History Of Migraine Headaches Research Articles

Sensory Processing Difficulties and Occupational Therapy Outcomes for Functional Neurological Disorder: A Retrospective Cohort Study.

Occupational therapy (OT) consensus recommendations and articles outlining a sensory-based OT intervention for functional neurological disorder (FND) have been published. However, limited research has been conducted to examine the efficacy of OT interventions for FND. We performed a retrospective cohort study aimed at independently replicating preliminarily characterized sensory processing difficulties in patients with FND and reporting on clinical outcomes of a sensory-based OT treatment in this population. We hypothesized that (1) a history of functional seizures, anxiety, and/or post-traumatic stress disorder would be associated with increased sensory processing difficulties and (2) the number of OT treatment sessions received would positively relate to clinical improvement. Medical records were reviewed for 77 consecutive adults with FND who received outpatient, sensory-based OT care. Data from the Adolescent/Adult Sensory Profile characterized self-reported sensory processing patterns across 4 quadrants (low registration, sensory sensitivity, sensory seeking, and sensory avoidance) in this population. Following univariate screenings, multivariate linear regression analyses were performed to identify neuropsychiatric characteristics associated with discrete sensory processing patterns. Clinical improvement was quantified using an estimated, clinician-determined improvement rating ("improved" vs "not improved"), and relationships between clinical participation, baseline neuropsychiatric factors, and outcomes were investigated. Patients with FND reported sensory processing patterns with elevated scores in low registration, sensory sensitivity, and sensation avoidance compared with normative values; differences in sensory processing scores were not observed across FND subtypes (i.e., motor, seizure, and speech variants). In linear regression analyses, lifetime history of an anxiety disorder, history of migraine headaches, current cognitive complaints, and a comorbid major neurologic condition independently predicted individual differences in sensory processing scores. Following a sensory-based OT intervention, 62% of individuals with FND were clinician determined as "improved." In a multivariate logistic regression analysis controlling for baseline characteristics associated with improvement ratings, number of treatment sessions positively correlated with clinical improvement. These findings support the presence of sensory processing difficulties in patients with FND and provide Class IV evidence for the efficacy of an outpatient, sensory-based OT intervention in this population. Controlled prospective trials are warranted.

Optimizing the Combination of Common Clinical Concussion Batteries to Predict Persistent Postconcussion Symptoms in a Prospective Cohort of Concussed Youth.

Studies have evaluated individual factors associated with persistent postconcussion symptoms (PPCS) in youth concussion, but no study has combined individual elements of common concussion batteries with patient characteristics, comorbidities, and visio-vestibular deficits in assessing an optimal model to predict PPCS. To determine the combination of elements from 4 commonly used clinical concussion batteries and known patient characteristics and comorbid risk factors that maximize the ability to predict PPCS. Cohort study; Level of evidence, 2. We enrolled 198 concussed participants-87 developed PPCS and 111 did not-aged 8 to 19 years assessed within 14 days of injury from a suburban high school and the concussion program of a tertiary care academic medical center. We defined PPCS as a Post-Concussion Symptom Inventory (PCSI) score at 28 days from injury of ≥3 points compared with the preinjury PCSI score-scaled for younger children. Predictors included the individual elements of the visio-vestibular examination (VVE), Sport Concussion Assessment Tool, 5th Edition (SCAT-5), King-Devick test, and PCSI, in addition to age, sex, concussion history, and migraine headache history. The individual elements of these tests were grouped into interpretable factors using sparse principal component analysis. The 12 resultant factors were combined into a logistic regression and ranked by frequency of inclusion into the combined optimal model, whose predictive performance was compared with the VVE, initial PCSI, and the current existing predictive model (the Predicting and Prevention Postconcussive Problems in Pediatrics (5P) prediction rule) using the area under the receiver operating characteristic curve (AUC). A cluster of 2 factors (SCAT-5/PCSI symptoms and VVE near point of convergence/accommodation) emerged. A model fit with these factors had an AUC of 0.805 (95% CI, 0.661-0.929). This was a higher AUC point estimate, with overlapping 95% CIs, compared with the PCSI (AUC, 0.773 [95% CI, 0.617-0.912]), VVE (AUC, 0.736 [95% CI, 0.569-0.878]), and 5P Prediction Rule (AUC, 0.728 [95% CI, 0.554-0.870]). Among commonly used clinical assessments for youth concussion, a combination of symptom burden and the vision component of the VVE has the potential to augment predictive power for PPCS over either current risk models or individual batteries.

Factors associated with initiation of pharmacological therapy and treatment changes in postural orthostatic tachycardia syndrome.

