Migraines, Malformations and More

Migraines, malformations and more….

 

 

There is a lot of new information coming out about Migraine headaches.  Much of this information has to do with the mechanism of migraine and the occurrence of migraine.  There is still not clear answers to these questions but the research is ongoing.  We are hoping that some of the information about migraines will help us better understand the migraines that children with PHACE often experience. 

 

 

Summary of information:

 

Migraines

 

• Migraine headaches have a female predominance with a peak occurring in the 30’s and 40’s.  Migraines can be divided into two major groups: migraine with aura and migraine without aura.  Migraine without aura is the most common type of migraine headache.  In both groups the headacahes are unilateral, moderate in intensisty, often pulsate, aggravate with routine physical activity, associated with nausea, photophobia and or phono-phobia.  Each migraine lasts from 4-72 hours.  Migraine with aura occurs in 37% of the women with reported migraine.  This type of migraine is associated by the presence of a neurological symptom that develops over 5-20 minutes and lasts for less then 60 minutes.  The aura precedes the headache in most cases.

 

• The most widely accepted mechanism for the development of migraine headache with aura is excitability of the neuronoal cells membranes of the occipital cortex of the brain.  The excitation spreads through the cortex leading to activation of the trigeminal nerve pathway causing pain. 

 

• In the absence of aura the mechanism of migraine pain is debated.  The main area of dispute is whether the migraine pain originates from the activation of the trigeminal nerve pathway due to a release in vasoactive chemicals from blood vessels or does this originate in the center of the trigeminal pathway in the brainstem.  Regardless of the origination pathway of the migraine the underlying cause appeases to be due to dilation of the large cranial vessels beneath the surface of the brain, (dura mater).  These vessels are interwoven in the trigeminal pathway.  Research has identified several vasoactive peptides in the trigeminal nerve cells including calcitonin gene related peptide, (CGRP).  This peptide seems to be the most important identified peptide in the development of a migraine headache.

 

 

• Pregnancy has a variable effect on both the intensity and the frequency of migraine without aura headaches.  A literature search shows that most women seem to have either some improvement or no change in migraine during pregnancy.  No data can be found establishing and objective set of criteria that will predict which patients will see improved symptoms of migraine and which patients will see no improvement.  Women with migraine with aura headaches are less likely to see improvement of symptoms during pregnancy. 

 

• Ovulation also seems to have an effect on migraine occurrence.  In one study reported in the literature women with history of migraine, undergoing induced ovulation had a higher incidence of headaches then those without history of migraine.  During ovulation levels of estrogen fluctuate.  Similarly in the perimenopausla state estrogen levels fluctuate.  The observation that migraine attacks increase during the 30’s – 40’s supports the suggestion that fluctuations and abrupt changes in estrogen levels triggers migraine headaches.

 

 

• Migraines headaches do not seem to directly affect the outcome of pregnancy.  There are no outcome studies that report an increase in the preterm labor, low birth weights or congenital anomalies.  There is a noted indirect effect.  Patients with migraine headaches have a higher risk of developing pre-eclampsia then those without migraine.  Migraines that develop during pregnancy or delivery must be evaluated and considered for other complications associated with headache such as pre-ecalmapsia and post-epidural headache.

 

 

• At the 14^th International Headache Congress it was reported that abdominal migraine represents %15 of gastrointestinal pain in the pediatric population.  If you track children with gastrointestinal migraine a significant number of these children will go on to have migraine headaches later in life.  Abdominal migraine is characterized by episodes of moderate to severe midline, periumbilical, or poorly localized pain lasting for 1 to 72 hours with nausea, anorexia, pallor, and occasionally headache. “But headache is not one of the cardinal features. It’s episodes of belly pain,” reports Dr. Donald Lewis Professor of Pediatrics Eastern Virginia Medical School.  In a retrospective study it was found that there is a large subset of children who have had a vague diagnosis of GI pain who most likely have abdominal migraine.  Making the correct diagnosis says Dr. Lewis, “ means the spectrum of migraine medications will become available to children.” 

 

Rare Vascular Tumors

 

• Verrucous hemangioma is an uncommon, localized vascular malformation associated with reactive epidermal acanthosis, papillomatosis and hyperkeratosis on histological examination.^[1] The lesions are bluish-red, well demarcated, soft, and compressible. In time, verrucous hemangiomas gradually enlarge and satellite nodules may arise. 

 

• It as a congenital vascular malformation comprising a capillary or cavernous hemangioma in the dermis and subcutaneous tissue associated with reactive epidermal acanthosis, papillomatosis, and hyperkeratosis, distinguishing it from angiokeratoma.^[4]

 

• Most verrucous hemangiomas are located on the lower extremities and involvement is generally unilateral. Lesions have usually been present since birth or have occurred in early childhood, although they may appear later or even in adult life.

 

• Verrucous hemangiomas do not resolve spontaneously and have a tendency to relapse. Early diagnosis is important to get a better cosmetic result. Verrucous hemangioma requires a large, deep excision. Incomplete excision leads to recurrence because of deeper components. Cryosurgery, electrocautery, and laser therapy can be used for smaller lesions.  It must be confirmed by histopathological examination.

 

 

Treatment:

 

• A recent published report in Pediatrics supports the opinion that Propranolol is a safe and effective treatment for severe infantile hemangioma.  Use of propranolol can markedly shorten the disease course according to the small study published in the September 2009 issue of Pediatrics. Authors of the study note that within a few hours of treatment with the beta-blocker Propranolol the color of the hemangioma lightens and the growth is reduced.  The authors conclude that if the results are confirmed by a large comparative study, propranolol could be come the first line treatment for infantile hemangioma.

NOVA provides this information as a resource.  It is not intended to engage in the practice of medicine or to replace the physician.  NOVA does not claim to have medical knowlege.  NOVA does not endorse any particular physician, treating facility or treatment protocol.  In all cases NOVA, the NOVA Board of Directors and associates recommends that you seek the opinion of a physician experienced in the diagnosis and treatment of hemangioma and vascular malformations.