MRI in migraineurs

The Prevalence of Magnetic Resonance Imaging Hyperintensity in Migraine Patients and Its Association with Migraine Headache Characteristics and Cardiovascular Risk Factors

OBJECTIVES

To determine the frequency of hyperintense foci in migraine patients and the relationship with migraine headache characteristics and cardiovascular risk factors.

METHODS

Ninety patients with migraine headache (70 without aura and 20 with aura) were enrolled and interviewed. Information on their headache (severity, frequency, and mean disease duration) and other related data was obtained by completing a clinical checklist. Subsequently, brain magnetic resonance imaging (MRI) was performed and each patient was then evaluated for hyperintense lesions.

RESULTS

Of the 90 patients, 29 (32%) had silent hyperintense lesions on their MRI. The mean age of the patients with hyperintense foci was 41 years while those with no lesions was 33 years (p<0.010). Supratentorial hyperintense lesions represented the majority of lesions in the patients (n=46, 63%). Moreover, 56.3% of the lesions (n=41) were located within the right hemisphere. Cardiovascular risk factors such as smoking, serum cholesterol, oral contraceptive pills use, and body mass index (BMI) were not significantly different in these two groups (p>0.050). The lesions were found significantly more frequently in the patients who experienced chronic migraine (p=0.032).

CONCLUSION

Our study adds weight to the theory that disease duration has a key role in the formation of hyperintense brain lesions. Certain cardiovascular risk factors such as sex, smoking, serum cholesterol, and BMI, do not affect the presence or absence of such lesions, suggesting that the relationship between migraine and these lesions may be directly due to the effects of migraine itself.

Progress in Clinical Neurosciences: Migraine-Stroke: A Causal Relationship, but Which Direction?

A significant association between migraine and ischemic stroke has been demonstrated in population and case-control studies. The risk of ischemic stroke appears to be higher in migraine with aura (MWA) than migraine without aura (MwoA). Migraine-stroke comprises a number of distinct entities, including migrainous infarction, in which ischemic stroke occurs during an attack of MWA and migraine-related stroke, in which the causal link is less clear. Migrainous infarction accounts for only one-third of migraine-stroke, strokes may occur during attacks of MwoA, and a number of cerebrovascular disorders may present as MWA or MwoA. Migraine may occur as a consequence of conditions that are known to cause stroke; therefore it remains to be determined whether migraine predisposes to stroke in the absence of any known disease associations, if it is an epiphenomenon of an underlying stroke diathesis, or if it requires the presence of another stroke risk factor to produce cerebral ischemia. Furthermore, it is unclear if ischemia results in migraine more often than migraine results in ischemia. Careful clinical studies that evaluate this bidirectional relationship are needed to determine why migraine patients are subject to a higher risk of ischemic stroke.

Incidental white matter lesions in children presentıng with headache

AIM

We aimed to describe the prevalence and significance of white matter lesions detected on magnetic resonance imaging (MRI) in children with headache.

MATERIAL AND METHODS

Children who were admitted with the complaint of headache and had neuroimaging between December 2007 and June 2012 were included in the study. The clinical and neuroimaging data of the patients were retrospectively evaluated. MRI results of the patients were documented in detail. The patients with non-specific white matter lesions were called for a control visit, and current status of headache and neurological findings were determined.

RESULTS

A total of 941 patients were included in the study. Sixty-one percent of the patients received cranial neuroimaging. 8.2% had only cranial computed tomography (CT), 7.5% had cranial CT and cranial MRI, and 84.3% had only cranial MRI. 22.1% of the patients had abnormal cranial MRI findings. The rate of incidental non-specific white matter changes detected in our study group was 23/527 (4.4%). Among the 23 patients, 12 (52.2%) were male and 11 (47.8%) were female. Fourteen (60.9%) had migraine without aura, 8 (34.8%) had tension-type headache, and 1 (4.3%) had migraine with aura. Mean age of patients at the time of imaging was 12.1 ± 3.4 years (range 4.0-16.0 years). All patients with non-specific white matter changes on MRI showed normal psychomotor development, and there was no history of seizures or head trauma. The physical and neurological examinations of all patients were normal. The mean clinical follow-up period of the patients was 16.8 ± 17.3 months (range 6-80 months). No patients showed neurological deterioration during the follow up. The white matter lesions were supratentorial in all patients. The mean size of the lesions was 5.1 ± 4.5 mm (minimum, 2 mm; maximum, 24 mm). Repeated radiological evaluations were performed in 11 (47.8%) of the patients. No new white matter lesions were detected in control MRI during follow up.