Postural Orthostatic Tachycardia Syndrome (POTS) is a heterogenous disorder of the autonomic nervous system that is often disabling. There are no FDA-approved therapies for the treatment of this condition. While some patients recover with baseline non-pharmacological intervention, others require repeated trials of off-label pharmacological therapies. The reasoning for this variable treatment response is unknown. The purpose of this work is to identify potential factors that are associated with higher odds of starting pharmacotherapy and/or a higher rate of POTS treatment changes. Chart review of demographic, disease and treatment descriptions, medical history, and tilt table examinations of 322 POTS patients who were diagnosed between 2018 and 2020 at our tertiary care center was completed. We first identified the most significant factors associated with an increased odds of starting pharmacotherapy using variable selection techniques and logistic regression. We then identified the most significant factors associated with changes in POTS treatment strategies using variable selection techniques and negative binomial regression modeling. A significance level of 0.05 was utilized. A total of 752 POTS-specific treatment courses were cataloged, and 429 treatment changes were observed. The most cited reason for a change in management was uncontrolled symptoms. History of migraine headaches, reported fatigue, reported palpitations and a previous POTS diagnosis at an outside institution were found to be associated with a higher odds of starting pharmacotherapy for POTS symptoms (Odds Ratio of 2.40, 1.94, 2.62, 2.08, respectively). History of migraine headaches, reported fatigue, and higher heart rate differences on tilt table examination were found to be associated with an increase in the rate of POTS treatment changes (44, 66, 13% increase in incidence rate, respectively), while reported neck pain was associated with a decrease (27% decrease in incidence rate). Our work identifies important areas of focus in the development of high-quality trials involving both the non-pharmacological and pharmacological treatment of POTS and highlights several characteristics of patients that may be more refractory to both baseline non-pharmacological treatments and current pharmacological treatment strategies.

THU619 Atypical Clinical Presentation Of Adrenal Hemorrhage

Abstract Disclosure: T.L. Madsen-Barbosa: None. F.H. Antoni: None. A. Ghazi: None. Introduction: Adrenal hemorrhage (AH) is an uncommon condition that is challenging to diagnose due to its nonspecific findings. We illustrate a case of AH that presented with acute clinical deterioration and had catecholamine overproduction. Case: A 58-year-old woman with a history of migraine headaches and prediabetes presented to the emergency department for “the worst headache of her life” and palpitations of 4 hours duration. On admission, her blood pressure was 224/139 mmHg and heart rate was 102 bpm. Her physical examination was significant for diaphoresis and active vomiting. Initial laboratory tests showed hyperglycemia and leukocytosis. Her ECG, non-contrast CT scan of the head and CT angiography of the head and neck were unremarkable. Her hospital course was complicated by recurrent hypertensive episodes, arrhythmias including Torsades de pointes, and left flank pain. A CT chest, abdomen, and pelvis revealed a large left retroperitoneal hemorrhagic collection which seemed to arise from the inferior aspect of the left adrenal gland. She subsequently underwent successful IR embolization of the left inferior suprarenal artery. Further workup showed elevated urinary fractionated metanephrine and normetanephrine levels, as well as elevated levels of plasma free metanephrine and normetanephrine. Given concern for pheochromocytoma, phenoxybenzamine was started. A repeat CT abdomen after six days demonstrated shrinkage in hematoma and a 7 mm hypoattenuating nodule arising from the medial limb of the left adrenal gland. Outpatient follow-up CT abdomen showed left adrenal thickening with a 2.3 cm nodular area with 78.9 Hounsfield units and absolute washout of 60.9% suggestive of adenoma. After one month, repeat catecholamine levels normalized. Discussion: The clinical manifestation of AH varies widely. Acute adrenal insufficiency is seen if bilateral glands and 90% of the cortices are compromised. However, unilateral AH is most often asymptomatic - found incidentally on imaging. Having elevated catecholamines is described in 30% of patients in one case series. Differentiating spontaneous AH from hemorrhagic adrenal tumors is also a dilemma. Among the hemorrhagic adrenal masses, pheochromocytoma is the most common. Conclusion: This case highlights that clinicians should be aware of clinical manifestations of catecholamine excess when evaluating patients with AH. A catecholamine producing adrenal mass (pheochromocytoma) should also be ruled out in these situations. Reference:1- Elhassan YS, Ronchi C, Wijewickrama P, Balvedeweg SE. Approach to the patient with adrenal hemorrhage. J Clin Endocrinol Metab. 2023, 108 (4):995-1006.2- Karwacka IM, Obolonczyk L, Sworczak K. Adrenal hemorrhage: a single center experience and literature review. Adv Clin Exp Med. 2018; 27 (5): 681-687. Presentation: Thursday, June 15, 2023

Benign Episodic Mydriasis as a Cause of Isolated Anisocoria.

