Familial hemiplegic migraine versus migraine with prolonged aura: an uncertain diagnosis in a family report

Signatures of migraine aura in high-density-EEG

OBJECTIVE

Cortical spreading depolarization is highly conserved among the species. It is easily detectable in direct cortical surface recordings and has been recorded in the cortex of humans with severe neurological disease. It is considered the pathophysiological correlate of human migraine aura, but direct electrophysiological evidence is still missing. As signatures of cortical spreading depolarization have been recognized in scalp EEG, we investigated typical spontaneous migraine aura, using full band high-density EEG (HD-EEG).

METHODS

In this prospective study, patients with migraine with aura were investigated during spontaneous migraine aura and interictally. Time compressed HD-EEG were analyzed for the presence of cortical spreading depolarization characterized by (a) slow potential changes below 0.05 Hz, (b) suppression of faster activity from 0.5 Hz - 45 Hz (c) spreading of these changes to neighboring regions during the aura phase. Further, topographical changes in alpha-power spectral density (8-14 Hz) during aura were analyzed.

RESULTS

In total, 26 HD-EEGs were recorded in patients with migraine with aura, thereof 10 HD-EEGs during aura. Eight HD-EEGs were recorded in the same subject. During aura, no slow potentials were recorded, but alpha-power was significantly decreased in parieto-occipito-temporal location on the hemisphere contralateral to visual aura, lasting into the headache phase. Interictal alpha-power in patients with migraine with aura did not differ significantly from age- and sex-matched healthy controls.

CONCLUSIONS

Unequivocal signatures of spreading depolarization were not recorded with EEG on the intact scalp in migraine. The decrease in alpha-power contralateral to predominant visual symptoms is consistent with focal depression of spontaneous brain activity as a consequence of cortical spreading depolarization but is not specific thereof.

SIGNIFICANCE

Cortical spreading depolarization is relevant in migraine, other paroxysmal neurological disorders and neurointensive care.

Migraine Aura-Catch Me If You Can with EEG and MRI-A Narrative Review

Roughly one-third of migraine patients suffer from migraine with aura, characterized by transient focal neurological symptoms or signs such as visual disturbance, sensory abnormalities, speech problems, or paresis in association with the headache attack. Migraine with aura is associated with an increased risk for stroke, epilepsy, and with anxiety disorder. Diagnosis of migraine with aura sometimes requires exclusion of secondary causes if neurological deficits present for the first time or are atypical. It was the aim of this review to summarize EEG an MRI findings during migraine aura in the context of pathophysiological concepts. This is a narrative review based on a systematic literature search. During visual auras, EEG showed no consistent abnormalities related to aura, although transient focal slowing in occipital regions has been observed in quantitative studies. In contrast, in familial hemiplegic migraine (FHM) and migraine with brain stem aura, significant EEG abnormalities have been described consistently, including slowing over the affected hemisphere or bilaterally or suppression of EEG activity. Epileptiform potentials in FHM are most likely attributable to associated epilepsy. The initial perfusion change during migraine aura is probably a short lasting hyperperfusion. Subsequently, perfusion MRI has consistently demonstrated cerebral hypoperfusion usually not restricted to one vascular territory, sometimes associated with vasoconstriction of peripheral arteries, particularly in pediatric patients, and rebound hyperperfusion in later phases. An emerging potential MRI signature of migraine aura is the appearance of dilated veins in susceptibility-weighted imaging, which may point towards the cortical regions related to aura symptoms ("index vein"). Conclusions: Cortical spreading depression (CSD) cannot be directly visualized but there are probable consequences thereof that can be captured Non-invasive detection of CSD is probably very challenging in migraine. Future perspectives will be elaborated based on the studies summarized.

Clinical neurophysiology of migraine with aura

BACKGROUND

The purpose of this review is to provide a comprehensive overview of the findings of clinical electrophysiology studies aimed to investigate changes in information processing of migraine with aura patients.