CONCLUSION

Non-specific incidental white matter changes may be seen in children with headache. For normal clinical follow up, in the absence of evident benefits from repeated imaging studies, we suggest that repeated imaging studies are not warranted in every patient and should be tailored according to clinical course.

Risk factors of migraine-related brain white matter hyperintensities: an investigation of 186 patients

Brain white matter hyperintensities are more prevalent in migraine patients than in the general population, but the pathogenesis and the risk factors of these hyperintensities are not fully elucidated. The authors analyzed the routine clinical data of 186 migraine patients who were referred to the Outpatient Headache Department of the Department of Neurology, Medical School, University of Pécs, Hungary between 2007 and 2009: 58 patients with white matter hyperintensities and 128 patients without white matter hyperintensities on 3 T MRI. Significant associations between the presence of white matter hyperintensities and longer disease duration (14.4 vs. 19.9 years, p = 0.004), higher headache frequency (4.1 vs. 5.5 attacks/month, p = 0.017), hyperhomocysteinemia (incidence of hyperintensity is 9/9 = 100%, p = 0.009) and thyroid gland dysfunction (incidence of hyperintensity is 8/14 = 57.1%, p = 0.038) were found. These data support the theory that both the disease duration and the attack frequency have a key role in the formation of migraine-related brain white matter hyperintensities, but the effects of comorbid diseases may also contribute to the development of the hyperintensities.

Migraine and patent foramen ovale: state of the science

Migraine is a prominent cause of recurrent pain, affecting 12% of the population. In several case series, approximately 50% of migraineurs with aura were found to have patent foramen ovale (PFO). The pathophysiological mechanism is speculated to be passage of microemboli and vasoactive chemicals through the PFO, thereby evading pulmonary filtration and triggering migraine symptoms. This article presents the results of retrospective and prospective research studies documenting the effects of PFO closure on migraine symptoms and presents emerging theories on possible pathologic mechanisms that may partially explain the increased risk of ischemic stroke in the migraine population. Finally, evidence-based recommendations are presented for health care providers for managing patients who have migraine and PFO.

Migraine and white matter hyperintensities

Patients with migraine are at increased risk for white matter hyperintensities detected on magnetic resonance imaging. The presence of nonspecific white matter hyperintensities may cause uncertainty for physicians and anxiety for patients. The pathophysiology and long-term consequences of these lesions are unknown. Occasionally, white matter lesions in a migraineur may indicate an underlying disease such as cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL), mitochondrial encephalopathy with lactic acidosis and stroke-like episodes (MELAS), or central nervous system vasculitis. The ability to distinguish between nonspecific and disease-specific patterns of white matter hyperintensities in migraine sufferers is important for the practicing clinician.

Relation between migraine and stroke

A complex bidirectional relation between migraine, mostly migraine with aura (MA), and ischaemic stroke is known. A cerebral infarction can occur during a MA, and MA is a risk factor for ischaemic stroke, particularly in young women. Conversely, cerebral ischaemia can induce MA. Both ischaemic stroke and MA might be consequences of many underlying vascular disorders. Despite the relation between migraine and stroke, migraine as a primary headache disorder is mostly benign.

Decreased vasoreactivity to right cerebral hemisphere pressure in migraine without aura: a near-infrared spectroscopy study

OBJECTIVE

Several studies have reported changes in cerebrovascular reactivity during the interictal period of migraine. To characterize mechanisms of migraine, we compared changes in total haemoglobin (THbl) and regional oxygen saturation (rSO(2)) of the right and left frontal lobes in response to intracranial pressure changes during the interictal period of migraine.

METHODS

Twelve right-handed migraineurs without aura and twelve age- and sex-matched healthy volunteers were asked to perform a head-down maneuver to increase intracranial venous pressure. Initial THbl was designated as 1.0, and all subsequent THbl measurements, which was proportional to the change in cerebral blood flow, were expressed as a value relative to this baseline.