A 22-year-old female presented to the emergency department with a dilated right pupil and mild blurry vision. Physical examination revealed a dilated, sluggishly reactive right pupil, without other ophthalmic or neurologic abnormalities. Neuroimaging was normal. The patient was diagnosed with unilateral benign episodic mydriasis (BEM). BEM is a rare cause of acute anisocoria with an underlying pathophysiology that is not well understood. The condition has a female predominance and is associated with a personal or family history of migraine headaches. It is a harmless entity that resolves without intervention and results in no known permanent damage to the eye or visual system. Benign episodic mydriasis is a diagnosis of exclusion that may be considered only after the life- and eyesight-threatening causes of anisocoria.

Combined Arterial and Venous Phase Computed Tomographic Imaging of the Skull Base in Pulsatile Tinnitus.

To describe the demographic, clinical, and radiologic findings in a consecutive series of patients presenting with a chief complaint of pulsatile tinnitus (PT). Retrospective review of 157 patients undergoing a combined arterial/venous phase computed tomographic (CT) imaging study. Tertiary referral center. Adult patients referred to neurotology faculty for evaluation of PT between 2016 and 2020. Triple phase high-resolution arteriography/venography/temporal bone CT. Prevalence of osseous, venous, and/or arterial pathology, clinicodemographic characteristics. One hundred fifty-seven adults (mean age, 52 years; 79.6% female) were evaluated. A history of migraine headaches was common (19.7%). The average body mass index was 30.0 (standard deviation, 6.8), and 17.2% of subjects had a diagnosis of obstructive sleep apnea. Idiopathic intracranial hypertension was diagnosed by elevated opening pressure on lumbar puncture in 13.4%. Comorbid depression and anxiety were common (25.5% and 26.1%, respectively). Overall, abnormalities were found in 79.0% of scans, with bilateral transverse sinus stenosis (TSS) seen in 38.9% and unilateral TSS found in 20.4%. Fifteen subjects (9.6%) had evidence of osseous etiologies, including superior canal dehiscence or thinning in 8.9% and sigmoid sinus dehiscence in one subject. There were 3 dural arteriovenous fistulae identified. Unilateral PT was ipsilateral to the side of TSS in 84.4% of subjects with unilateral TSS. In a large consecutive series of patients with PT referred for CT venography/arteriography, transverse sinus stenosis was the most common finding at 59%. Venous etiologies for PT should be suspected when patients are referred to neurotologists for evaluation.

CAROTID ARTERY DISSECTION FOLLOWING CERVICAL SPINE MANIPULATION: AN ASSOCIATION OR CAUSATIVE RELATIONSHIP

TYPE: Late Breaking Case Report TOPIC: Cardiovascular Disease INTRODUCTION: Spinal manipulation is a hallmark practice of chiropractic providers and sometimes by physiotherapists, and osteopaths. It is a controversial and potentially dangerous procedure.1 Associations have been observed between chiropractic maneuvers and cervical artery dissection, although it remains difficult to prove causal relationship.2-4 We report a case of carotid artery dissection following chiropractic manipulation in a young male with no risk factors for carotid artery dissection. CASE PRESENTATION: This is a 40-year-old male with medical history of migraine headaches and cervicalgia, evaluated for a sudden onset of headache, associated with nausea, vomiting, blurred vision, and dizziness, two months after a chiropractic manipulation. He also reported rigorous exercise and sexual intercourse prior to the headache onset. Vital sign is significant for a 10/10, non-radiating right-sided headache. Neurological examination revealed right ptosis and miosis. Labs were unremarkable. CTA of neck showed tapering of the right ICA with near occlusion at the skull base. He was started on acetylsalicylic acid and clopidogrel, and subsequently discharged home to follow-up with Neurologist. Six-month follow-up revealed resolution of his symptoms and resolved right ICA dissection thrombosis. DISCUSSION: Spinal manipulation is commonly practiced by chiropractic and other providers. Even though it remains difficult to prove causal relationship between spinal manipulation and carotid artery dissection, several cases have been reported in the literature. Potential consequence of cervical artery dissection is stroke, which have increased morbidity and mortality.5 CONCLUSIONS: Our case highlights the dangers of chiropractic manipulation and provides a thorough review of the literature relating to chiropractic manipulation and carotid artery dissection. DISCLOSURE: Nothing to declare. KEYWORD: Cervical spine manipulation

Can vestibular migraine development be predicted in patients with new onset migraine headaches?

