Sporadic hemiplegic migraine

The Dawn and Advancement of the Knowledge of the Genetics of Migraine

Background: Migraine is a prevalent episodic brain disorder known for recurrent attacks of unilateral headaches, accompanied by complaints of photophobia, phonophobia, nausea, and vomiting. Two main categories of migraine are migraine with aura (MA) and migraine without aura (MO). Main body: Early twin and population studies have shown a genetic basis for these disorders, and efforts have been invested since to discern the genes involved. Many techniques, including candidate-gene association studies, loci linkage studies, genome-wide association, and transcription studies, have been used for this goal. As a result, several genes were pinned with concurrent and conflicting data among studies. It is important to understand the evolution of techniques and their findings. Conclusions: This review provides a chronological understanding of the different techniques used from the dawn of migraine genetic investigations and the genes linked with the migraine subtypes.

A Retrospective, Epidemiological Review of Hemiplegic Migraines in a Military Population

INTRODUCTION

Headaches are one of the world's most common disabling conditions. They are also both highly prevalent and debilitating among military personnel and can have a significant impact on fitness for duty. Hemiplegic migraines are an uncommon, yet severely incapacitating, subtype of migraine with aura for which there has been a significant increase amongst US military personnel over the past decade. To date, there has not been a scientific report on hemiplegic migraine in United States military personnel.

MATERIALS AND METHODS

The aim of this study was to provide an overview of hemiplegic migraine, to analyze data on the incidence of hemiplegic migraine in US military service members, and to evaluate demographic factors associated with hemiplegic migraine diagnoses. First time diagnoses of hemiplegic migraine were extracted from the Defense Medical Epidemiological Database according to ICD-9 and ICD-10 codes for hemiplegic migraine. One sample Chi-Square goodness of fit tests were conducted on weighted demographic samples to determine whether significant proportional differences existed between gender, age, military grade, service component, race, and marital status.

RESULTS

From 1997 to 2007 there were no cases of hemiplegic migraine recorded in the Defense Medical Epidemiological Database. However, from 2008 to 2017 there was a significant increase in the number of initial diagnoses of hemiplegic migraine, from 4 in 2008 to a high of 101 in 2016. From 2008 to 2017, 597 new cases of hemiplegic migraine were reported among US military service members. Disproportional incidence of hemiplegic migraine was observed for gender, X2 (1, 597) = 297.37, p <.001, age, X2 (5, 597) = 62.60, p <.001, service component, X2 (3, 597) = 31.48, p <.001, pay grade X2 (3, 597) = 57.96, p <.001, and race, X2 (2, 597) = 37.32, p <.001, but not for marital status X2 (1, 597) = 2.57, p >.05.

CONCLUSION

Over the past decade, there has been a significant increase in the number of initial diagnoses of hemiplegic migraine in Active Duty United States military personnel. Based on these diagnosis rates, there is evidence to suggest that hemiplegic migraine has a higher incidence and prevalence rate among post 9/11 service members of the United States military as compared to the general population. Given the sudden increase in new patients diagnosed with hemiplegic migraine in the past decade, the global prevalence estimates of hemiplegic migraine should be reconsidered. Additionally, the impact of hemiplegic migraine on service member's duties and responsibilities deserves further consideration.

Diagnostic and therapeutic aspects of hemiplegic migraine

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.

Novel missense mutation in the ATP1A2 gene associated with atypical sporapedic hemiplegic migraine

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.

Familial hemiplegic migraine in a child with seizure disorder: clinical history is the key to diagnosis

Headache is a common presenting complaint in the paediatric population, with often migraine being a clinical diagnosis. Hemiplegic migraine is characterised by aura, sudden onset weakness of one side of the body which usually recovers without any residual neurological deficit. We report a child with a history of seizure disorder, well controlled and off medication for 3 years, who presented with a headache, aura and transient hemiplegia. Similar history in the patient's mother suggests the diagnosis of familial hemiplegic migraine. We would like to emphasise the importance of detailed history as an important aid in the diagnosis of neurological disorders in children.

