Neurol Sci DOI 10.1007/s10072-013-1625-0
LETTER TO THE EDITOR
Temporal intermittent rhythmic delta activity and abdominal migraine Yosuke Kakisaka • Kazutaka Jin • Kazuhiro Kato Masaki Iwasaki • Nobukazu Nakasato
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Received: 17 October 2013 / Accepted: 27 December 2013 Ó Springer-Verlag Italia 2014
Dear Editor, Abdominal migraine is regarded as one of the migraineequivalent syndromes of childhood, as episodes of stomach pain are known to alternate with the occurrence of migraine headache in adults [1]. We present a 34-year-old female, with a positive family history of migraine in her sister and grandmother, who was referred to our department to evaluate her recurrent severe, epigastric, and cramping abdominal pain, which could be triggered by mental stress, persisting from the age of 9 with a current frequency of once per month. The pain appeared a few hours after sleeping, lasted from 1–6 h, and always remitted spontaneously without intervention. Her conscious was always preserved during the episode. Medical investigations including gastrointestinal evaluation performed between attacks showed no abnormality. Repeated short-term EEG showed temporal intermittent rhythmic delta activity (TIRDA) in the left hemisphere without obvious spikes, hence temporal lobe epilepsy was diagnosed. Throbbing headaches of severe intensity lateralized Y. Kakisaka (&) K. Jin N. Nakasato Department of Epileptology, Tohoku University School of Medicine, Seiryo-machi 2, Aoba-ku, Sendai 980-8575, Japan e-mail:
[email protected] Y. Kakisaka Department of Pediatrics, Tohoku University School of Medicine, Sendai, Japan K. Kato Department of Neurology, Tohoku University School of Medicine, Sendai, Japan M. Iwasaki Department of Neurosurgery, Tohoku University School of Medicine, Sendai, Japan
to the right temporal region appeared from the age of 24 years, which could last for several days at maximum with a current frequency of once per month. The headache was so severe that she could not engage in social activity. She reported photophobia and phonophobia during headache episodes, but no obvious scotoma. Detailed questioning revealed that photophobia and phonophobia as well as sensory aura involving the extremities had also occurred during her abdominal pain episodes. Neurological examinations performed between the attacks showed no abnormalities, blood and urine tests were within normal limits, and brain magnetic resonance image (MRI) excluded the presence of lesions. Fluorodeoxyglucose positron emission tomography (PET) also found no abnormalities. Long-term EEG detected TIRDA predominantly in the left hemisphere, as found by the previous EEG, with rare TIRDA in the right hemisphere, and generalized intermittent rhythmic slow waves. No obvious spikes were detected. The final diagnosis was abdominal migraine and migraine with aura based on the diagnostic criteria of the International Classification of Headache Disorder II [2]. Under this diagnosis, she was told to take sumatriptan (50 mg) tablet at the prodrome of the abdominal pain episodes, which successfully controlled the attack [3]. Episodes of abdominal pain and headache were improved with prophylactic medication of valproic acid 400 mg/day and lomerizine 10 mg/day. The present case identified a rare abdominal symptom of migraine-related conditions in an adult, and also challenges the conventional clinical understanding of TIRDA. TIRDA is generally believed to represent the presence of temporal lobe epilepsy, although the epileptiform nature of this pattern is still unclear [4]. Focal or generalized slowing in EEG is reported to appear in migraine patients, although the mechanisms and significance are unknown [5]. Based
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on our experience and previous reports, we propose that TIRDA could also reflect some migraine-related conditions such as transient cortical dysfunction. We also propose that TIRDA should be cautiously interpreted, especially if clinical features cannot be clearly explained as manifestations of epilepsy. The mechanism causing TIRDA in patients with epilepsy and migraine may be clarified with more experience. The diagnosis requires careful attention to the neurological features associated with abdominal pain [6]. In our case, specific inquiries about the neurological features clarified that her abdominal pain episodes could be evoked by mental stress, and were associated with sensory aura and hypersensitivity to light and sound. Physicians should ask detailed questions about the patient’s pathophysiology to establish the diagnosis, especially if the patient does not appreciate the possible relationship between the main presenting symptom and any under-recognized associated symptoms, which may offer the key for the correct diagnosis [7]. Conflict of interest
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Nothing to declare.
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