Objective: This study aims to determine the clinical features associated with the development of vestibular migraine (VM) in patients with migraine headaches. Methods: A cross-sectional, multicenter study was performed in nine tertiary neurology clinics. Patients with migraine without vestibular symptoms were classified as having migraine only (MO) and compared with patients with VM to determine any differences in clinical features, associated disorders, past medical history, and family history of migraine headaches. Moreover, we investigated the features that might predict the development of VM. Results: Two hundred forty-four patients with MO and 461 patients with VM were included. The age of onset of headache attacks was later in life for patients with VM (p<0.001). Migraine without aura (MwoA) was significantly more common than migraine with aura (MwA) in patients with VM (p=0.016). All associated features of migraine headaches were significantly more frequent in patients with MO than patients with VM (p<0.005). The same was true for all triggers, including fasting, sleep disturbances, menstruation, stress, flickering lights, and smartphones/computer games (p<0.005). A family history of migraine headaches was more common in MO patients (p=0.002). However, a previous history of motion sickness was significantly more common in patients with VM (p<0.001), as was aural fullness/tinnitus accompanying attacks (p<0.001). Logistic regression analysis indicated that aural fullness/tinnitus accompanying attacks and a previous history of motion sickness were risk factors for the development of VM. Conclusion: Patients with migraine reporting aural symptoms accompanying attacks and motion sickness in their past medical history are at increased risk of vestibular attacks fulfilling the diagnosis of VM later in life.

The Association between Migraine and Fetal-Type Posterior Cerebral Artery in Patients with Ischemic Stroke

Objective: The aim of the study was to determine if migraine is associated with fetal-type posterior cerebral artery (PCA) in patients with ischemic stroke. Method: In this cross-sectional study, patients with acute ischemic stroke were enrolled from two hospitals. The history of migraine headache was evaluated during a face-to-face interview. The variants of fetal-type PCA were assessed with MRA, CTA, or DSA. Patients with and without migraine were compared in terms of fetal-type PCA status and other clinic characteristics. Multivariate logistic regression analyses were performed to adjust for confounders and provide risk estimates for observed associations. Result: In 750 patients qualified for analysis, 85 (11.3%) were determined with migraine. Patients with migraine had a higher proportion of female gender (51.8% vs. 31.0%, p < 0.001), hypertension (72.9% vs. 57.7%, p = 0.007), and fetal-type PCA (36.5% vs. 20.1%, p = 0.001), while lower proportion of current smoking (25.9% vs. 38.3%, p = 0.025) than patients without migraine. National Institutes of Health Stroke Scale (NIHSS) score (3 vs. 2, p = 0.016) was also higher in migraineurs than in non-migraineurs. After adjustment for confounders, fetal-type PCA status was independently associated with migraine (odds ratio [OR] = 2.06; 95% confidence interval [CI], 1.25–3.38; p = 0.005). Other factors associated to migraine included female gender (OR = 2.03; 95% CI, 1.13–3.62; p = 0.017), hypertension (OR = 1.97; 95% CI, 1.17–3.34; p = 0.011), and NIHSS score (OR = 1.08; 95% CI, 1.01–1.16; p = 0.018). Conclusion: Migraine was associated with fetal-type PCA in patients with ischemic stroke. This finding supported the hypothesis that vascular mechanisms get involved in the migraine-stroke association.

Abdominal Migraine among Children in Diyala Province

Background: Abdominal migraine is characterized by frequent, paroxysmal, and acute attacks of abdominal pain. There are many hypotheses which contribute to its pathophysiology, but abnormal gastric motility can play a role in the disease's pathogens. Abdominal migraine affects 0.2% to 4.1% of children. Diagnosis of abdominal migraine depends on history and physical examination, radiological and laboratory tests which help to exclude other causes of abdominal pain. Treatment is focused on non-pharmacological and pharmacological therapy. Objective: To identify abdominal migraine among children in Diyala province and summarize the relationship between abdominal migraine and other disorders. Patients and Methods: A cross-sectional study was carried out in Al-Batool teaching hospital in Diyala Province for 8 months from 1st November 2020 till 30th June 2021. The target population was the children who were attending pediatric consultant clinics who were examined and recorded according to Rome Ⅳ Criteria for diagnosis of abdominal migraine. A total of 300 children were included in the study. The information was taken from mothers of children using a questionnaire that was used for the study of abdominal migraine. All data were collected by introducing and analyzing information by using computer (Microsoft Excel 2010 software for windows). Statistical analysis was done by number and percentage as description. Results: The results of demographic data were conducted on 300 child their ages ranged between 3-15 years presented with paroxysmal abdominal pain associated with at least two of following features as anorexia, nausea, vomiting, headache , palpitation , decrease school performance and pallor . Peak percentage of abdominal migraine was seen in age between 6-9years (54.7%). Females affected nearly equal to males, females were (51.6%) and males were (48.3%). Regarding the location of abdominal pain, it occurred mainly in periumbilical site (80%). In children with abdominal migraine, there was history of migraine headache and motion sickness in first-degree relatives. There were many triggering factors for abdominal migraine such as foods like sweets, chinese food, carbonated drinks which were found in (90.3%) of children and watching TV, mobile,and electronic games for long time in (96.7%) of children. The duration of symptoms less than 6 months was seen in (13.3%) of children while the duration of symptoms in between 6-12 months was seen in (60%) of children while the duration of symptoms above one year was seen in (26.7%) of children . Conclusion: Abdominal migraine was mostly seen in school age children. Family education about the causes ,trigger factors and management of disease is important. Keywords: Abdominal migraine, abdominal pain , children

