Status migrainosus as an initial presentation of multiple sclerosis

Raed Alroughani 1, Samar F Ahmed 2, Riyadh Khan 3, Jasem Al-Hashel 4

Affiliations

23 January 2015

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doi: 10.1186/s40064-015-0818-9

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.

Keywords: MRI; Migraine; Multiple Sclerosis.

Figures

Figure 1 Baseline axial and sagittal T2/flair MRI brain images (September 2011) showed demyelinating plaques involving the right middle cerebellar peduncles (a), periventricular areas (b,c) and corpus callosum (d-f).

Figure 1 Baseline axial and sagittal T2/flair MRI brain images (September 2011) showed demyelinating plaques involving the right middle cerebellar peduncles (a), periventricular areas (b,c) and corpus callosum (d-f).

Figure 2 Follow-up MRI brain images (October 2012) showed an increase in the lesion load on axial (a-c) and Sagittal (d-e) T2/flair images when compared to the baseline MRI. Sagittal T2 spine images revealed a demyelinating plaque at C6 level (f).

Figure 2 Follow-up MRI brain images (October 2012) showed an increase in the lesion load on axial (a-c) and Sagittal (d-e) T2/flair images when compared to the baseline MRI. Sagittal T2 spine images revealed a demyelinating plaque at C6 level (f).

Figure 3 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). show full caption

Figure 3 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). show full caption

Figure 4 Follow-up MRI brain scans (March 2014) showed a significant increase in the lesion load involving the periaqueductal gray matter (a), periventricular and juxtacortical regions (b,c), corpus callosum, extending lesions to cortical areas (d,e) in both axial and sagittal T2/flair scans. Enhanced axial T1 MRI scans showed the presence of new gadolinium-enhancing lesions in the temporal, frontal and parietal lobes (f-h). show full caption

Figure 4 Follow-up MRI brain scans (March 2014) showed a significant increase in the lesion load involving the periaqueductal gray matter (a), periventricular and juxtacortical regions (b,c), corpus callosum, extending lesions to cortical areas (d,e) in both axial and sagittal T2/flair scans. Enhanced axial T1 MRI scans showed the presence of new gadolinium-enhancing lesions in the temporal, frontal and parietal lobes (f-h). show full caption

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