A Report of Cranial Autonomic Symptoms in Migraineurs

Abstract

The presence of cranial autonomic symptoms in migraine is well known and thought to represent activation of the trigeminal parasympathetic reflex pathway similar to trigeminal autonomic cephalalgias. However, studies regarding the prevalence of these symptoms are few. The characteristics of migraineurs with cranial autonomic symptoms and the association of cranial autonomic symptoms with laterality of headache have never been studied in a clinic population. Seventy-eight consecutive subjects with migraine were recruited from the Headache Clinic of the Department of Psychiatry after exclusion of subjects with secondary headache. Their demographic data and detailed history of headache were noted and leading questions were asked regarding cranial autonomic symptoms. chi(2) test and Fisher's exact test was used for categorical variables, whereas an independent sample t-test was applied on numerical data. Spearman's correlation was used for correlational analysis of categorical variables. Female subjects (78.2%) outnumbered males and the average duration of illness in the whole sample was 3.81 years. Migraine without aura (53.8%) was the commonest diagnosis, followed by migraine with aura (24.4%). Cranial autonomic symptoms were present in 73.1% of subjects and, commonly, they were ipsilateral to headache. Moreover, strictly unilateral cranial autonomic symptoms were reported by only 32% of patients. The anatomical side of headache did not affect the presence of autonomic symptoms. Those with or without autonomic symptoms did not differ with respect to gender, diagnosis, laterality of headache or associated symptoms except phonophobia, which was more common in subjects with autonomic symptoms (P = 0.05). Those with autonomic symptoms had longer duration of illness (P = 0.03) and longer headache episodes (P = 0.04). In addition, sleep was ineffective in relieving their headache (P = 0.02). Cranial autonomic symptoms are frequent in migraineurs and are common in subjects with long duration of illness and longer headache episodes. Clinical evidence in the present study suggests that subjects with cranial autonomic symptoms have a hyperactive efferent arm of trigeminal autonomic reflex. The connections of trigeminal nucleus with the locus coeruleus and dorsal raphe nucleus may account for the observed phenotypic differences between the two groups. Further research, however, is required to elucidate the underlying neural mechanisms of cranial autonomic symptoms in migraine.

Cranial autonomic symptoms in pediatric migraine are the rule, not the exception

“…Similarly, in adult studies, the majority of migraineurs with cranial autonomic symptoms express more than one symptom. [3][4][5] Age, sex, presence of aura, and having episodic vs chronic migraine did not predict likelihood of having cranial autonomic symptoms in this study. This is similar to adult studies wherein these variables were also not predictive.…”

“…[3][4][5][6] Recognizing that cranial autonomic symptoms are a common component of migraine is important diagnostically and thus therapeutically. Sinusitis, which also may present with head pain, is one of the most common misdiagnoses given to migraineurs.…”

“…In an adult study, strictly unilateral cranial autonomic symptoms were present in only 32% of adult migraineurs. 4 Similarly, in this pediatric study, only 23% of the cranial autonomic symptoms were strictly unilateral. This tendency for bilaterality may explain why studies that examined only for unilateral cranial autonomic symptoms in adult migraineurs reported a lower prevalence of cranial autonomic symptoms (26.9%-45.8% 3,5 ).…”

“…These figures are comparable to some studies in adults; for example, in one study, 73.1% of adult migraineurs had cranial autonomic symptoms. 4 Of note, in one study, 75% of adults migraineurs labeled as having sinus headache experienced cranial autonomic symptoms. 7 Moreover, in adult practice, such patients respond to treatment with sumatriptan.…”

Sphenopalatine ganglion neuromodulation in migraine: What is the rationale?

“…In addition to the diagnostic criteria specified by the International Headache Society (1), migraine can be associated with cranial autonomic symptoms (CAS) of lacrimation, conjunctival injection, eyelid edema, nasal congestion, and forehead/facial sweating (3,4) in 27% to 73% of cases depending on criteria and study design (3)(4)(5)(6). This correlation is not limited to adults but also includes migraineurs under the age of 18 years, with a recent study showing 62% of children and adolescents complaining of migraine-associated CAS (7).…”