Determinants of migraine headache among regular undergraduate students, of Wollo University, Dessie, Ethiopia: cross\u2013sectional study

BackgroundThe prevalence of migraine headaches varied from 2.4 to 48.5% worldwide among university students. As per the knowledge of the investigators, the study of migraine headaches is not done in this study area. Hence, this study aimed to assess determinates of migraine headaches among regular undergraduate students, of Wollo University, Dessie, Ethiopia, 2020.MethodInstitution-based cross-sectional study design was conducted from November 15–30 /2020 by using a self-administered questionnaire among 371 regular undergraduate students at Wollo University. A multistage sampling technique was employed to represent our study population. Identity migraine test, Migraine Disability Assessment Questionnaire, perceived stress scale, and Oslo social support scale was used. Descriptive statistics, binary and multiple logistic regression were employed. The adjusted odds ratio at a 95% confidence interval and level of significance (p-value < 0.05) was used to interpret the findings.ResultsFrom 371 participants, the prevalence of migraine headache in this study was 34% (95% CI: 29.2, 38.5). Variables statistically associated with migraine headache, were a family history of headache (AOR = 3.83, CI: 2.313, 6.366), suicidal thoughts in the past 3 months (AOR = 10.76, CI: 2.117, 54.74), and had low perceived stress 62.6% (AOR = 0.374, CI: 0.205, 0.683).ConclusionIn this study, the prevalence of migraine headaches was very high. Family history of headache, suicidal thoughts, and low perceived stress were determinates for migraine headache. So special emphasis shall be given to those participants who had high perceived stress, a family history of migraine headache, and suicidal thoughts.

Associations between Dietary Acid Load and Migraine Headache Severity and Duration among Women: A Cross-Sectional Study

Background: Migraine is considered the most common cause of long-term disability in under-50s, which can lead to unbearable pain and neurological dysfunction. Many factors, especially dietary factors, are suggested to trigger migraine headaches. The present study aimed to examine the association between diet-dependent acid load and severity and duration of headaches among migraine patients. Methods: In this cross-sectional study, a sample of 266 women (18-45 years) with history of migraine headaches was enrolled. Dietary data was collected by using a validated Food Frequency Questionnaire (FFQ). Then, diet-dependent acid load indices including Potential Renal Acid Load (PRAL) and Net Endogenous Acid Production (NEAP) were calculated for the participants. For all cases, anthropometric measurements and headache duration were assessed. Headache severity was determined by Visual Analog Scale (VAS) and Migraine Disability Assessment (MIDAS) questionnaires. Results: In this study, individuals with higher PRAL (OR=1.87, 95% CI=1.19-2.96, p=0.007) and NEAP (OR=1.58, 95% CI=1.02-2.44, p=0.03) scores were 87 and 58%, respectively, more likely to have severe headaches. Moreover, our results showed a significant direct correlation between PRAL (β=0.14, 95% CI=0.56-2.94, p=0.04) and NEAP (β=0.18, 95% CI=0.45-3.34, p=0.01) scores and headache duration of participants. Conclusion: The present study showed that higher diet-dependent acid load scores may be associated with higher headache severity and duration in migraine patients.

