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Status migrainosus as an initial presentation of multiple sclerosis.

Alroughani R, Ahmed SF, Khan R, Al-Hashel J - Springerplus (2015)

Bottom Line: Both the headache and neurological signs improved with IV methylprednisolone therapy.Her headache entered remission after initiation of a disease modifying therapy.Unresponsiveness to migraine prophylactic therapy in the presence of active demyelinating plaque in MRI brain may pose a diagnostic challenge and a diagnosis of MS might be considered.

View Article: PubMed Central - PubMed

Affiliation: Division of Neurology, Department of Medicine, Amiri Hospital, Arabian Gulf Street, Sharq, 13041 Kuwait ; Neurology Clinic, Department of Medicine, Dasman Diabetes Institute, P.O. Box 1180, Dasman, 15462 Kuwait.

ABSTRACT

Background: Demyelinating plaques may induce headache through disruption of the pathways, which are implicated in the pathogeneses of migraine. We report a case of 25-year-old female patient, who presented with status migrainosus fulfilling the criteria of international classification of headache disorder. She was eventually diagnosed with multiple sclerosis (MS) after an extensive work-up and long-term clinical and radiological follow-up.

Findings: At the onset of status migrainosus, magnetic resonance imaging (MRI) revealed the presence of several demyelinating lesions fulfilling Swanton criteria. She was started on migraine prophylactic treatment but there was no subsequent response. One year later, she presented with recurrent status migrainosus and a follow-up MRI revealed multiple gadolinium-enhancing lesions in the brain. She was treated with abortive migraine medications. Within the following 2 year, she developed ascending parasthesia and weakness of both lower limbs indicative of incomplete transverse myelitis in association with recurrent status migrainosus. A diagnosis of MS was established based on a follow-up MRI that satisfied the revised 2010 McDonald criteria. Both the headache and neurological signs improved with IV methylprednisolone therapy. Her headache entered remission after initiation of a disease modifying therapy.

Conclusion: Status migrainosus can be the initial presentation of MS. Unresponsiveness to migraine prophylactic therapy in the presence of active demyelinating plaque in MRI brain may pose a diagnostic challenge and a diagnosis of MS might be considered.

No MeSH data available.


Related in: MedlinePlus

Follow-up MRI brain scans (April 2013) showed new T2/flair lesions in periventricular and juxtacortical regions with an increase in the overall lesion load when compared to the previous MRI scan as seen in the axial (a-c) and sagittal images (d-e). Enhanced Axial T1 MRI images showed five gadolinium-enhancing supratentorial lesions involving both hemispheres (f-h).
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Fig3: Follow-up MRI brain scans (April 2013) showed new T2/flair lesions in periventricular and juxtacortical regions with an increase in the overall lesion load when compared to the previous MRI scan as seen in the axial (a-c) and sagittal images (d-e). Enhanced Axial T1 MRI images showed five gadolinium-enhancing supratentorial lesions involving both hemispheres (f-h).

Mentions: A 25-year-old female patient presented with severe, left parieto-temporal throbbing headache associated with nausea, vomiting and photophobia, which lasted for 7 days. Although she never had a previous history of headache, she continued to have recurring migraine headaches several times per week. Her headache fulfilled the diagnostic criteria of international classification of headache disorder, third edition (ICHD-3) (Headache Classification Committee of the International Headache S 2013). Her neurologic examination was unremarkable. At the time of the initial presentation, unenhanced magnetic resonance imaging (MRI) brain showed subcortical and periventricular T2/Flair hyperintense lesions, with involvement of corpus callosum, left temporal lobe and right middle cerebellar peduncle fulfilling Swanton Criteria (Figure 1) (Swanton et al. 2006). She was diagnosed as migraine with radiologically isolated syndrome (RIS). She was started on topiramate as a prophylactic migraine therapy, which was subsequently discontinued due to poor response. She continued to use abortive medications (triptans & non-steroidal anti-inflammatory drugs “NSAIDs”) till her presentation with recurrent status migrainosus one year later. A follow-up MRI revealed multiple new T2/ flair hyperintense lesions in the brain and spinal cord indicative of radiological progression (Figure 2). A course of propranolol was initiated as alternative prophylactic migraine treatment but she continued to have recurrent severe headaches. A follow-up MRI brain with gadolinium, 6 months later, showed new T2/flair lesions in the periventricular, corpus callosal and juxtacortical areas along with new Gad-enhancing lesion at multiple supratentorial sites (Figure 3).Figure 1


Status migrainosus as an initial presentation of multiple sclerosis.

