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NEUROSURGICAL ANESTHESIOLOGY

Migraine with Atypical Aura in the Recovery Room: A Sometimes Complicated Diagnosis!

Antoine Pianezza, MD^*, Romain Barthélémy, MD^*, Vincent Minville, MD^*, Frédérique Martin, MD^*, and Michel Faggianelli, MD

From the *Department of Anesthesiology and Intensive Care, University Hospital of Toulouse, University Paul Sabatier, Toulouse, France; and Department of Anesthesiology and Intensive Care, Hospital of Rodez, Rodez, France.

Address correspondence and reprint requests to Dr. Antoine Pianezza, Department of Anesthesiology and Intensive Care, University Hospital of Toulouse, Rangueil Hospital, Orthopedic section, Toulouse, France. Address e-mail to a.pianezza{at}wanadoo.fr.

Abstract

Migraine is a frequent neurological pathology. However, the diagnosis can be difficult to establish, especially when it is accompanied with an atypical aura that can be confounded with a stroke. We describe a case of 38-yr-old patient who presented just after general anesthesia with a perioperative acute migraine with atypical aura which was wrongly treated as a serious cerebral stroke. The patient had not mentioned migraine in her history before the surgery. This lack of information led to unnecessary therapy.

Migraine is a common neurological condition. Its pathophysiology has not yet been fully elucidated and it can be divided into two subtypes: migraine with aura and migraine without aura. Migraine with aura is accompanied by variable nonconstant neurological signs that can also appear in variable chronological order. It can therefore be a very difficult condition to diagnose. Indeed, it can be confused with a cerebral stroke and lead to unsuitable therapy as happened in the following case.

CASE DESCRIPTION

We report on the case of a 38-yr-old woman who presented for total abdominal hysterectomy for a voluminous fibromyoma. Her only medical history was of hypothyroidism treated by L-thyroxine. General anesthesia was performed with propofol (3 mg/kg), sufentanil (0.3 µg/kg), and cisatracurium (0.15 mg/kg). After tracheal intubation, anesthesia was maintained with sevoflurane and nitrous oxide in oxygen (50%/50%). The intervention lasted 90 min and was uneventful. Analgesia was provided with IV paracetamol, ketoprofen, and 8 mg of morphine administered before the end of the procedure. The patient was woken-up and tracheally extubated at the end of surgery and brought to the recovery room. She stayed there for 120 min and had a satisfying clinical course and vital observations. She was given a supplementary titration of 10 mg of IV morphine for analgesia and 4 mg of ondansetron for postoperative nausea.

Just before being transferred to her room, she had a sudden decrease in consciousness with deviation of her eyes to the right. There was no obvious sign of a seizure. Her arterial blood pressure was 151/67 with a heart rate of 99 bpm. Bradypnoea and desaturation to 85% occurred and the anesthesiologist decided to tracheally intubate and ventilate her lungs. She received a bolus of propofol of 150 mg, followed by a continuous infusion at 15 mg · kg^–1 · h^–1. Emergency cerebral and thoracic computed tomography scans were performed to exclude a stroke and a pulmonary embolism and were negative. Her glucose level, serum electrolytes, and muscle enzymes were also normal. With all investigations negative, sedation was discontinued. The patient was then tracheally extubated after she had regained spontaneous ventilation and a suitable level of consciousness. Neurological examination postextubation was normal with no confusion and no localizing signs. On further questioning, the patient admitted that she had experienced similar episodes of loss of consciousness over the past 2 yr. They had been accompanied by headaches and occurred especially during the premenstrual period. She had however never been examined by a neurologist, and to her knowledge, no member of her family suffered with migraine. Thirty minutes later, her neurological symptoms recurred. She was aphasic and her eyes were deviated to the right side but she was able to follow simple commands. A neurologic deficit of the left upper limb was noted, but no convulsion was observed. Her blood pressure was 140/58 with a heart rate of 90/bpm. Her respiratory frequency was frequent (24/min), but there was no desaturation. No therapeutic measures were initiated at that time, and after 10 min of observation, she recovered her neurological functions and her ability to speak. She complained then of hemicranial headache associated with photophobia, but had neither nausea nor visual disturbances. The symptoms were fully reversible and the patient was transferred to intensive care for observation where she had no further episodes. An electroencephalogram performed the next day showed no abnormalities. Neurological opinion was sought and the final diagnosis was migraine with atypical aura.