Ciliary Ganglioplegic Migraine Associated with SACS Mutation

Migraine patients often complain of repeated attacks of monocular visual disturbance including scintillations, scotomas, blindness and pupillary dysfunction. Temporary pupillary enlargement of the ipsilateral side during migraine attack, although rarely reported, is referred to as an Adie’s-like tonic pupil [1]. Adie’s tonic pupil is caused by denervation of the postganglionic parasympathetic pupillary nerves, with light-near dissociation, and cholinergic supersensitivity. Autosomal Recessive Spastic Ataxia of Charlevoix-Saguenay (ARSACS) is characterized by early-onset spastic ataxia, peripheral sensorimotor neuropathy, and pyramidal symptoms. ARSACS is caused by mutations in the SACS gene, which encodes the Sacsin expressed in various tissues including brain motor systems. Sacsin is believed to integrate the ubiquitin-proteasome system and Hsp70 chaperone machinery, which are important components of the cellular response associated with neurodegenerative diseases [2]. Here, we describe a patient suffering from chronic migraine without aura who developed cerebellar ataxia and unilateral mydriasis during acute migraine persisted after resolved headache. Presence of a SACS gene mutation is an expansion of the clinical phenotype associated with SACS mutations to ciliary ganglioplegic migraine. A 47-year-old female who suffers from long standing headache developed unsteady gait and poor coordination. With a diagnosis of migraine without aura based on the third edition of the International Classification of Headache Disorders (ICHD-III) criteria, she was prescribed preventive medicine with topiramate and onabotulinumtoxinA injection on occasion. Physical examination revealed a dilated pupil in the left eye without reflexive constriction to light or accommodation which persisted after resolution of migraine. Except for anisocoria, no other abnormal findings were identified. Remarkable reduction of the left pupil size was observed in response to 0.125% pilocarpine (Figure 1). The patient also showed mild nonataxic spastic paraplegia but without distal weakness or pyramidal signs. A family history of migraine headache and other neurological disorders was denied. Nerve conduction studies confirmed the mixed demyelinating and axonal character of polyneuropathy. Brain MRI with angiography did not reveal any abnormalities.

The Relationship Between Vestibular Migraine and Motion Sickness Susceptibility.

To determine the relationship between vestibular migraine (VM) and motion sickness (MoS) susceptibility and their comorbidity in a large student population, and to assess whether experiencing MoS is associated with higher susceptibility for VM. Surveys including Motion Sickness Susceptibility Questionnaire (MSSQ) and questions assessing migraine-related symptoms as well as family history of motion sickness and migraine headache were distributed to the university undergraduate students through Facebook and email. Diagnosis of definite VM (dVM) was based on the criteria of the International Classification of Headache Disorders. Of 277 survey responders, 148 (53%) were found to be susceptible to MoS in which 74 (50%) met the criteria for dVM. Only childhood MSSQ score was significantly higher in participants with dVM compared with those without dVM (25.78 ± 15.89 versus 20.77 ± 14.28, p = 0.04); however, its significance faded out by regression analysis. Multivariate logistic regression showed having 1st degree relative with migraine headache (p = 0.02), neck stiffness (p = 0.001), and sinus pain, facial pressure, or headache with wind exposure (p = 0.02) to be independently associated with presence of dVM in MoS subjects. Though participants with MoS and dVM had significantly greater rates of migraine-related symptoms and family history of migraine headache compared with those with MoS only, childhood and adulthood MSSQ scores were similar. This and the high prevalence of dVM in our MoS cohort may suggest an existing association between MoS susceptibility and VM.

SUN-933 Lactic Acidosis as a Rare and Unusual Presentation of Pheochromocytoma

Background: Pheochromocytoma is a rare catecholamine-producing tumor of chromaffin cells in the adrenal medulla or of a paraganglion. Typically it presents with sustained or paroxysmal hypertension, severe headaches, palpitations and sweating due to hormone excess. However, the presentation can be variable and can mimic many other diseases. If left undiagnosed or untreated, it can lead to life-threatening consequences.Case Presentation:A 35 year old female with significant past medical history of migraine headaches, poorly controlled hypertension and a recent new onset seizure, presented with progressive worsening shortness of breath and persistent abdominal pain following a gastrointestinal illness. She also reported diaphoresis, cold fingers and toes, abnormal weight gain, and orthostatic symptoms that gradually worsened for two months prior to presentation. Laboratory evaluation revealed lactic acidosis, leukocytosis, and hypokalemia. Subsequently, a CT scan of the abdomen was performed that revealed an adrenal mass with significant elevation in urine metanephrines. As a result, the patient was diagnosed with pheochromocytoma and successfully treated with laparoscopic left adrenalectomy.Conclusion: Pheochromocytoma is a rare but can be life threatening if left undiagnosed. It is of utmost importance for clinicians to keep in mind such unusual presentation of a potentially life threatening tumor. To the best of our knowledge, this is an unusual presentation of Pheochromocytoma with severe lactic acidosis.

Migraine History and Recurrence in Military Pilot Applicants.

