Episodic migraine associated with postural orthostatic tachycardia syndrome and vasovagal syncope: migraine triggers neuromediated syncope

Abstract

Migraine is a common episodic headache disorder characterized by attacks consisting of various combinations of headache, neurologic, gastrointestinal and autonomic symptoms. Autonomic symptoms, such as a cold feeling, increased urination, anorexia, diarrhea, constipation and fluid retention 1 , can occur during the premonitory phase, and nausea, vomiting, diarrhea, cutaneous vasoconstriction (pallor), vasodilation (flushing), piloerection and diaphoresis can occur during the pain phase 2 . Migraine patients with accompanying autonomic symptoms seem to experience their pain more unilateral and more severe than non autonomic migraine patients. Studies of autonomic nervous system dysfunction in migraine have been performed 2 . Cardiovascular tests, vasomotor reactions to temperature changes and responses to pharmacological tests, and changes in biochemical parameters suggest abnormalities (hypo-or hyperfunctioning) of both the sympathetic and parasympathetic nervous systems 2 . These inconsistent findings may be explained by different types of autonomic dysregulation. Syncope and migraine are both highly prevalent in the general population 3 . Both disorders occur together more frequently than chance would predict 3 , i.e., they are comorbid. Studies using the orthostatic (tilt) test suggest that migraine patients have vagal hyperactivity and α-sympathetic system hypoactivity 2 . Migraineurs may have a genetic predisposition leading to autonomic nervous system (ANS) dysfunction. The link between migraine and abnormal ANS function is unclear. ANS dysfunction may be involved in both increased susceptibility to migraine headaches and increased response to triggers. Migraine patients with typical autonomic symptoms, such as postural orthostatic tachycardia syndrome (POTS) and vasovagal syncope (VS), as well as patients with migraine with prolonged aura, are potential candidates for genetic studies 4 . Mitochondrial dysfunction may play a role in migraine pathophysiology 4-6 . It is not known whether the mitochondrion (encoded by the nuclear and mitochondrial genomes) is the primary site of the dysfunction, or whether the mitochondrial disturbance occur secondary to another cause 6 . Mitochondria may play a role in the genesis of migraine, especially in these groups (migraine plus autonomic symptoms) 4,5 . Connecting networks exist between pain and autonomic functions in the brain (Fig 1); thus pain can produce autonomic symptoms.We describe a group of patients in whom autonomic symptoms (POTS and VS) occurred only during migraine attacks. We also studied the presence of the mitochondrial DNA (mtDNA) A3243G 5 point mutation, common in patients with mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes (MELAS). METHODSix patients with migraine attacks associated with postural orthostatic tachycardia syndrome followed by vasovagal syncope (4 females aged 28.05±8.21 years and 2 males aged 31.21±5 years) were selected from our migraine patient group (n= 3215). Only patients who had more than 20 perce...

Caught in the thickness of brain fog: exploring the cognitive symptoms of Chronic Fatigue Syndrome

“…Typical symptoms of OI that occur include dizziness, neurocognitive impairment, tremulousness, nausea, and long-term fatigue (Schondorf and Freeman, 1999; Medow and Stewart, 2007). Some individuals with POTS experience migraine headaches (Piovesan et al, 2008). While standing upright, physiologic changes noted in POTS include increased diastolic BP and total peripheral resistance, decreased stroke volume, and impaired venoconstriction (Low et al, 1994).…”

A Case of Postural Orthostatic Tachycardia Syndrome Associated with Migraine and Fibromyalgia

“…The association between migraine, POTS and vasovagal syncope was found in 0.18% of migraine [1]. The link between migraine and autonomic dysfunction is not clear, which may be explained by an imbalance between the sympathetic and parasympathetic systems [1].…”

“…Postural orthostatic tachycarda syndrome (POTS) has been documented in migraine [1] and fibromyalgia [2], which is defined when the orthostatic symptoms are associated with a heart rate (HR) increment of more than 30 beats per minute (bpm) or a standing HR of 120 bpm or more in the absence of postural hypotension [3]. Fibromyalgia is a debilitating psychosomatic illness with widespread pain characterized by various combinations of neurologic and autonomic symptoms [4].…”

“…Fibromyalgia was diagnosed in migraine patients with frequencies between 22% and 40% [8]. There are sporadic reports of the autonomic nervous system dysfunction in migraine [1] and fibromyalgia [2,9]. We present a case with POTS associated with migraine and fibromyalgia.…”

Comorbid health conditions in women with syncope

“…Autonomic studies may reveal orthostatic hypotension and/or autonomic neuropathy [21]. Other reports suggest a higher prevalence of migraine, chronic fatigue syndrome, and interstitial cystitis in women [10,13,20,23,27,29]. These differences may be more evident in females during the reproductive age suggesting a hormonal mechanism [25].…”