MAIN BODY

Abnormalities in alpha rhythm power and symmetry, the presence of slowing, and increased information flow in a wide range of frequency bands often characterize the spontaneous EEG activity of MA. Higher grand-average cortical response amplitudes, an increased interhemispheric response asymmetry, and lack of amplitude habituation were less consistently demonstrated in response to any kind of sensory stimulation in MA patients. Studies with single-pulse and repetitive transcranial magnetic stimulation (TMS) have reported abnormal cortical responsivity manifesting as greater motor evoked potential (MEP) amplitude, lower threshold for phosphenes production, and paradoxical effects in response to both depressing or enhancing repetitive TMS methodologies. Studies of the trigeminal system in MA are sparse and the few available showed lack of blink reflex habituation and abnormal findings on SFEMG reflecting subclinical, probably inherited, dysfunctions of neuromuscular transmission. The limited studies that were able to investigate patients during the aura revealed suppression of evoked potentials, desynchronization in extrastriate areas and in the temporal lobe, and large variations in direct current potentials with magnetoelectroencephalography. Contrary to what has been observed in the most common forms of migraine, patients with familial hemiplegic migraine show greater habituation in response to visual and trigeminal stimuli, as well as a higher motor threshold and a lower MEP amplitude than healthy subjects.

CONCLUSION

Since most of the electrophysiological abnormalities mentioned above were more frequently present and had a greater amplitude in migraine with aura than in migraine without aura, neurophysiological techniques have been shown to be of great help in the search for the pathophysiological basis of migraine aura.

Sporadic Hemiplegic Migraine

Sporadic hemiplegic migraine (SHM) is defined as migraine attacks associated with some degree of motor weakness/hemiparesis during the aura phase and where no first degree relative (parent, sibling or child) has identical attacks. The present review deals with recent scientific studies according to which: The SHM prevalence is estimated to be 0.005%; SHM patients have clinical symptoms identical to patients with familial hemiplegic migraine (FHM) and significantly different from patients with migraine with typical aura (typical MA); SHM affected had no increased risk of migraine without aura (MO), but a highly increased risk of typical MA compared to the general population; SHM patients only rarely have mutations in the FHM gene CACNA1A; SHM attacks in some cases can be treated with Verapamil. The reviewed data underlie the change in the International Classification of Headache Disorders 2nd edition where SHM became separated from migraine with typical aura or migraine with prolonged aura. All cases with motor weakness should be classified as either FHM or SHM.

Familial Hemiplegic Migraine: Follow-up Findings of Diffusion-Weighted Magnetic Resonance Imaging (MRI), Perfusion-MRI and [99mTc] HMPAO-SPECT in a Patient with Prolonged Hemiplegic Aura

Familial hemiplegic migraine (FHM) is a rare inherited autosomal dominant disorder. Migraine aura may last up to several weeks and then resolve without sequel. We report a 21-year-old male with FHM since the age of 3 years. Diffusion-weighted magnetic resonance imaging (DWI), perfusion-MR imaging (P-MRI) and [99mTc] hexamethyl-propyleneamine-oxime-single photon emission tomography (HMPAO-SPECT) were performed on day 2, when he was somnolent with right-sided hemiplegia, on day 9 when a mild hemiparesis was still present and on day 24 after recovery. The right central region showed normal findings in DWI, whereas P-MRI and SPECT revealed hyperperfusion on day 2, less marked on day 9, and normal findings on day 24. In conclusion, this case report indicates for the first time, by means of SPECT, P-MRI and DWI studies, that even extremely long-lasting migraine aura is not associated with cerebral ischaemia. Therefore, it supports the revised International Headache Society criteria where the term ‘persistent’ aura is proposed.

Long-term outcome of cognitive functions, emotional behavior, and quality of life in a family with familial hemiplegic migraine

OBJECTIVE

To investigate long-term cognitive outcome, mood, and quality of life in a family with genetically proven familial hemiplegic migraine (FHM).