BACKGROUND: Migraine is a common condition with features that can adversely impact aviation activities. The diagnosis of migraine is often compatible with civil aviation training, but is much more concerning for military pilot applicants. A history of migraine headache traditionally medically excluded potential military pilot applicants due to unpredictability of occurrence and potential for operational distraction or incapacitation. Medical standards and policy applications have been quite variable, ranging from total exclusion for even one headache occurrence to as low as a 1-yr migraine-free period before consideration. In many instances, policy application has been subjective and not based on objective evidence. This presents a challenge to waiver authorities and also potentially sends a mixed message to command authorities. There is essentially no current literature evidence applicable to the aviation population on migraine occurrence risk.METHODS: This study reviewed 71 U.S. Air Force pilot applicants who were diagnosed with migraine and had been granted waivers to assess any predictive factors for migraine recurrence and its aeromedical impact.RESULTS: Only three applicants had recurrence after waiver was granted, with two of these occurring within 2 yr of their last reported migraine event, and all recurrences noted within 3 yr.DISCUSSION: Data indicated favorable risk with suitable migraine-free observation before military pilot training, which could be incorporated into aeromedical standards and policies.Hesselbrock RR, Haynes JT. Migraine history and recurrence in military pilot applicants. Aerosp Med Hum Perform. 2020; 91(1):37-40.

2646 Ischemic Colitis Secondary to Sumatriptan Overuse Along With Estrogen

INTRODUCTION: Sumatriptan, a 5-HT1B/1D (5-hydroxytryptamine-1B/1D) receptor agonist is the first line medication currently available for migraine and cluster headaches. The drug acts by selectively constricting the intracranial blood vessels. Also, studies have shown that estrogen modifies the levels of MAO-A (Monoamine oxidase-A) in the body thereby decreasing the metabolism of sumatriptan. In the past few decades, there has been a handful of reported cases of coronary vasospasm, myocardial infarction and ischemic colitis associated with sumatriptan use. We report a 57-year-old female who developed ischemic colitis in the setting of usage of increasing doses of sumatriptan along with estrogen. CASE DESCRIPTION/METHODS: A 57-year-old woman with a history of migraine headache, fibromyalgia, hypertension, diet-controlled diabetes mellitus, diverticulitis presented to the emergency room with sudden onset of left sided abdominal pain and 5 episodes of Bright red blood per rectum for one day. Medications included sumatriptan, estradiol, enalapril, venlafaxine, aspirin, and atorvastatin. On examination, left lumbar and left iliac quadrants tenderness was noted. Negative for peritoneal signs. Labs showed WBC 19.6 [3.7–10.6 cells/ul], Hb 15 [11.5–15.5 cells/ul], glucose 106 [70–139 mg/dL], lactic acid 3.2 [0.5–2.2 mmol/L], ESR 18 [&lt;=30 mm/hr], CRP 10.2 [0.3–1.0 mg/dL]. CT abdomen and pelvis revealed findings suggestive of colitis extending from the hepatic flexure to sigmoid colon. Of note, she was using increasing doses of sumatriptan [100 mg tabs, at least 3 to 4 times a day] in the past few weeks for increased frequency of migraine headaches. Endoscopic findings are suggestive of ischemic colitis versus the others. Pathology of the mucosal biopsy showed hallmarks of ischemic colitis. Sumatriptan and estrogen were discontinued. The patient was followed up for a few weeks to months. She reported remarkable improvement of symptoms without any recurrence. DISCUSSION: Sumatriptan is a commonly prescribed abortive medicine for migraine, while ischemic colitis is one of its rare side effects. We aim to emphasize the synergistic effect of increasing doses of sumatriptan along with estrogen in causing ischemic colitis. Physicians should consider the diagnosis of sumatriptan-induced ischemic colitis in patients taking increased doses of this medication with concurrent estrogen usage, who develop severe abdominal pain, hematochezia and potentially counsel patient on cautious use of 5HT1 receptor agonist.

Influence of Pre-Morbid Migraine History on Baseline Vestibular/Ocular Motor Screening and King-Devick Test Performance

Abstract Purpose To examine the effects of premorbid migraine history on baseline Vestibular/Ocular Motor Screening (VOMS) and King-Devick (KD) test performance in youth athletes. Methods This study implemented a cross-sectional design and was conducted at a series of youth sport venues in a designated research area. Youth athletes between the ages of 8 and 14 years with a diagnosed history of migraine headaches (n=28) and match controls (n=28) were administered a baseline VOMS and KD test. Between-group comparisons for provocation scores on the VOMS (smooth pursuit, saccades, convergence, vestibular-ocular reflex [VOR], and visual motion sensitivity [VMS]), Near-point of convergence [NPC] average distance (cm), and KD time (seconds) were conducted. Results Individuals diagnosed with migraine headaches reported greater VOMS scores compared to match controls on smooth pursuit (0.43±1.1 vs. 0.00±0.0; p=.02), convergence (0.46±1.2 vs. 0.04±0.1; p=.04), horizontal VOR (0.89±1.4 vs. 0.07±0.2; p&lt;.001), vertical VOR (0.61±1.1 vs. 0.11±0.3; p=.04), and VMS (0.86±1.5 vs. 0.04±0.1; p=.01). Differences were also observed on the KD test with worse times in the diagnosed migraine group (54.33±11.8s) compared to match controls (47.17±8.9s; p=.02). No differences were reported on NPC distance between the migraine (2.22±3.1cm) and control group (0.83±1.2; p=.06). Conclusion Youth athletes with diagnosed migraine history reported higher baseline VOMS scores and worse KD time compared to match controls, further illustrating the influence of premorbid migraine headaches as a risk factor for elevated baseline concussion assessment. Special consideration may be warranted for post-concussion assessment in athletes with diagnosed migraine headaches.

