Cerebrospinal fluid (CSF) investigations in migraine

An adult woman with transient headache, neurological deficits, and lymphocytic pleocytosis (HaNDL syndrome) with intracerebral melanosis: case report

Headache with a neurological deficit and cerebrospinal fluid (CSF) lymphocytosis (HaNDL) is usually under-recognized and under-reported. HaNDL is a self-limiting condition, but the grave symptoms require a large-scale differential diagnosis. We report a case of a 24-year-old female who developed dysarthria for several hours and decreased use of the right arm with right-sided facial weakness. After extensive investigation of blood, CSF, and neuroimaging, we excluded central nervous system infections and autoimmune and vascular diseases. A diagnosis of HaNDL was made according to clinical symptoms and CSF analysis. The prognosis was good, and the symptoms resolved. Repeated physical examination after 48 h was unremarkable. HaNDL is probably not as rare as commonly thought; awareness of its existence can avoid unnecessary and potentially harmful investigations and therapies. The clinical challenge relies on the fact that it remains a diagnosis of exclusion.

[Headache in multiple sclerosis]

The relationship between headache and multiple sclerosis (MS) has been a matter of controversy for over 60 years. Headaches are still rated as a "red flag", indicating alternative diagnoses to MS, although in the last few years numerous studies have shown a frequent association between headache and MS. In recent studies on MS patients, a link was found between lower age/shorter disease duration of MS and frequent headaches. A study of 50 patients manifesting MS for the first time showed the highest headache prevalence in MS of 78% reported so far.Headaches can also be a possible side effect of most disease-modifying MS drugs. In many cases, however, the headache appears to be a symptom of MS in terms of secondary headache. This is also supported by pathophysiological implications, for example, by detecting B cell follicles in the meninges of MS patients.Migraine is the most common type of headache in MS. In some cases, this is a comorbidity of two diseases with many similarities, but headaches caused by inflammatory MS lesions also appear to be phenomenologically very similar to classic migraines; thus, distinguishing between them is often only successful with the help of thorough differential diagnostics (cerebrospinal fluid, MRI etc.).The task of future studies must be to specify the phenomenology of headache in MS even more precisely, in order to, to gain knowledge in, among others, patients with radiologically isolated syndrome, who often suffer from headache, because in these patients a considerable differential diagnostic and therapeutic uncertainty exists.

Headache in the course of multiple sclerosis: a prospective study

Multiple sclerosis (MS) is the most common immune-mediated inflammatory disease of the central nervous system (CNS). Early diagnosis and treatment is important to prevent progression of disability in the course of the chronic disease. Therefore, correct and fast identification of early symptoms is vital. Headache is generally not recognized as an early symptom of MS, although numerous studies could show a high prevalence of headache in MS patients. The most common misdiagnosis is migraine. The aim of this study is to investigate the prevalence as well as the phenomenology of headache in MS especially with regard to the progression of the disease. In a prospective, multicenter study, we unbiasedly recruited 150 patients with manifest MS based on the criteria of McDonald. 50 patients at the timepoint of initial diagnosis and 100 of them with a long-term course of the disease were included. Based on a semi-structured interview, we evaluated the occurrence of headache over the last 4 weeks as well as case history, clinical-neurological investigation and questionnaires about depression, fatigue, and quality of life. Prevalence of headache in all patients was 67%. Patients at the timepoint of symptom manifestation of MS showed the highest prevalence of headache that was ever been recorded of 78%. In general, patients with headache were younger, had a shorter duration of the disease, and were less physically affected. We noticed frequent occurrence of migraine and migraine-like headache. In the course of the disease, patients without disease-modifying drug (DMD) complained more frequently headaches than patients with any kind of therapy. Headache is an important early symptom of MS. This could be shown especially among 78% of patients with clinically isolated syndrome (CIS). Therefore, young people with frequent headache should undergo MRI of the head and in the case of abnormal findings a consecutive detailed differential diagnosis. This could reduce the latency until final diagnosis of MS, which is in general much too long. That way these patients could get the earliest possible treatment, which is important to stop the progression of the disease.