RESULTS

The head-down maneuver resulted in a significantly smaller increase in right-sided THbl in migraineurs when compared to volunteers (migraineurs, -0.1+/-0.04; volunteers, 30+/-13; P=0.027), but there was no significant difference in left-sided THbl when comparing migraineurs and volunteers. Further, the head-down maneuver produced a significantly smaller increase in right-sided THbl than in left-sided THbl in migraineurs (right side, -0.1+/-0.04; left side, 0.35+/-0.08; P<0.0001), but produced a significantly greater increase in right-sided THbl than in left-sided THbl in volunteers (right side, 30+/-13; left side, 0.44+/-0.13; P=0.030). The head-down maneuver resulted in a smaller decrease in right-sided rSO(2) in migraineurs when compared to volunteers (migraineurs, -4.1+/-2.2%; volunteers, -16+/-9.1%), but produced a significantly greater decrease in left-sided rSO(2) in migraineurs when compared to volunteers (migraineurs, -1.3+/-1.1%; volunteers, 2.8+/-0.63%; P=0.0037).

CONCLUSIONS

These data indicate that pressure-related vasoreactivity is suppressed in the right hemisphere of migraineurs during the interictal period.

SIGNIFICANCE

The suppression of vasoreactivity in the right hemisphere might be related to the pathogenesis of migraine.

MR Imaging in the Evaluation of Chronic or Recurrent Headache

PURPOSE

To evaluate ability of magnetic resonance (MR) imaging to depict an abnormality in patients with chronic or recurrent headache without neurologic abnormality.

MATERIALS AND METHODS

Institutional review board approval and patient informed consent were not required. A total of 306 patients with normal neurologic findings and chronic or recurrent headache were examined with MR imaging. Patients were divided into three groups: those with no abnormality, those with minor abnormality, and those with clinically important intracranial abnormality, which may result in chronic or recurrent headache. Literature review was also performed. Upper 99.5% confidence bound for frequency of abnormal MR findings was calculated.

RESULTS

A total of 169 patients (55.2%) were placed in the first group, 135 (44.1%) were placed in the second group, and two (0.7%) were placed in the third group because they had a clinically important abnormality at MR imaging. Neither contrast material enhancement (n = 195) nor repeated MR imaging (n = 23) contributed to the diagnosis. Literature review revealed two previous studies concerning unspecified headache (in addition to the current study), including a total of 1036 MR imaging results and 22 (2.1%) clinically important results (upper 99.5% confidence bound, 3.4%). Twelve studies of migraine headache were found, with a total of 790 MR imaging examinations. Excluding the 19 patients with complicated migraine, the 99.5% confidence bound of the frequency of clinically important abnormality at MR imaging was estimated as 0.68%. Clinically important infarctions were noted on MR images in five (26.3%) of 19 patients with complicated migraine.

CONCLUSION

MR imaging is an unrewarding technique in the evaluation of patients with chronic or recurrent headache and normal neurologic findings. Neither contrast enhancement nor repeated MR imaging contributed to diagnosis, although the number of patients in the latter category was small.

Migraine and Cerebral White Matter Lesions

BACKGROUND

Patients with migraine are at an increased risk for white matter lesions, typically multiple, small, punctate hyperintensities in the deep or periventricular white matter, best observed on magnetic resonance imaging utilizing T2-weighted or FLAIR sequences. The underlying pathogenesis of white matter lesions in migraineurs is unknown, and the lesions are usually nonspecific and of unclear clinical significance.

REVIEW SUMMARY

Often the presence of white matter lesions causes uncertainty for physicians and anxiety for patients and may lead to a variety of diagnostic tests and treatments. Occasionally, white matter lesions may represent a secondary cause for headaches such as CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy). CADASIL is underrecognized and underdiagnosed; it should be suggested by (i) 1 or more of recurrent subcortical ischemic strokes (especially before age 60 and in the absence of vascular risk factors), migraine (especially with aura, including atypical or prolonged auras) and/or early cognitive decline or subcortical dementia; (ii) bilateral, multifocal, T2/FLAIR hyperintensities in the deep white matter and periventricular white matter with lesions involving the anterior temporal pole, external capsule, basal ganglia, and/or pons; and (iii) an autosomal-dominant family history of migraine, early-onset stroke, or dementia. The clinical spectrum of CADASIL is broad, and there is a poor genotype-phenotype correlation. In certain individuals or families, migraine may be the only clinical manifestation.

