Migraine-like Headache from an Infarction in the Periaqueductal Gray Area of the Midbrain

Abstract

Dear Editor: Growing evidence indicates that migraine is primarily a brain disorder, probably involving subcortical sensory modulation with a secondary neurovascular response. It has been postulated that the loss of inhibition descending from certain nuclei, e.g., locus coeruleus, periaqueductal gray (PAG), and nucleus cuneiformis in the midbrain, results in hyperexcitability of trigeminovascular neurons leading to migraine headache ⇓. Here, we describe an older adult patient who developed new onset migraine-like headache after a small-sized infarction in the PAG area. A 64-year-old woman presented with the acute onset of episodic headache attacks. Her symptoms began 5 days before her first clinic visit with the sudden onset, while she was having dinner, of a feeling of dizziness and a subsequent severe right-sided throbbing headache. The headache was accompanied with nausea, photophobia, and aggravated by head movement. Two hours later, the headache disappeared but the feeling of mild dizziness persisted. From then on, she had recurrent headache everyday with a frequency of two to three times a day. Each episode of headache would last 1–3 hours with persisted mild dizziness between episodes. The headache was moderate to severe in severity and throbbing and pressure-like in character. Photophobia and nausea accompanied when the headache was severe. Physical activity had …