Mild Traumatic Brain Injury in a High School Football Player With Familial Hemiplegic Migraine: A Case Report

Mild traumatic brain injury is a major concern in young athletes, with an estimated 1.6-3.8 million reported concussions in the United States annually. Familial hemiplegic migraine is a rare autosomal-dominant condition characterized by sporadic episodes of transient unilateral motor weakness that may begin at any age. We present a case of a 17-year-old boy with a history of familial hemiplegic migraine who suffered prolonged symptoms after a mild traumatic brain injury during sports participation.

LEVEL OF EVIDENCE

V.

Acute-onset migrainous aura mimicking acute stroke: MR perfusion imaging features

BACKGROUND AND PURPOSE

In a very limited number of cases, acute migrainous aura may mimic acute brain infarction. The aim of this study was to recognize patterns of MR perfusion abnormalities in this presentation.

MATERIALS AND METHODS

One thousand eight hundred fifty MR imaging studies performed for the suspicion of acute brain infarction were analyzed retrospectively to detect patients with acute migrainous aura not from stroke. All patients were examined clinically by 2 neurologists and underwent a standard stroke MR imaging protocol, including PWI. Two radiologists reviewed the perfusion maps visually and quantitatively for the presence, distribution, and grade of perfusion abnormalities.

RESULTS

Among 1850 MR imaging studies, 20 (1.08%) patients were found to have acute migrainous aura. Hypoperfusion was found in 14/20 patients (70%) with delayed rMTT and TTP, decreased rCBF, and minimal decrease in rCBV. In contrast to the typical pattern in stroke, perfusion abnormalities were not limited to a single vascular territory but extended to >1. Bilateral hypoperfusion was seen in 3/14 cases. In 11/14 cases, hypoperfusion with a posterior predominance was found. TTP and rMTT were the best maps to depict perfusion changes at visual assessment, but also rCBF maps demonstrated significant hypoperfusion in quantitative analysis. In all patients, clinical and imaging follow-up findings were negative for stroke.

CONCLUSIONS

Acute migrainous aura is rare but important in the differential diagnosis among patients with the suspicion of acute brain infarction. Atypical stroke perfusion abnormalities can be seen in these patients.

Pediatric hemiplegic migraine: susceptibility weighted and MR perfusion imaging abnormality

We report on an 11-year-old girl suffering from a typical attack of hemiplegic migraine with characteristic abnormalities in perfusion MR and susceptibility-weighted MR imaging findings. The imaging abnormalities were resolved 48 h after the attack. Susceptibility-weighted MR imaging findings correlated well with the MR perfusion, thus it can be used along with conventional MRI for evaluation of children with complex migraine attacks. Susceptibility-weighted MR imaging might have a diagnostic role in assessing the vascular events in hemiplegic migraine.

Minor head trauma-induced sporadic hemiplegic migraine coma

Familial hemiplegic migraine is a severe, rare subtype of migraine. Gene mutations on chromosome 19 have been identified in the calcium channel, voltage-dependent, P/Q type, alpha-1A subunit gene (chromosome 19p13) for familial hemiplegic migraine. Recently a gene mutation (Serine-218-Leucine) for a dramatic syndrome associated with familial hemiplegic migraine, commonly named "migraine coma", has implicated exon 5 of this gene. The occurrence of trivial head trauma, in such familial hemiplegic migraine patients, may also be complicated by severe, sometimes even fatal, cerebral edema and coma occurring after a lucid interval. Sporadic hemiplegic migraine shares a similar spectrum of clinical presentation and genetic heterogeneity. The case report presented in this article implicates the involvement of the Serine-218-Leucine mutation in the extremely rare disorder of minor head trauma-induced migraine coma. We conclude that the Serine-218-Leucine mutation in the calcium channel, voltage-dependent, P/Q type, alpha-1A subunit gene is involved in sporadic hemiplegic migraine, delayed cerebral edema and coma after minor head trauma.