Abstract
Background and Objective: Migraineurs often complain of orthostatic intolerance (OI), and its recognition is vital to appropriate treatment. This study attempts to identify and characterize autonomic dysfunction, comparing a sample of migraineurs with OI with a sample of migraineurs without OI. Methods: In a prospective cohort study, we examined one migraine sample complaining of OI for > 6 months (Group 1) and another group without OI (Group 2), using a 70-degree, 45-minute head-up passive tilt-table (HUT45) test, electrocardiographic R-R interval measurements during deep breathing, blood pressure and heart rate monitoring during Valsalva and release, QSART, and skin biopsy for nerve fiber density. We compared results with standard, 10-minute head-up passive tilt-table (HUT10) results to determine which test promoted greater sensitivity, specificity and diagnostic accuracy. Descriptive statistics were computed for each group, defined by the presence or absence of OI. We conducted several receiver operating characteristic analyses to determine whether certain clinical characteristics were predictive of symptoms of OI. Results: Thirty-nine Group 1 and 22 Group 2 subjects were studied and were similar demographically. Thirty eight of 39 (97.4%) Group 1, versus 15/22 (68.2%) Group 2 subjects, manifested abnormal HUT45 results, a significant difference (p=0.002). The HUT45 showed higher sensitivity (0.59; 95% CI: 0.42-0.74) than the standard 10-minute tilt-table test (HUT10) for all expressions of OI (0.31; 95% CI: 0.17-0.48). No differences in autonomic laboratory or skin biopsy findings distinguished the groups. We detected biopsy-proven small fiber neuropathy in 22/39 (56.4%) Group 1 and 10/22 (45.5%) Group 2 subjects. Discussion and Conclusions: In migraineurs, OI is an expression of autonomic dysfunction. We found evidence for a peripheral autonomic deficit on skin biopsy in 45% or more of both groups of migraineurs. Extending the head-up tilt table test to 45-minutes increases diagnostic sensitivity, spares patients misdiagnosis and unnecessary testing, and satisfies the principle of ecological validity.
Highlights
Among the primary headache disorders, trigeminal autonomic cephalalgias (TACs) and migraine headaches are associated with autonomic symptoms and signs.1, 2 While TACs are operationally defined by focal autonomic signs and symptoms, among migraineurs these focal signs occur but are less common.2 With migraine headaches, autonomic dysfunction may present more systemically as orthostatic intolerance (OI) – dizziness or lightheadedness, weakness, near syncope or syncope – and lead to considerable physical and psychological morbidity
The Head-Up Tilt-table test over 45minutes (HUT45) showed higher sensitivity (0.59; 95% confidence intervals (CI): 0.420.74) than the standard 10-minute tilt-table test (HUT10) for all expressions of OI (0.31; 95% CI: 0.170.48)
In the general neurology population, one cause of OI, pandysautonomia, results from peripheral nervous system (PNS) dysfunction due to damage to small poorly myelinated nerve fibers, including autonomic nerve fibers, 3, and new information has emerged on the presence of autoantibodies directed at ganglionic cholinergic and noradrenergic receptors causing peripheral neuropathic forms of orthostatic intolerance. 4, OI can be attributed to any of a variety of neurological disorders of the central nervous system (CNS), such as neurodegenerative diseases, 8 and factors such as blood loss, hypovolemia, or volume dysregulation may contribute to the symptoms of the posturally challenged, dizzy, tachycardic migraineur
Summary
Among the primary headache disorders, trigeminal autonomic cephalalgias (TACs) and migraine headaches are associated with autonomic symptoms and signs. While TACs are operationally defined by focal autonomic signs and symptoms, among migraineurs these focal signs occur but are less common. With migraine headaches, autonomic dysfunction may present more systemically as orthostatic intolerance (OI) – dizziness or lightheadedness, weakness, near syncope or syncope – and lead to considerable physical and psychological morbidity. Autonomic dysfunction may present more systemically as orthostatic intolerance (OI) – dizziness or lightheadedness, weakness, near syncope or syncope – and lead to considerable physical and psychological morbidity. In the general neurology population, one cause of OI, pandysautonomia, results from PNS dysfunction due to damage to small poorly myelinated nerve fibers, including autonomic nerve fibers, 3, and new information has emerged on the presence of autoantibodies directed at ganglionic cholinergic and noradrenergic receptors causing peripheral neuropathic forms of orthostatic intolerance. 4, OI can be attributed to any of a variety of neurological disorders of the CNS, such as neurodegenerative diseases, 8 and factors such as blood loss, hypovolemia, or volume dysregulation may contribute to the symptoms of the posturally challenged, dizzy, tachycardic migraineur. This study attempts to identify and characterize autonomic dysfunction, comparing a sample of migraineurs with OI with a sample of migraineurs without OI
Sign-in/Register to view highlights & summary Sign-in/Register to access full text options 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a callDisclaimer: All third-party content on this website/platform is and will remain the property of their respective owners and is provided on "as is" basis without any warranties, express or implied. Use of third-party content does not indicate any affiliation, sponsorship with or endorsement by them. Any references to third-party content is to identify the corresponding services and shall be considered fair use under The CopyrightLaw.