Spectrum of complicated migraine in children: A common profile in aid to clinical diagnosis

Complicated migraine encompasses several individual clinical syndromes of migraine. Such a syndrome in children frequently presents with various neurological symptoms in the Emergency Department. An acute presentation in the absence of headache presents a diagnostic challenge. A delay in diagnosis and treatment may have medicolegal implication. To date, there are no reports of a common clinical profile proposed in making a clinical diagnosis for the complicated migraine. In this clinical review, we propose and describe: (1) A common clinical profile in aid to clinical diagnosis for spectrum of complicated migraine; (2) How it can be used in differentiating complicated migraine from migraine without aura, migraine with aura, and seizure; (3) We discuss the status of complicated migraine in the International Headache Society classification 2013; and (4) In addition, a common treatment strategy for the spectrum of migraine has been described. To diagnose complicated migraine clinically, it is imperative to adhere with the proposed profile. This will optimize the use of investigation and will also avoid a legal implication of delay in their management. The proposed common clinical profile is incongruent with the International Headache Society 2013. Future classification should minimize the dissociation from clinically encountered syndromes and coin a single word to address collectively this subtype of migraine with an acute presentation of a common clinical profile.

Is the migrainous brain normal outside of acute attacks? Lessons learned from psychophysical, neurochemical and functional neuroimaging studies

Migraine is a largely inherited disorder of the brain with recurrent head pain attacks. There is an increasing awareness, however, that the manifestation of migrainous biology is not restricted to such acute head pain attacks, but that migraine is rather a disorder with a continuous complex and broad sensory processing dysfunction in which normal sensory stimuli (somatosensory, visual, auditory and olfactory) are misinterpreted by the brain. This dysfunction is most prominent during attacks, but there are more and more evidences that the processing and perception of stimuli is abnormal also outside of attacks to a varying degree. In this topical review, we will summarize and discuss the current clinical, neurochemical and functional neuroimaging literature on this paradigm shift from a strictly episodic head pain disorder to migraine as a more general dysfunction of sensory processing.

Headache attributed to non-vascular intracranial disorder

This chapter deals with non-vascular intracranial disorders resulting in headache. Headache attributed to high or low cerebrospinal fluid pressure is separated into headache attributed to idiopathic intracranial hypertension (IIH), headache attributed to intracranial hypertension secondary to metabolic, toxic, or hormonal causes, headache attributed to intracranial hypertension secondary to hydrocephalus, post-dural puncture headache, cerebrospinal fluid (CSF) fistula headache, headache attributed to spontaneous (or idiopathic) low CSF pressure. Headache attributed to non-infectious inflammatory disease can be caused by neurosarcoidosis, aseptic (non-infectious) meningitis or lymphocytic hypophysitis. Headache attributed to intracranial neoplasm can be caused by increased intracranial pressure or hydrocephalus caused by neoplasm or attributed directly to neoplasm or carcinomatous meningitis. Other causes of headache include hypothalamic or pituitary hyper- or hyposecretion and intrathecal injection. Headache attributed to epileptic seizure is separated into hemicrania epileptica and post-seizure headache. Finally headache attributed to Chiari malformation type I (CM1) and the syndrome of transient headache and neurological deficits with cerebrospinal fluid lymphocytosis (HaNDL) are described.

A patient of migraine-like headache with amnesia, pleocytosis and transient hypoperfusion of cerebral blood flow

Pseudomigraine with pleocytosis (PMP) is an uncommon disease in Japan. The diagnostic criteria include at least one episode of transient neurological deficit accompanied or followed by migraine-like severe headache, cerebrospinal fluid (CSF) lymphocytosis, and normal neuroimaging. Both the etiology and the pathophysiology of PMP is not yet well defined. We report a 40-year-old man with a PMP-like syndrome. He came to our clinic because of severe throbbing headache and amnesia, and the examination showed CSF lymphocytosis of 23/mm3, a transient decrease of cerebral blood flow in the left thalamus. All the symptoms were completely resolved within 2 months.

