Migraine with aura, bipolar depression, ACM aneurysm. A case report

Abstract

B.D. is a 48-year-old professional woman. She has been suffering for migraine since she was 28, but she did not have serious problems until last year, when headache episodes became more frequent and it was necessary an admission to emergency room. At the beginning, the events were about 6 per month, lasting from 2 to 4 days, beating and of high intensity together with nausea, vomit, photo and phonophobia and visual area. Looking at the anamnesis, we report a psychiatric treatment since about ten years, because of type II bipolar disorder. In spite of the psychopharmacological treatment, as the patient came in our Regional Headache Center, she talked about 7 events with aura (scintillating scotomas, emianopsia) per month, lasting 2-4 days with photo and phonophobia, nausea, crying crisis, anxiety. Although the neurological examination was normal, the sudden aggravation of pain symptomatology and the unresposiveness to usual painkillers, suggested a cerebral CT and CT-angiography. CT and CT-angiography discovered the presence of an aneurysm of the right middle cerebral artery (MCA) of 4 mm diameter, with parietal irregularities. The patient was operated to reduce the hemorrhagic risk, with a positive result. One year after the operation, the patient reports a decrease of headache events with a frequency of 2 per month, lasting only a few hours, which she can now solve with COXIB. [PUBLICATION ABSTRACT]

J Headache Pain (2005) 6:9396

DOI 10.1007/s10194-005-0159-0BRIEF REPORTSergio de Filippis

Emiliano Salvatori

Alessandro Bozzao

Luigi Maria Fantozzi

Paolo MartellettiMigraine with aura, bipolar depression, ACM

aneurysm. A case reportReceived: 7 May 2004Accepted in revised form: 21 February 2005

Published online: 8 April 2005S. de Filippis () E. Salvatori P. Martelletti

Regional Referral Headache Centre,

Department of Medicine,

SantAndrea Hospital,

II School of Medical Sciences,

University La Sapienza,

Via di Grottarossa 1035,

I-00189 Rome, Italy

e-mail: [email protected]

Tel.: [phone]

Fax: [phone]A. Bozzao L.M. Fantozzi

UOC Neuroradiology,

Department of Diagnostic Sciences,

SantAndrea Hospital,

II School of Medical Sciences,

University La Sapienza,

Rome, ItalyAbstract B.D. is a 48-year-old professional woman. She has been suffering for migraine since she was 28,

but she did not have serious problems until last year, when headache

episodes became more frequent and

it was necessary an admission to

emergency room. At the beginning,

the events were about 6 per month,

lasting from 2 to 4 days, beating and

of high intensity together with nausea, vomit, photo and phonophobia

and visual aura. Looking at the

anamnesis, we report a psychiatric

treatment since about ten years,

because of type II bipolar disorder.

In spite of the psychopharmacological treatment, as the patient came in

our Regional Headache Center, she

talked about 7 events with aura (scintillating scotomas, emianopsia) per

month, lasting 24 days with photoand phonophobia, nausea, crying crisis, anxiety. Although the neurological examination was normal, the sudden aggravation of pain symptomatology and the unresposiveness to

usual painkillers, suggested a cerebral CT and CT-angiography. CT and

CT-angiography discovered the presence of an aneurysm of the right

middle cerebral artery (MCA) of 4

mm diameter, with parietal irregularities. The patient was operated to

reduce the hemorrhagic risk, with a

positive result. One year after the

operation, the patient reports a

decrease of headache events with a

frequency of 2 per month, lasting

only a few hours, which she can now

solve with COXIB.Key words Migraine with aura Type

II bipolar disorder MCA aneurysmIntroductionThe primary target in migraine diagnosis is to identify the

main problem, i.e., the real origin of the pain. In many

cases, the patient does not seem to understand the complexity of the disorder; sometimes, the headache is so

troublesome, that it directly induces the patient to seek

help from the physician, probably resorting to emergency

room. This occurrence causes problems for the first aid

physician, who usually, to be prudent, sends the patient

for quite sophisticated diagnostic exams.According to the 2004 IHS classification, the headache

associated with cerebrovascular pathology (transient

ischaemia, cerebrovascular pathology, ischaemic stroke)

is included in the secondary class. A pre-existent headache

aggravation should be considered together with the evolution of clinical conditions.Headache may occur suddenly or gradually, usually

remaining unilateral, well located, with a low or moderate94intensity, and sometimes becoming a disabling pain in

many patients.Although aneurysms remain clinically silent until the

breaking moment, sometimes they cause clear symptomatology, which should not be underestimated for obtaining

an early correct diagnosis [1].In addition to the cranial nerves deficit, deriving from

the deformitys compression on that nerve, and from the

vascular problems, headache is often referred to as a prebreaking symptom [2].The headache can occur as a long-lasting and sometimes beating dull pain, or it could assume more tensive

characteristics. Pain location can be different: unilateral,

bilateral, diffused, sometimes in peri-retro-orbital region,

not according to the aneurysms position.The co-occurrence relief is very important for the

treatment: for example, in the treatment of migraine, as in

our clinical case, a concomitant mental disorder can make

some therapeutical opportunities preferable, but, on the

other hand, it can also be restrictive. Psychiatric co-occurrence shows a more serious clinical symptomatology, a