CONCLUSIONS

While the prevalence of nonspecific white matter lesions in migraineurs is increased, the white matter lesions may occasionally represent a secondary cause for headache such as CADASIL. Greater awareness of the unique clinical, neuroimaging, and pathologic features, as well as the availability of diagnostic genetic testing, should enhance the recognition and diagnosis of this fascinating condition.

Cranial magnetic resonance imaging findings in patients with migraine

OBJECTIVE

To investigate the frequency of cranial magnetic resonance imaging abnormalities in patients with migraine and their relationship to type, duration, and frequency of migraine attacks.

METHODS

Forty-five patients (43 women, 2 men) with migraine whose ages ranged between 19 and 53 years (mean, 40.91 [SD, 7.69]) were evaluated. Of the 45 patients, 20 had migraine with aura and 25 had migraine without aura, according to the diagnostic criteria of the International Headache Society.

RESULTS

In 13 (28.8%) of 45 patients, white matter foci were present on magnetic resonance imaging. Eight of these patients (61.5%) had migraine with aura, and 5 patients (38.4%) had migraine without aura. The presence of white matter foci was significantly higher in the patients with aura (8 [40%] of 20) than in those without aura (5 [20%] of 25). It was found that as the frequency of attacks per month increased, the number of patients with white matter foci also increased. Although the mean duration of migraine was longer in patients with white matter foci (149.5 months [SD, 87.9]) than in those without white matter foci (134.1 months [SD, 88.3]), there was no significant difference (P >.05).

CONCLUSION

Although there are no specific magnetic resonance imaging findings peculiar to migraine, detection of white matter foci should be taken into consideration in patients with migraine (especially migraine with aura). Frequency of attacks is an important indicator of existence of white matter foci.

Evidence for cortical functional changes in patients with migraine and white matter abnormalities on conventional and diffusion tensor magnetic resonance imaging

BACKGROUND

In this study, we used functional MRI (fMRI) to investigate the pattern of cortical activations after a simple motor task in patients with migraine and white matter (WM) abnormalities on conventional MRI scans of the brain. We also investigated whether the extent of brain activations was correlated with WM structural pathology measured using diffusion tensor (DT) MRI.

METHODS

From 15 right-handed patients with migraine and 15 sex- and age-matched, right-handed healthy volunteers, we obtained the following: (1) fMRI (repetitive flexion-extension of the last 4 fingers of the right hand), (2) dual-echo turbo spin echo scans, and (3) pulsed-gradient spin-echo echo-planar sequence to calculate DT-MRI maps. fMRI analysis was performed using SPM99 and cluster detection. We measured the volume, the average mean diffusivity (), and the average fractional anisotropy of all lesions seen on the dual-echo scans. histograms of the normal-appearing WM were also produced.

RESULTS

Compared with healthy volunteers, migraine patients had a larger relative activation of the contralateral primary sensorimotor cortex (P=0.01) and a rostral displacement of the supplementary motor area (P=0.03). The shapes of the curves reflecting the time course for fMRI signal intensity changes were similar between migraine patients and controls for all of the cortical areas we studied. Compared with healthy subjects, migraine patients had significantly lower histogram peak height of the normal-appearing WM histogram (P=0.02), which was found to be correlated with the extent of displacement of the supplementary motor area (r=-0.80, P<0.001).

CONCLUSIONS

This study suggests that functional cortical changes occur in patients with migraine and brain MRI abnormalities and that they might be secondary to the extent of subcortical structural damage.

An MR study of tissue damage in the cervical cord of patients with migraine

Hyperintense abnormalities on T2-weighted magnetic resonance (MR) scans of the brain from patients with migraine are a relatively frequent finding and may represent a diagnostic challenge. We studied the cervical cord of patients with migraine using T2-weighted and magnetization transfer (MT) scans to assess whether the study of macro- and microscopic tissue damage in the cervical cord of these patients may have some diagnostic utility. T2-weighted and MT scans of the cervical cord and dual-echo scans of the brain were acquired from 16 patients with migraine and 17 sex- and age-matched healthy volunteers. Cervical cord MT ratio (MTR) histograms were obtained from all subjects and the relative peak height, the peak position, and the average MTR measured. Five migraine patients (31%) had hyperintense lesions in the brain. Neither healthy controls nor patients with migraine had any abnormalities on cervical cord MR scans. There was no difference for any of the cord MTR histogram-derived metrics between patients with migraine and healthy controls. No MTR histogram-derived measures from migraine patients were 2 standard deviations below the mean values from controls. Patients with migraine do not have MR or MT abnormalities in the cervical cord. MR scanning of the cervical cord in patients with migraine and hyperintense brain lesions of unknown etiology may be a useful investigation to facilitate the diagnostic workout.