BACKGROUND

FHM is a rare autosomal-dominant subtype of migraine with aura, characterized by some degree of hemiparesis during the aura. In a previous study, we showed preserved and impaired cognitive functions in patients with FHM. Until now, the progression of cognitive dysfunctions has not been known. However, the ability to predict progression is important for counseling patients about education, career, and family life.

METHODS

Seven years after extensive baseline neuropsychological testing, we retested 6 members of a family with FHM, including questionnaires about mood and quality of life.

RESULTS

The follow-up assessment revealed no global cognitive decline. All the patients' linguistic abilities and verbal memory remained intact; however, their figural memory, attention, and some aspects of executive function were impaired. Half the patients had a slight deterioration in their visuoconstructional functions. Half had higher scores on the trait and state anxiety measures.

CONCLUSIONS

Cognitive deficits in a family with FHM persisted, but without marked progression. Worsening of visuoconstructional abilities may be related to executive dysfunction, confirming a disturbance of cerebrocerebellar circuits.

Cognitive functions, emotional behavior, and quality of life in familial hemiplegic migraine

OBJECTIVES

To describe the cognitive functions, mood, and quality of life in a family with genetically proved familial hemiplegic migraine (FHM), carrying a missense mutation on chromosome 19 (T666M), corresponding to the most frequent FHM subtype.

BACKGROUND

FHM is an autosomal dominant subtype of migraine with an aura, characterized by hemiparesis during the aura. Whereas the genetic background of FHM has been studied intensely, less attention has been paid to cognitive functions and mood between attacks.

METHOD

Six patients performed neuropsychologic assessment between attacks. Depression, anxiety, and quality of life were evaluated by questionnaires. Cerebral magnetic resonance imaging was performed.

RESULTS

Neuropsychologic assessment revealed a distinct pattern of preserved and impaired functions. Whereas linguistic abilities and verbal memory were intact, all patients showed deficits in figural memory, executive functions, in some aspects of attention, and in dexterity. Intelligence of 1 patient was below average. All but 1 patient reported normal quality of life; there were no symptoms of depression or state anxiety. All patients showed cerebellar atrophy and cerebellar ataxia.

CONCLUSION

Cognitive abnormalities and cerebellar atrophy were found in all patients. FHM-related cognitive deficits may be associated to a disturbance of cerebrocerebellar circuits.

Headache attributed to infections nosography and differential diagnosis

Headache is a very frequent symptom of infection. It has many possible underlying mechanisms, of which two or more can coexist in a single patient. It can be caused by direct stimulation of intracranial pain-producing structures, as in the case of brain abscesses, by irritation of the pachy- and leptomeninges, as in cases of bacterial or viral meningitis, or by a state of intracranial hypertension, as seen in obstructive hydrocephalus. There is no doubt that headache is often the first or the predominant symptom of serious, sometimes life-threatening, infectious diseases; certainly, it is a condition frequently encountered in all epidemiological studies. Indeed, it is estimated that over 60% of people have, at some point in their lives, experienced headache during an infection. This evidence leads to the need for a systematic approach to headache secondary to infection. This chapter provides some elements on pain mechanisms in systemic and intracranial infections and on the possible role of antimicrobial agents in the genesis of headache. The first section provides a detailed "etiology-based" description of the International Classification of Headache Disorders, 2nd edition (ICHD-II: Headache Classification Subcommittee of the International Headache Society, 2004), while the second section presents a "symptom-based" algorithm applicable in the first diagnostic assessment, according to the headache features and to the most frequently associated clinical manifestations during infections of the central nervous system (CNS).

