Metamorphopsia associated with topiramate for migraine prevention

Abstract

pyramidal syndrome characterized by incomplete hemiparesis on the right hemibody. Myotatic exalted reflexes in the right hemibody and plantar-cutaneous reflex were indifferent. DiSCuSSionReviewing the relevant literature worldwide, Labrune syndrome was considered as a possible diagnosis for the present case 2 . Despite the presence of cysts, calcification, and edema of the white substance found in our patient, suggesting neurocysticercosis, equinecocosis 3 or neoplasia, there was no serologic or histopathologic confirmation.This syndrome is characterized by calcifications, leukodystrophy, and formation of parenchymal cysts 1 . Its onset can occur during childhood or adolescence, in an average of 12 years (7 months -59 years), but there was not one in adults in Brazil, with neurological signs such as cognitive decline, seizures and pyramidal, extrapyramidal or cerebellar signs 1,2 . Our patient, unlike the other cases reported in literature, presented its first neurological manifestation at the age of 24. CT and MRI seen in our case were similar to the cases reported in literature, showing increased signal intensity of the white matter on MRI (T2 and FLAIR), basal ganglia calcification, and development of cysts [1][2][3] .Labrune reported the results of histopathology with rearrangement involving the microvessels, whereas perivascular foci of calcifications, hyaline deposits, and formation of Rosenthal fibers seem to be compatible with this change 1 . The histopathological findings of our patient were consistent with LCC. According to them, the likely primary pathologic feature is a rearrangement involving the microvessels and the formation of Rosenthal fibers 1,4 .In conclusion, the etiology of LCC remains unknown. In spite of relatively characteristic findings in imaging and histopathological examination, there is no uniformity in the clinical findings noted in the published articles. It can be speculated that the later age of onset, normal intelligence and slow progression, like in our patient, may indicate the shape of this rare disease in adults. A 33-year-old woman (registration 70-247/ IPUB-UFRJ) has had recurring headaches since the age of 18. She described more right-sided than left-sided throbbing, which could be severe and associated with nausea, light and noise sensitivity, and vomiting. She has had a visual aura, seeing "zig-zags", lasting for 20 to 30 minutes before the headaches. The only preventive measure she had taken in the past was divalproex sodium, with good efficacy. Because of the weight gain as a side effect, she refused to take it again. Her body mass index (BMI) was 35.3. She was started on preventive therapy with topiramate at 25 mg daily for two weeks that was to be increased weekly

Should topiramate use be added to the differential diagnosis of visual illusions?

“…In conclusion, we believe that, along with other drugs, TPM use should be added to the differential diagnosis of visual illusions in migraineurs or non-migraineurs either. Nonetheless, we endorse the notion that the underlying migraine in a vast proportion of TPM consumers can substantially predispose them to these symptoms 1,3,4 .…”

“…It is important to underline that the authors reported a positive dechallenge test that corroborates a causal relationship between TPM and such an adverse effect 1,6 . Nevertheless, in their final conclusion on the etiology of such an association, they stated that "because it may occur in the aura of migraines, these visual illusions are likely to be a result of the migraine" 1 . Indeed, one of the leading TPM indications is prevention of migraine attacks and herein comes the uncertainty of whether illusions are linked to migraine or to TPM use.…”

“…In our very recent article, we have reviewed the wide range of TPM side effects on vision of 84 patients culled from the literature 2 . As far as we are aware in terms of TPM related visual illusions, five other cases [3][4][5] are described in the literature, and the authors of the above report have added the sixth one 1 . It is important to underline that the authors reported a positive dechallenge test that corroborates a causal relationship between TPM and such an adverse effect 1,6 .…”

“…As far as we are aware in terms of TPM related visual illusions, five other cases [3][4][5] are described in the literature, and the authors of the above report have added the sixth one 1 . It is important to underline that the authors reported a positive dechallenge test that corroborates a causal relationship between TPM and such an adverse effect 1,6 . Nevertheless, in their final conclusion on the etiology of such an association, they stated that "because it may occur in the aura of migraines, these visual illusions are likely to be a result of the migraine" 1 .…”

“…We read with great interest the recent paper by Cerqueira and Nardi 1 reporting the association of topiramate (TPM) use and visual illusion in a migraine patient. In our very recent article, we have reviewed the wide range of TPM side effects on vision of 84 patients culled from the literature 2 .…”