Alroughani R, Ahmed SF, Khan R, Al-Hashel J - Springerplus (2015)

Follow-up MRI brain scans (April 2013) showed new T2/flair lesions in periventricular and juxtacortical regions with an increase in the overall lesion load when compared to the previous MRI scan as seen in the axial (a-c) and sagittal images (d-e). Enhanced Axial T1 MRI images showed five gadolinium-enhancing supratentorial lesions involving both hemispheres (f-h).
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4308583&req=5

Fig3: Follow-up MRI brain scans (April 2013) showed new T2/flair lesions in periventricular and juxtacortical regions with an increase in the overall lesion load when compared to the previous MRI scan as seen in the axial (a-c) and sagittal images (d-e). Enhanced Axial T1 MRI images showed five gadolinium-enhancing supratentorial lesions involving both hemispheres (f-h).
Mentions: A 25-year-old female patient presented with severe, left parieto-temporal throbbing headache associated with nausea, vomiting and photophobia, which lasted for 7 days. Although she never had a previous history of headache, she continued to have recurring migraine headaches several times per week. Her headache fulfilled the diagnostic criteria of international classification of headache disorder, third edition (ICHD-3) (Headache Classification Committee of the International Headache S 2013). Her neurologic examination was unremarkable. At the time of the initial presentation, unenhanced magnetic resonance imaging (MRI) brain showed subcortical and periventricular T2/Flair hyperintense lesions, with involvement of corpus callosum, left temporal lobe and right middle cerebellar peduncle fulfilling Swanton Criteria (Figure 1) (Swanton et al. 2006). She was diagnosed as migraine with radiologically isolated syndrome (RIS). She was started on topiramate as a prophylactic migraine therapy, which was subsequently discontinued due to poor response. She continued to use abortive medications (triptans & non-steroidal anti-inflammatory drugs “NSAIDs”) till her presentation with recurrent status migrainosus one year later. A follow-up MRI revealed multiple new T2/ flair hyperintense lesions in the brain and spinal cord indicative of radiological progression (Figure 2). A course of propranolol was initiated as alternative prophylactic migraine treatment but she continued to have recurrent severe headaches. A follow-up MRI brain with gadolinium, 6 months later, showed new T2/flair lesions in the periventricular, corpus callosal and juxtacortical areas along with new Gad-enhancing lesion at multiple supratentorial sites (Figure 3).Figure 1

Bottom Line: Both the headache and neurological signs improved with IV methylprednisolone therapy.Her headache entered remission after initiation of a disease modifying therapy.Unresponsiveness to migraine prophylactic therapy in the presence of active demyelinating plaque in MRI brain may pose a diagnostic challenge and a diagnosis of MS might be considered.

View Article: PubMed Central - PubMed

Affiliation: Division of Neurology, Department of Medicine, Amiri Hospital, Arabian Gulf Street, Sharq, 13041 Kuwait ; Neurology Clinic, Department of Medicine, Dasman Diabetes Institute, P.O. Box 1180, Dasman, 15462 Kuwait.

ABSTRACT

Background: Demyelinating plaques may induce headache through disruption of the pathways, which are implicated in the pathogeneses of migraine. We report a case of 25-year-old female patient, who presented with status migrainosus fulfilling the criteria of international classification of headache disorder. She was eventually diagnosed with multiple sclerosis (MS) after an extensive work-up and long-term clinical and radiological follow-up.

Findings: At the onset of status migrainosus, magnetic resonance imaging (MRI) revealed the presence of several demyelinating lesions fulfilling Swanton criteria. She was started on migraine prophylactic treatment but there was no subsequent response. One year later, she presented with recurrent status migrainosus and a follow-up MRI revealed multiple gadolinium-enhancing lesions in the brain. She was treated with abortive migraine medications. Within the following 2 year, she developed ascending parasthesia and weakness of both lower limbs indicative of incomplete transverse myelitis in association with recurrent status migrainosus. A diagnosis of MS was established based on a follow-up MRI that satisfied the revised 2010 McDonald criteria. Both the headache and neurological signs improved with IV methylprednisolone therapy. Her headache entered remission after initiation of a disease modifying therapy.

Conclusion: Status migrainosus can be the initial presentation of MS. Unresponsiveness to migraine prophylactic therapy in the presence of active demyelinating plaque in MRI brain may pose a diagnostic challenge and a diagnosis of MS might be considered.

No MeSH data available.


Related in: MedlinePlus