Multiple sclerosis presenting initially with a worsening of migraine symptoms

Guan-Yu Lin,Giia-Sheun Peng,Fu-Chi Yang,Chih-Wei Wang,Tsung-Ta Chiang

doi:10.1186/1129-2377-14-70

Abstract

Multiple sclerosis (MS) is a chronic autoimmune disease that targets myelinated axons in the central nervous system. Headache has been reported as a subtle symptom of the onset of MS, with a variable frequency of 1.6–28.5%; however, it remains unclear whether headache is a true symptom of MS onset. Here, we report the case of a female patient who had a history of migraine without aura and experienced worsening of migraine-headache symptoms as the initial manifestation of MS. Three similar cases were reported previously; however, unlike this case, those cases had no history of migraine without aura. In our case, we excluded factors that could trigger migraine attacks, such as changes in weather, drugs, alcohol, caffeine withdrawal, stress, fatigue, lack of sleep, hormonal therapy, diet, and hunger. The patient had one episode of MS attack with the simultaneous presence of asymptomatic gadolinium-enhancing and non-enhancing lesions, including hyperintense lesions in the bilateral periventricular white matter, body of the corpus callosum, and periaqueductal grey matter, as observed on the T2-weighted images obtained at the first brain magnetic resonance imaging. In addition, after the injection of gadolinium contrast, ring enhancement over these lesions was noted in T1-weighted images, which was suggestive of active demyelination. MS was diagnosed according to the McDonald criteria (2010 revision). We conclude that MS with periaqueductal grey matter involvement may present with worsening migraine. It is important to be cautious if any secondary causes exist, especially when the patient has a history of migraine without aura. MS should be one of the differential diagnoses in young women showing a change in headache pattern or poor clinical drug response to migraine treatment accompanied by episodes of focal neurological deficit. Failure to recognize MS may lead to inappropriate treatment and worse prognosis; early diagnosis in patients with MS is essential to improve their clinical outcomes and quality of life.

Highlights

Multiple sclerosis (MS) is a chronic autoimmune disease that affects the myelinated axons in the central nervous system (CNS) [1]
Our study suggest that it is important to consider the possibility of MS in patients with worsening migraine symptoms accompanied by episodes of focal deficit and to follow-up these patients regularly
We demonstrated the importance of periaqueductal grey matter (PAG) involvement in a patient presenting with acute worsening migraine headache as an initial manifestation of MS

Summary

Background

Multiple sclerosis (MS) is a chronic autoimmune disease that affects the myelinated axons in the central nervous system (CNS) [1]. Case presentation A 33-year-old woman experienced severe right- or leftsided parietal–temporal throbbing headache accompanied by blurred vision, photophobia, vomiting, and anorexia at a frequency of 1–2 days per month since she was an adolescent. She was diagnosed with migraine without aura and received no prophylactic treatment. On the basis of our physical observation, we performed a low thoracic and lumbar spine MRI, which showed a hyperintense lesion in the spinal cord (T9 level) on T2-weighted images and enhancement after gadolinium injection (Figure 3).

Findings

Discussion

Conclusions