Does migraine headache affect cognitive function in the elderly? Report from the Maastricht Aging Study (MAAS)

The aim of this study was to examine two aspects of cognitive functioning-information processing speed and memory-in both young/middle-aged and older subjects with and without migraine, using data from a large population-based sample. We found that, although age had a large effect on processing speed and memory, migraine did not influence cognitive performance. In addition, there was no significant interaction between age and migraine on processing speed and memory. Our results suggest that, in the general population, migraine does not seriously affect cognitive functioning in young/middle-aged or older adults.

Structural and neurochemical markers of brain injury in the migraine diathesis of systemic lupus erythematosus

OBJECTIVE

To determine whether migraine in systemic lupus erythematosus (SLE) is associated with accentuated brain injury and disease activity.

METHODS

Forty SLE patients (11 without headache, 11 with non-migraine headache, and 18 with migraine) underwent clinical evaluation, magnetic resonance imaging (MRI), and spectroscopy (MRS).

RESULTS

Recurrent headache occurred in 75% of SLE patients. MRI abnormalities and reduced N-acetylaspartate were common. However, migraine in SLE was not associated with increased disease activity or severity, neuropsychiatric manifestations, or end-organ involvement compared to patients without migraine (p > 0.05). There were no differences in the prevalence or severity of MRI or MRS abnormalities between SLE patients with migraine, with non-migraine headache, or without headache (p > 0.05).

CONCLUSIONS

Headache does not identify SLE patients at risk for brain injury, increased disease activity, or increased end-organ involvement. Aggressive immunosuppressive therapy for headache alone is not indicated in SLE.

Alternate finger tapping test in patients with migraine

Migraine patients are thought to show some cognitive dysfunction and slight structural abnormalities in the white matter of the brain, whereas most patients with multiple sclerosis (MS) are known to have numerous white matter lesions, often affecting the corpus callosum. To demonstrate psychomotor dysfunction, an alternate finger tapping task (a-FTT) on a PC was administered to controls (n = 41), migraine patients (n = 25), and multiple sclerosis patients (n = 22). Five MS patients with secondary callosal atrophy detected by MRI were also investigated as a separate group. Significant slowing was demonstrated in migraine (P = 0.0005) and MS (P<0.0001). The poorest test results were found in patients with callosal atrophy. In summary, a-FTT on a PC is able to detect minimal psychomotor dysfunction in migraine.

Brain MRI in children with migraine: a controlled morphometric study

Sixteen children and adolescents, aged 5-17 years, with migraine and 24 migraine-free age-matched healthy volunteers underwent brain MRI (1.0 T). Signal intensities of the brain, midsagittal and coronal diameters of the brainstem were quantitatively measured. General signal intensities did not differ between the groups. Compared to controls (17%), more migraine patients (50%) had high-signal foci on T2-weighted images. The diameters of the pons were greater in the migraine group (p = 0.016), although within the normal range. The diameters of the mesencephalon and the medulla oblongata did not differ between the groups, perhaps because they reach the adult size in early childhood in contrast to the pons, which continues to grow. Childhood migraine may be associated with slightly more than average growth of the pons. As the pathophysiology of migraine is still unclear, it might be worth studying with new MR methods.

Agraphia as the only symptom of migraine aura: a case report

A 37-year-old female migraine patient is described, who suffered from episodes with pure lexical agraphia as the only symptom of migraine aura. The MRI showed multiple subcortical white matter lesions. Central inflammatory and demyelinating disorders were excluded. This case suggests that, during a migraine aura, even very circumscribed brain areas involved in complex neuro-psychological processing can be affected.