Neural correlates of trust

Trust is a critical social process that helps us to cooperate with others and is present to some degree in all human interaction. However, the underlying brain mechanisms of conditional and unconditional trust in social reciprocal exchange are still obscure. Here, we used hyperfunctional magnetic resonance imaging, in which two strangers interacted online with one another in a sequential reciprocal trust game while their brains were simultaneously scanned. By designing a nonanonymous, alternating multiround game, trust became bidirectional, and we were able to quantify partnership building and maintenance. Using within- and between-brain analyses, an examination of functional brain activity supports the hypothesis that the preferential activation of different neuronal systems implements these two trust strategies. We show that the paracingulate cortex is critically involved in building a trust relationship by inferring another person's intentions to predict subsequent behavior. This more recently evolved brain region can be differently engaged to interact with more primitive neural systems in maintaining conditional and unconditional trust in a partnership. Conditional trust selectively activated the ventral tegmental area, a region linked to the evaluation of expected and realized reward, whereas unconditional trust selectively activated the septal area, a region linked to social attachment behavior. The interplay of these neural systems supports reciprocal exchange that operates beyond the immediate spheres of kinship, one of the distinguishing features of the human species.

A G301R Na+/K+ -ATPase mutation causes familial hemiplegic migraine type 2 with cerebellar signs

Familial hemiplegic migraine (FHM) is an autosomal dominant subtype of migraine with hemiparesis during the aura. In over 50% of cases the causative gene is CACNA1A (FHM1), which in some cases produces a phenotype with cerebellar signs, including ataxia and nystagmus. Recently, mutations in ATP1A2 on chromosome 1q23 encoding a Na+/K+ -ATPase subunit were identified in four families (FHM2). We now describe an FHM2 pedigree with a fifth ATP1A2 mutation coding for a G301R substitution. The phenotype was particularly severe and included hemiplegic migraine, seizure, prolonged coma, elevated temperature, sensory deficit, and transient or permanent cerebellar signs, such as ataxia, nystagmus, and dysarthria. A mild crossed cerebellar diaschisis during an attack further supported the clinical evidence of a cerebellar deficit. This is the first report suggesting cerebellar involvement in FHM2. A possible role for CACNA1A in producing the phenotype in this family was excluded by linkage studies to the FHM1 locus. The study of this family suggests that the absence of cerebellar signs may not be a reliable indicator to clinically differentiate FHM2 from FHM1.

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.

An epidemiological survey of hemiplegic migraine

The objective of the present study was to use systematic nation-wide case-finding methods to establish the prevalence and sex ratio of hemiplegic migraine (HM) in the entire Danish population of 5.2 million inhabitants. Affected patients were identified from three different recruitment sources: the National Patient Register, case records from private practising neurologists and advertisements. Based on the observed number of affected patients from each case-finding method, it was attempted to estimate the total number of affected patients by means of the statistical method known as capture-recapture. Two hundred and ninety-one affected patients were identified; 147 were familial HM from 44 different families, 105 were sporadic HM and 39 were unclassifiable HM. The HM sex ratio (M:F) was 1:3. Based on the identified number of affected patients the prevalence of HM at the end of 1999 was estimated to be 0.01% in Denmark, where the familial and sporadic form were equally frequent.

[Severe form of familial migraine with coma]

The authors report the case of a 43-year-old man experiencing a migraine attack with coma requiring a treatment in an intensive care unit for 9 days. The probable triggering cause as a cerebral arteriography.

The place of migraine as a channelopathy

Over the past 8 years an increasing awareness of the role of mutant ion channels in episodic diseases of humans has emerged. The importance of these discoveries is now being extended to a growing list of membrane excitability disorders of the nervous system. Molecular characterization of episodic diseases that are rare and monogenic will ultimately shed light on more common and complex disorders, such as epilepsy and migraine.

A family with hemiplegic migraine and focal seizures

Familial hemiplegic migraine is a distinctive form of migraine with autosomal dominant inheritance. The patients undergo attacks of migraine complicated by hemiplegia. Seizures have not been reported as comprising a part of this syndrome. We describe three generations of a family with hemiplegic migraine and focal seizures occurring concurrently with the migrainous attacks. There were five affected family members whose clinical features included unilateral headache and transient hemiplegia. Two family members also had focal seizures during the migrainous attacks. One of the patients was treated with carbamazepine with good results. The only associated neurological finding was ataxia which was found in the oldest patient. The presence of focal seizures during an episode of hemiplegic migraine suggests that the two phenomena of migraine and focal seizures may share the same underlying pathophysiology.