tendency to chronicity and a lower response to pharmacological treatment. It is clear that anxiety and mood trouble

represent typical characteristics of the migrainous personality. Recent trials show a high incidence of major depression associated with anxiety in migraine patients.The concomitance of several diseases can complicate

the diagnosis, therefore it is important for the physician to

pay attention, in order to correctly diagnose all the different components of a specific clinical disease. During the

anamnesis, an accurate medical and neurological examination is important in order to have a wide and almost

complete vision of the clinical case.Only in cases of sudden symptomatology variation and

the appearance of neurological signs is a diagnostic instrumental examination mandatory [3].Table 1 Clinical profileBeginning age 28 yearsEvent duration 24 daysEvent frequency 12/monthPain location Front orbital, topPain type BeatingPain intensity Very severeAggravation in physical activity YesClinical caseB.D. is a 48-year-old professional woman. She has been

suffering from migraine since she was 28, but she did not

have serious problems until last year, when headache

episodes became more frequent and an admission to emergency room was necessary.At the beginning, the events were about 6 each month,

lasting at most 2 days, with quite a low intensity, but during the last year they became nearly 12 each month, lasting from 2 to 4 days, beating and of high intensity together with nausea, vomiting, photo- and phonophobia, and

visual aura. Because of this symptomatology, the patient

had to refer to emergency room many times (Table 1).Looking at her anamnestic family history, we observed

that her father is affected by headache, while her mother

is affected by an ischaemic cardiopathy and arterial hypertension. From the pathologic anamnesis we could deduce

that the patient has been in treatment in a psychiatric centre for about 10 years, because of type II bipolar disorder

with lithiocarbonatum, paroxetine, lorazepam and

amitriptyline. At the beginning of the pathology, she was

screened with brain RMN; the result was negative.From previous first aid exams and other neurological

visits we could not find any significant result for secondary

pathologies, but they showed a psychiatric co-occurrence.In spite of the psychopharmacological treatment, when

the patient came to our Regional Headache Center, she

talked about 7 events with aura (shining scotomas, hemianopia) in a month, lasting 24 days with photo- and phonophobia, nausea, crying crisis and anxiety. This symptomatology induced us to evaluate the possibility of an organic

origin of the headache, hence of its secondary nature [4].A middle-grade hypertension emerged during a clinical examination, confirmed by a pressure holter exam. We

did not find anything abnormal in the neurological exam.

A CT and CT-angiography discovered the presence of an

aneurysm of the MCA (Fig. 1 and Table 2).Fig. 1 Aneurysm of 4 mm in diameter located at the level of the

right middle cerebral artery bifurcation95Table 2 Diagnostic profileClinical exam A.P. 165/110, c.f. 72 b/mNeurological exam NegativeNMR hypophysis and brain Presence of hypophisary microadenoma, small gliotic aspecific focusCerebral angio NMR Presence of local aneurysmatic dilatations of 4 mm diameter near the

middle right cerebral artery bifurcationCT Aneurysm at the middle right cerebral arteryCerebral CT-angiography It confirms presence of an aneurysm

of middle right cerebral arteryCommentB.D. described a migraine with aura. The increase of her

symptomatology and of the frequency of events led her to

go more often to her physician. The psychiatric co-occurrence induced the physician to treat the bipolar disorder,

avoiding the migraine symptomatology.ConclusionsWe can say that anamnesis, medical and neurological

exams are definitely necessary to correctly diagnose

headache. In this case, we considered it useful to suggest

a cerebral CT-angiography, because an apparently tensive

headache, with nausea and vomiting and a sudden aggravation of symptomatology were not clear enough to confirm the previous diagnosis. In fact, this aggravation was

the predictive sign of a cerebral lesion.The importance of CT or NMR with the study of both

cerebral and extra-cerebral arteries and veins in those

headaches which show clinical changes from the previous

situation, is now clear [12].Migraine is one of the most interesting clinical

pathologies, because headache is the most frequent symptom and, at the same time, it could be the warning of an

aneurysmatic break. In the small amount of time available

in emergency room, it seems impossible to diagnose a

headache, so it could be useful to improve co-operation

between headache specialists and emergency room.In that way, it could be easier to send patients, who usually resort to emergency room, to a headache centre so as

to reduce costs and to have more comfortable conditions

for a suitable visit. The patient will be more at ease and

there will surely be less confusion taking the anamnestic

history.Fig. 2 CT after surgical intervention shows a reduction of MCA

aneurismIn migraine this occurrence is considered a confounding factor for a potential diagnostic delay [5, 6].Despite the fact that the aneurysm diameter was inferior in respect to the dimensions indicated in the guidelines, its complex morphology with parietal irregularities

placed it, in both our experience and in the literature,

among the aneurysms with breaking risk [711]. The

patient was operated to reduce the aneurysmatic sack,

with a positive result (Fig. 2).Eighteen months after the operation, the patient still registers headache, but events have decreased, with a frequency of 2 per month, lasting a few hours, which she truncates

with COXIB. She also takes carbolithium and paroxetine.96References1. Pico F, Biousse V, Chapot R, Bousser

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