Pseudomigraine with lymphocytic pleocytosis

Pseudomigraine with temporary neurologic symptoms and lymphocytic pleocytosis is a self-limited syndrome of unknown origin characterized by headache accompanied by transient neurologic symptoms and cerebrospinal fluid lymphocytosis. Patients with this condition are between 15 and 40 years of age. The syndrome is more frequent in men. The clinical picture encompasses one to 12 episodes of changing variable neurologic deficits accompanied by moderate to severe headache and occasional fever. These headaches are described as predominantly throbbing and bilateral with a variable duration (mean, 19 hours). The average duration of the transient neurologic deficit is 5 hours. Sensory (78% episodes), aphasic (66%), and motor (56%) disturbances are the most common. Migraine-like visual symptoms are relatively rare (18% episodes). Patients are asymptomatic between episodes and after the symptomatic period (duration > 3 months). Lymphocytic pleocytosis (10 to 760 cells mm(3)) and increased cerebrospinal fluid protein are found with negative bacteriologic, viral, fungal, and immunologic studies. Brain computed tomography and magnetic resonance imaging are normal, but an electroencephalogram frequently shows focal slowing over the symptomatic brain area. Single photon emission computed tomography reveals transient focal areas of decreased uptake consistent with the clinical symptoms. It is possible that pseudomigraine with temporary neurologic symptoms and lymphocytic pleocytosis could result from an activation of the immune system secondary to a recent viral infection, which would produce antibodies against neuronal or vascular antigens. This autoimmune attack may induce an aseptic leptomeningeal vasculitis, accounting for the headache and the transient symptoms likely through a spreading depression-like mechanism.

Differing central amine receptor sensitivity in different migraine subtypes? A neuroendocrine study using buspirone

Despite the importance of the 5HT1A receptor in regulating central serotonergic tone, there is a dearth of research examining its role in migraine. In this study, we examined the hypothesis that there would be altered neuroendocrine responses to a 5HT1A agonist challenge in different migraine subtypes. Prolactin (PRL) responses to the 5HT1A receptor agonist drug buspirone were compared in 30 female subjects with migraine (ten migraine with aura, MA; ten migraine without aura, MO and ten chronic/transformed migraine, CM), and ten healthy controls matched for age, gender and menstrual status. None of the subjects were taking psychotropic medication or migraine prophylactic treatment and those with formal psychiatric disorder were excluded. Endocrine responses were determined by measuring differences between baseline PRL and maximum increases post-buspirone (deltaPRL). There was no difference in baseline PRL between groups. MA subjects did not differ in their PRL responses to buspirone compared to healthy controls. The MO group had a four-fold increase in mean deltaPRL responses compared to healthy controls. Mean deltaPRL was also increased in the CM group compared to controls, but the difference was less exaggerated. This study indicates that there is supersensitive central amine receptor function in MO and CM, but not in MA. These findings support the hypothesis that central 5HT function differs among the migraine subtypes. The results also suggest that migrainous 'transformation' may be associated with adaptive changes in central 5HT receptor sensitivity. The relative contribution of 'state' and 'trait' receptor function to these findings as well as the possible role of dopamine receptors is discussed.

Pseudomigrânea com pleocitose liquórica: monitorização intermitente da pressão intracraniana. Relato de caso

A pseudomigrânea com pleocitose é uma desordem benigna e auto limitada, caracterizada por sintomas recorrentes, sugestivos de migrânea associada a comprometimento neurológico focal e a alterações no líquido cefalorraquidiano. Monitorizamos a pressão intracraniana em um paciente com este diagnóstico durante os seus períodos sintomáticos e assintomáticos. O paciente foi submetido a três punções lombares com análise citoquímica demonstrando aumento de leucócitos, predominando monomorfonucleares, sem a identificação de agente etiológico. Durante a primeira e a terceira punção lombar o paciente apresentava sintomas neurológicos e cefaléia com características de migrânea, sua pressão intracraniana era de 400 e 440 mmH2O respectivamente. Em um momento assintomático realizamos nova punção lombar ao qual demonstrou pressão intracraniana de 190 mmH20. Os mecanismos fisiopatológicos desta desordem permanecem ainda desconhecidos, existindo algumas evidências que ela esteja relacionada a fenômenos autoimunes, que durante os períodos sintomáticos produzem uma redução no fluxo sangüíneo cerebral assemelhando-se a depressão alastrante. Os achados neste relato de caso sugerem a possibilidade de influência das oscilações da pressão intracraniana nos possíveis mecanismos fisiopatológicos da pseudomigrânea com pleocitose.