Multiple sclerosis presenting initially with a worsening of migraine symptoms

Abstract

Multiple sclerosis (MS) is a chronic autoimmune disease that targets myelinated axons in the central nervous system. Headache has been reported as a subtle symptom of the onset of MS, with a variable frequency of 1.6-28.5%; however, it remains unclear whether headache is a true symptom of MS onset. Here, we report the case of a female patient who had a history of migraine without aura and experienced worsening of migraine-headache symptoms as the initial manifestation of MS. Three similar cases were reported previously; however, unlike this case, those cases had no history of migraine without aura. In our case, we excluded factors that could trigger migraine attacks, such as changes in weather, drugs, alcohol, caffeine withdrawal, stress, fatigue, lack of sleep, hormonal therapy, diet, and hunger. The patient had one episode of MS attack with the simultaneous presence of asymptomatic gadolinium-enhancing and non-enhancing lesions, including hyperintense lesions in the bilateral periventricular white matter, body of the corpus callosum, and periaqueductal grey matter, as observed on the T2-weighted images obtained at the first brain magnetic resonance imaging. In addition, after the injection of gadolinium contrast, ring enhancement over these lesions was noted in T1-weighted images, which was suggestive of active demyelination. MS was diagnosed according to the McDonald criteria (2010 revision). We conclude that MS with periaqueductal grey matter involvement may present with worsening migraine. It is important to be cautious if any secondary causes exist, especially when the patient has a history of migraine without aura. MS should be one of the differential diagnoses in young women showing a change in headache pattern or poor clinical drug response to migraine treatment accompanied by episodes of focal neurological deficit. Failure to recognize MS may lead to inappropriate treatment and worse prognosis; early diagnosis in patients with MS is essential to improve their clinical outcomes and quality of life.

Figure 1

Hyperintense lesions in the bilateral periventricular white matter (arrow), body of the corpus callosum (arrow), and periaqueductal grey matter (arrowhead) are noted on the T2-weighted image. After gadolinium contrast injection, ring enhancement over these lesions is noted on the T1-weighted image (curved arrows), which is suggestive of active demyelination. In the sagittal view, multiple sclerosis plaques with a typical perpendicular orientation at the callososeptal interface are noted (Dawson’s fingers) (black arrow).

Figure 2

Two months later, the hyperintense lesions located in the bilateral periventricular white matter (arrow), body of the corpus callosum (arrow), and right periaqueductal grey matter (arrowhead) were increased in number and size, as observed on T2-weighted images. After gadolinium contrast injection, more prominent ring and incomplete ring enhancement over these lesions is noted on the T1-weighted image (curved arrows). In the sagittal view, multiple sclerosis plaques with an increased number of Dawson’s fingers are noted (black arrow).

Figure 3

Low thoracic and lumbar spine MRI showing a hyperintense lesion in the spinal cord (T9 level), which is observable on the T2-weighted image (arrow). The lesion exhibits contrast enhancement after gadolinium injection (curved arrow).