Diagnostic testing for the evaluation of headaches

Headaches are one of the most common symptoms that neurologists evaluate. Although most are caused by primary disorders, the list differential diagnoses is one of the longest in all of medicine, with over 300 different types and causes. The cause or type of most headaches can be determined by a careful history supplemented by a general and neurologic examination. Reasons for obtaining neuroimaging include medical indications as well as anxiety of patients and families and medico-legal concerns. In the era of managed care, concerns over deselection and negative capitation may dissuade the physician from ordering even a medically indicated scan. The yield of neuroimaging in the evaluation of patients with headache and a normal neurologic examination is quite low. Combining the results of multiple studies performed since 1977 for a total of 3026 scans reveals the overall percentages of various pathologies as: brain tumors, 0.8%; arteriovenous malformations, 0.2%; hydrocephalus, 0.3%; aneurysm, 0.1%; subdural hematoma, 0.2%; and strokes, including chronic ischemic processes, 1.2%. EEG is not useful in the routine evaluation of patients with headache. Similarly, the yield of neuroimaging in the evaluation of migraine is quite low. Combining the results of multiple studies performed since 1976 for a total of 1440 scans of patients with various types of migraine, the overall percentages of various pathologies are: brain tumor, 0.3%; arteriovenous malformation, 0.07%; and saccular aneurysm, 0.07%. WMA have been reported on MRI studies of patients with all types of migraine, with a range from 12% to 46%. The cause of WMA in migraine is not certain. Cerebral atrophy has been variable reported as more frequent and no more frequent in migraineurs compared with controls. The "first or worst" headache has a long list of possible causes and always includes the possibility of acute subarachnoid hemorrhage. Headaches--especially the sentinel type caused by SAH--often are misdiagnosed. The probability of detecting an aneurysmal hemorrhage of CT scans performed at various intervals after the ictus is: day 0.95%; day 3, 74%; 1 week, 50%; 2 weeks, 30%; and 3 weeks, almost nil. The location of a ruptured saccular aneurysm often is suggested by the predominant site of the SAH. The probability of detecting xanthochromia with spectrophotometry in the CSF at various times after a subarachnoid hemorrhage is: 12 hours, 100%; 1 week, 100%; 2 weeks, 100%; 3 weeks, more than 70%; and 4 weeks, more than 40%. The management of thunderclap headaches with normal CT scan and CSF examinations is controversial. Most patients have a benign course but an unruptured saccular aneurysm occasionally may be responsible for the headache. MR angiography may be a reasonable test to obtain instead of a cerebral arteriogram in many of these cases. About 30% to 90% of patients have headaches of various types and causes after mild head injury. Although most headaches are relatively benign, perhaps 1% to 3% of these patients have life-threatening pathology, including subdural and epidural hematomas, that are detected on CT and MRI scans. Headaches caused by subdural hematomas can be nonspecific. When new-onset headaches begin in patients over the age of 50 years, the physician always should consider whether it may be a secondary headache disorder requiring specific diagnostic testing and treatment. Up to 15% of patients 65 years and over who present to neurologists with new-onset headaches may have serious pathology such as stroke, TA, neoplasm, and subdural hematoma. Headaches are the most common symptom of TA, reported by 60% to 90%. The only over the temple. The diagnosis of TA is based on a high index of clinical suspicion that usually but not always is confirmed by laboratory testing. The erythrocyte sedimentation rate can be normal in 10% to 36% of patients with TA. A superficial temporal artery biopsy can give a false-negative result in 5% to 44% of patients.

Might migraine damage the brain?

Recent debate concerning the interpretation of studies of regional cerebral blood flow in migraine has re-emphasized that cerebral ischaemia may occur during attacks of migraine with aura. In this article we suggest that the presence of ischaemia during attacks makes it possible that migraine with aura causes neuronal damage in the long term. We argue that damage is likely to occur in the primary visual cortex, given that a recent high-resolution rCBF study has found flow reductions confined to this area. Furthermore, we hypothesize that the extent to which rCBF is reduced in migraine with aura is sufficient to cause damage only to GABA-ergic inhibitory interneurons in layer IV of this cortex. In animal models, similar cells are known to be selectively vulnerable to damage as a result of hypoxic conditions. Evidence consistent with our hypothesis is provided by recent studies of visual function in migraine. Some clinical and pathophysiological implications of this hypothesis are discussed.