agonist sumatriptan induces type I hyperalgesic priming

We have recently described a novel form of hyperalgesic priming (type II) induced by agonists at two clinically important Gi-protein-coupled receptors (Gi-GPCRs), mu-opioid and A1-adenosine. Like mu-opioids, the antimigraine triptans, which act at 5-HT1B/D Gi-GPCRs, have been implicated in pain chronification. We determined whether sumatriptan, a prototypical 5-HT1B/D agonist, produces type II priming. Characteristic of hyperalgesic priming, intradermal injection of sumatriptan (10 ng) induced a change in nociceptor function such that a subsequent injection of prostaglandin-E2 (PGE2) induces prolonged mechanical hyperalgesia. However, onset to priming was delayed 3 days, characteristic of type I priming. Also characteristic of type I priming, a protein kinase Cε, but not a protein kinase A inhibitor attenuated the prolongation phase of PGE2 hyperalgesia. The prolongation of PGE2 hyperalgesia was also permanently reversed by intradermal injection of cordycepin, a protein translation inhibitor. Also, hyperalgesic priming did not occur in animals pretreated with pertussis toxin or isolectin B4-positive nociceptor toxin, IB4-saporin. Finally, as observed for other agonists that induce type I priming, sumatriptan did not induce priming in female rats. The prolongation of PGE2 hyperalgesia induced by sumatriptan was partially prevented by coinjection of antagonists for the 5-HT1B and 5-HT1D, but not 5-HT7, serotonin receptors and completely prevented by coadministration of a combination of the 5-HT1B and 5-HT1D antagonists. Moreover, the injection of selective agonists, for 5-HT1B and 5-HT1D receptors, also induced hyperalgesic priming. Our results suggest that sumatriptan, which signals through Gi-GPCRs, induces type I hyperalgesic priming, unlike agonists at other Gi-GPCRs, which induce type II priming.

Spontaneous extracranial hemorrhagic phenomena in primary headache disorders: A systematic review of published cases

Background Head pain is a cardinal feature of primary headache disorders (PHDs) and is often accompanied by autonomic and vasomotor symptoms and/or signs. Spontaneous extracranial hemorrhagic phenomena (SEHP), including epistaxis, ecchymosis, and hematohidrosis (a disorder of bleeding through sweat glands), are poorly characterized features of PHDs. Aim To critically appraise the association between SEHP and PHDs by systematically reviewing and pooling all reports of SEHP associated with headaches. Methods Advanced searches using the PubMed/MEDLINE, Web of Science, Cochrane Library, Google Scholar, and ResearchGate databases were carried out for clinical studies by combining the terms "headache AND ecchymosis", "headache AND epistaxis", and "headache AND hematohidrosis" spanning all medical literature prior to October 10, 2015. Preferred Reporting Items for Systematic Reviews and Meta-analyses and Meta-analysis of Observational Studies in Epidemiology guidelines were applied. Results A total of 105 cases of SEHP associated with PHDs (83% migraine and 17% trigeminal autonomic cephalgias) were identified (median age 27 years, male to female ratio 1:2.3); 63% had epistaxis, 33% ecchymosis, and 4% hematohidrosis. Eighty-three percent of studies applied the International Classification of Headache Disorders diagnostic criteria. Eighty percent of the reported headaches were episodic and 20% were chronic. Twenty-four percent of studies reported recurrent episodes of SEHP. Conclusions Our results suggest that SEHP may be rare features of PHDs. Future studies would benefit from the systematic characterization of these phenomena.

Abdominal migraine reviewed from both central and peripheral aspects

Despite the 2%-5% prevalence of abdominal migraine (AM) during childhood, the precise mechanism remains unknown. In this review, we present recent studies on AM and speculate its mechanism from both peripheral and central nervous system aspects. Although the main symptoms of AM exist at the peripheral level, previous studies have reported possible dysfunction of central nervous system, including photophobia, phonophobia and abnormal visual evoked responses. Recently, a case has been reported with AM combined with “Alice in Wonderland” syndrome with visual and/or bodily distortions, which serves as another piece of evidence of central dysfunction. Another case reported an AM patient having peculiar stereotypical ecchymosis in the legs and buttocks associated with pain attack, which implied possible involvement of peripheral nervous system. Although further investigations and accumulation of AM cases are still needed, we believe that the schema hypothesized here is helpful to plan further experimental approach to clarify the mechanism of this peculiar disease.

Serotonin and CGRP in migraine

Migraine is defined as recurrent attack of headache that are commonly unilateral and accompanied by gastrointestinal and visual disorders. Migraine is more prevalent in females than males with a ratio of 3:1. It is primarily a complex neurovascular disorder involving local vasodilation of intracranial, extracerebral blood vessels and simultaneous stimulation of surrounding trigeminal sensory nervous pain pathway that results in headache. The activation of 'trigeminovascular system' causes release of various vasodilators, especially calcitonin gene-related peptide (CGRP) that induces pain response. At the same time, decreased levels of neurotransmitter, serotonin have been observed in migraineurs. Serotonin receptors have been found on the trigeminal nerve and cranial vessels and their agonists especially triptans prove effective in migraine treatment. It has been found that triptans act on trigeminovascular system and bring the elevated serum levels of key molecules like calcitonin gene related peptide (CGRP) to normal. Currently CGRP receptor antagonists, olcegepant and telcagepant are under consideration for antimigraine therapeutics. It has been observed that varying levels of ovarian hormones especially estrogen influence serotonin neurotransmission system and CGRP levels making women more predisposed to migraine attacks. This review provides comprehensive information about the role of serotonin and CGRP in migraine, specifically the menstrual migraine.

Atypical Chronic Headache and Recurrent Facial Ecchymosis: A Case Report

We present the case of a 57-year-old woman with chronic paroxysmal headache and recurrent facial ecchymosis. The headaches are chronic, unilateral, sharp, electric shock-like, of short duration, without nausea nor vomiting, ptosis, miosis, conjunctival injection nor tearing. The facial ecchymoses have been mainly located in the periorbital and epicanthal areas. General, neurological and ophthalmological examinations were unremarkable. Work-up was unremarkable, including negative skin biopsy. The headache was difficult to include in any particular category given the atypical features, but the characteristics were suggestive of a variant of trigeminal autonomic cephalalgia with lack of responsiveness to indomethacin. We discuss the possible pathogenetic mechanism of the occurrence of facial ecchymosis in primary headache disorders.