Case 270.

History A 54-year-old woman presented with typical chest pain during physical training at the gym. She had a history of hypertension controlled with hydrochlorothiazide, without any other cardiovascular risk factor and with neither personal nor family history of ischemic heart disease. She was postmenopausal and had a long-standing history of migraine headaches without hormonal or drug therapy. The patient had no history of clinically important thoracic trauma or invasive chest interventions. Initial electrocardiography (ECG) showed signs of ongoing anterior ST segment elevation myocardial infarction, and emergent coronary angiography with angioplasty and intravascular US were performed ( Fig 1 ). Maximal level of high-sensitive T troponins was 820 ng/L (normal, <13 ng/L), while echocardiography showed a normal left ventricular ejection fraction, with no apparent regional wall motion abnormalities. General physical examination findings were unremarkable, excluding ligamentous hyperlaxity and joint instability. C-reactive protein, rheumatoid factor, antinuclear antibody, cytoplasmic antineutrophil cytoplasmic antibody, and angiotensin-converting enzyme blood test results were negative. For further evaluation, arterial phase ECG-synchronized CT angiography from the skull base to the pubis symphysis was performed ( Fig 2 ). Figure 1a: Coronary angiography of the left anterior descending (LAD) and left circumflex (LCX) arteries (30° right anterior oblique and 20° caudally angulated projection) and intravascular US of the LCX artery were performed. (a) Initial coronary angiography projection. (b) Coronary angiography projection after LAD stent placement. (c, d) Intravenous US images of the distal (c) and proximal (d) LCX artery obtained after b. Figure 1b: Coronary angiography of the left anterior descending (LAD) and left circumflex (LCX) arteries (30° right anterior oblique and 20° caudally angulated projection) and intravascular US of the LCX artery were performed. (a) Initial coronary angiography projection. (b) Coronary angiography projection after LAD stent placement. (c, d) Intravenous US images of the distal (c) and proximal (d) LCX artery obtained after b. Figure 1c: Coronary angiography of the left anterior descending (LAD) and left circumflex (LCX) arteries (30° right anterior oblique and 20° caudally angulated projection) and intravascular US of the LCX artery were performed. (a) Initial coronary angiography projection. (b) Coronary angiography projection after LAD stent placement. (c, d) Intravenous US images of the distal (c) and proximal (d) LCX artery obtained after b. Figure 1d: Coronary angiography of the left anterior descending (LAD) and left circumflex (LCX) arteries (30° right anterior oblique and 20° caudally angulated projection) and intravascular US of the LCX artery were performed. (a) Initial coronary angiography projection. (b) Coronary angiography projection after LAD stent placement. (c, d) Intravenous US images of the distal (c) and proximal (d) LCX artery obtained after b. Figure 2a: Arterial phase electrocardiography-synchronized CT angiography from the skull base to the pubis symphysis was performed after coronary angiography, subsequent interventional procedures, and intravenous US. (a, b) Axial oblique slab maximum intensity projection image at the level of the left (a) and right (b) renal arteries. (c) Coronal volume-rendering image shows an anterior view of the renal arteries. Figure 2b: Arterial phase electrocardiography-synchronized CT angiography from the skull base to the pubis symphysis was performed after coronary angiography, subsequent interventional procedures, and intravenous US. (a, b) Axial oblique slab maximum intensity projection image at the level of the left (a) and right (b) renal arteries. (c) Coronal volume-rendering image shows an anterior view of the renal arteries. Figure 2c: Arterial phase electrocardiography-synchronized CT angiography from the skull base to the pubis symphysis was performed after coronary angiography, subsequent interventional procedures, and intravenous US. (a, b) Axial oblique slab maximum intensity projection image at the level of the left (a) and right (b) renal arteries. (c) Coronal volume-rendering image shows an anterior view of the renal arteries.

A History of Migraine Headache is Associated with Worse Disability and Walking Speed in a Cohort of Patients with MS (P5.2-005)

A History of Migraine Headache is Associated with Worse Disability and Walking Speed in a Cohort of Patients with MS (P5.2-005)