Sudden Onset of Vestibular Migraine Complicated with BPPV and Mal de Debarquement Syndrome – a Diagnostic Dilemma

Vestibular migraine is combination of migraine and vestibular symptoms. In clinical examination it can be replaced with benign paroxysmal positional vertigo (BPPV) cupulolithiasis, but also BPPV is common comorbidity in migraine patients. There is also high association between vestibular migraine and Mal de Debarquement syndrome. Patient came to hospital with vertigo that was diagnosed as left PC-BPPV canalolithiasis. After first Epley's maneuver symptoms didn't resolved. Week after, at second Epley's maneuver performed patient developed left PC-BPPV cupulolithiasis. Month after, at third Epley's maneuver BPPV resolved but patient developed Mal de Debarquement syndrome. Laboratory testing showed hyperhomocisteinemia and homozygous MTHFR C677T and PAI, with low vitamin D. After reviewing the vestibular symptoms in the first attack which was misdiagnosed as BPPV canalolithiasis, and history of migraine, patient was diagnosed with vestibular migraine. Patient well responded to migraine diet and supplementation with B complex. Vestibular disorders are similar to each other and they can overlap. More attention in taking detailed medical history should be given to patients with vertigo or dizziness.

The Psychiatric Symptomology of Visual Snow Syndrome

Objective: To characterise the psychiatric symptoms of visual snow syndrome (VSS), and determine their relationship to quality of life and severity of visual symptoms.Methods: One hundred twenty-five patients with VSS completed a battery of questionnaires assessing depression/anxiety, dissociative experiences (depersonalisation), sleep quality, fatigue, and quality of life, as well as a structured clinical interview about their visual and sensory symptoms.Results: VSS patients showed high rates of anxiety and depression, depersonalisation, fatigue, and poor sleep, which significantly impacted quality of life. Further, psychiatric symptoms, particularly depersonalisation, were related to increased severity of visual symptoms. The severity/frequency of psychiatric symptoms did not differ significantly due to the presence of migraine, patient sex, or timing of VSS onset (lifelong vs. later onset).Conclusion: Psychiatric symptoms are highly prevalent in patients with VSS and are associated with increased visual symptom severity and reduced quality of life. Importantly, patients with lifelong VSS reported lower levels of distress and milder self-ratings of visual symptoms compared to patients with a later onset, while being equally likely to experience psychiatric symptoms. This suggests that the psychiatric symptoms of VSS are not solely due to distress caused by visual symptoms. While no consistently effective treatments are available for the visual symptomology of VSS, psychiatric symptoms offer an avenue of treatment that is likely to significantly improve patient quality of life and ability to cope with visual symptoms.

Extreme ecchymoses in a migraine patient using concomitant treatment with calcitonin gene-related peptide receptor antibodies and fish oil supplements: a case report

Background Erenumab, a monoclonal antibody against the calcitonin gene-related peptide (CGRP) receptor, is registered for migraine prevention. Compared to other conventional migraine prevention medicines (i.e. topiramate, betablockers and amitriptyline) erenumab has better tolerability. Impaired hemostasis has not been reported previously. Here, we report the first case of an increased tendency to bruise in a migraine patient treated with erenumab. Case presentation A 41-year old female migraine patient was treated with erenumab for 12 months, which led to a significant reduction of headache and migraine days. Three months after treatment start, she experienced increased tendency to bruise leading to extreme ecchymosis after 4 months treatment. Platelet counts and aggregation, thromboelastography, activated partial thromboplastin time (APTT) and international normalized ratio (INR) were all normal. Thorough interview revealed intake of fish oil supplements for many years prior to treatment. The increased tendency to bruise subsided after discontinuation of fish oil supplements. Conclusion The combination of fish oil supplements and erenumab may cause increased tendency to bruise. Erenumab has no effect on the platelets per se but may cause impaired wound healing by suppression of CGRP. Thus, small and unnoticeable bruises may be aggravated instead in patients with tendency to bruise caused by for instance fish oil supplements.

A pilot study of the feasibility of a Swedish multimodal group intervention for severe migraine—The migraine patient school

Objectives: To evaluate a multidisciplinary group intervention, the migraine patient school (MPS), for patients with severe, mostly chronic migraine. Method: A 13-week group intervention program including seven sessions of patient education, practical body awareness and relaxation exercises, and home assignments was performed in small groups with 5–11 participants. Four groups were consecutively included from spring 2014 to fall 2015. Headache diaries and standardized and study-specific questionnaires were used for evaluation at baseline before MPS (pre-interventional phase), and at follow-up. Results: Twenty-four of 30 included patients completed the study, i.e. attended ≥ four sessions. Most participants found it rewarding to participate in the MPS and easy to take part in, understand and complete home assignments. Validated standardized questionnaires delivered before, and after (follow-up) MPS showed that the impact on life (HIT-6) and avoidance behavior (PIPS-A) were significantly improved whereas quality of life (MSQL), anxiety and depression (HAD) and perceived stress (PSS-14) did not show a statistically significant change. Conclusion: The Migraine patient school with a multimodal educational and behavioral group intervention program was feasible to perform and seem to benefit patients with severe (high-frequency or chronic) migraine.

Differential Expression and Bioinformatic Analysis of the circRNA Expression in Migraine Patients

Background. CircRNAs are noncoding RNA molecules that have recently been described and shown to regulate miRNA functionality. While recent studies have suggested such circRNAs to be associated with pain related diseases in humans, no comprehensive migraine-related circRNA profiles have been generated, and there is currently no clear understanding of whether they can serve as regulators of migraine pathology. Methods. We initially conducted a circRNA microarray analysis of the plasma of migraine patients and healthy controls. Based upon these data, we then selected 8 differentially expressed circRNAs and confirmed their expression in more migraine patient plasma samples via real-time PCR. We then performed functional and pathway enrichment analyses. Lastly, using a robust rank aggregation approach, we constructed a ceRNA network according to predicted circRNA–miRNA and miRNA–mRNA pairs in these migraine patient samples. Results. We were able to detect 2039 circRNAs in our patient samples, with 794 of 1245 these circRNAs being up- and downregulated in migraine patients relative to controls, respectively ( fold change ≥ 1.5 , p < 0.01 ). A qRT-PCR analysis confirmed that the expression of hsa_circRNA_100236, hsa_circRNA_102413, and hsa_circRNA_000367 was significantly enhanced in migraine patients, whereas the expression of hsa_circRNA_103809, hsa_circRNA_103670, and hsa_circRNA_101833 was significantly reduced in these individuals relative to healthy controls. We found these differentially regulated circRNAs to be associated with numerous predicted biological processes, with enrichment analyses suggesting that they may modulate the PI3K-Akt signaling so as to promote inflammation to drive migraine development. However, further research will be needed to formally test these mechanistic possibilities and to validate these circRNAs as potential biomarkers of migraine patients. Conclusions. Our results offer new potential insights into the mechanistic basis of this condition and suggest that hsa_circRNA_000367 and hsa_circRNA_102413 may offer value as regulators of migraine pathology.