DISCUSSION

This case report illustrates the difficulty of establishing a perioperative diagnosis of acute migraine and in taking appropriate action. The physiopathology of migraine is complex. It involves genetic origins,1 hormonal changes,2 abnormalities of glutamate metabolism, and abnormal platelet function.3 The migraine’s origin can be primary (genetic cause1) or secondary to neurological pathologies.4 Migraine attacks can be spontaneous or provoked by stress, drugs, or by extensive sensory stimulations.5 Women are more frequently affected, especially between 25- and 35-yr-of-age. Establishing the diagnosis does not require specific morphological examinations unless a secondary origin is suspected or to eliminate a differential diagnosis.

In our patient, the diagnosis of migraine with aura was difficult to establish because she did not mention her neurological symptoms history before surgery. Moreover, when faced with postoperative altered consciousness, the priority is to exclude urgent treatable pathologies.

The International Headache Society reviewed the criteria defining migraine.6 It is a clinical diagnosis involving headache, vomiting, and neurological signs (Table 1). The aura is most frequently visual (scintillating scotoma or obscuration7,8) but it can also occasionally be a neurological deficit, vertigo, paresthesia, or aphasia. Thus, the aura can mimic a neurological stroke or a partial seizure.9 Aura and headache are always associated in migraine with aura, even though they can be dissociated in time. The aura can even appear before the headache, as happened in our patient.

In our case, the aura was atypical and was not initially accompanied by a headache, which complicated the diagnostic approach. It is therefore understandable that the anesthesiologist who assessed her initially thought to exclude a stroke and ordered an emergency computed tomography scan. One could speculate that the headache occurred during the scanning, while the patient was sedated. The addition of some form of angiography may have further assisted in excluding a stroke and in making a diagnosis of migraine. However, migraine was finally diagnosed on the basis of negative investigations and a retrospective history of the patient’s migraine. Indeed, the patient remembered past similar episodes, corresponding with the International Headache Society’s criteria.

The perioperative period can predispose patients to migraine episodes because of stress, mental tension, and bright lights.5 Some authors also suggest the possibility of a relationship between general anesthesia10 or opioids11 with migraine attacks. When the medical history of migraine is known by the anesthesiologist, the occurrence of symptoms can be more easily controlled and prevented. A few cases of postoperative hemiplegic migraines have been reported in the literature,12 and illustrate, like our case report, the difficulty of diagnosing a postoperative migraine with atypical aura, especially when the patient’s preexisting migraine history is not known. Thorough knowledge of a patient’s medical history before surgical interventions is a major factor in performing suitable anesthesia and postoperative care.

What was unusual in our patient was the bradypnea with desaturation. An overdosage of opioids might have been responsible or contributory although the occurrence of apneac spells with migraine attacks has been reported.13

We wonder if the anesthesiologist’s examination, with a more accurate neurological examination at the time, would have shown an appropriate response to command in the nondeficient upper limb and could have saved the patient a second tracheal intubation. However, we assume the neurological status was difficult to evaluate because of recent anesthesia and residual effects of the narcotics, which certainly decreased the level of consciousness.

In conclusion, migraine with aura, especially when the aura is atypical, can be difficult to diagnose. It is essential to identify this condition before a surgical intervention is planned. This allows the exclusion of more sinister differential diagnoses. As the perioperative period is conducive to migraine episodes,5 it also allows for careful planning of the conduct of anesthesia and postoperative care. Finally, it is also important to keep in mind that migraine, especially with aura,14 is considered a risk factor for vascular stroke.15

Footnotes

Accepted for publication January 25, 2008.

REFERENCES

1. Montagna P. The physiopathology of migraine: the contribution of genetics. Neurol Sci 2004;25(suppl 3):S93–S96[Web of Science][Medline]
2. Cupini LM, Matteis M, Troisi E, Calabresi P, Bernardi G, Silvestrini M. Sex-hormone related events in migrainous females. A clinical comparative study between migraine with aura and migraine without aura. Cephalalgia 1995;15:140–4[Web of Science][Medline]
3. D’Andrea G, Granella F, Leone M, Perini F, Farruggio A, Bussone G. Abnormal platelet trace amine profiles in migraine with and without aura. Cephalalgia 2006;26:968–72[Web of Science][Medline]
4. Gabrielli M, Gasbarrini A, Fiore G, Santarelli L, Padalino C, De Martini D, Giacovazzo M, Pola P. Resolution of migraine with aura after successful treatment of a pituitary microadenoma. Cephalalgia 2002;22:149–50[Free Full Text]
5. Ulrich V, Olesen J, Gervil M, Russell MB. Possible risk factors and precipitants for migraine with aura in discordant twinpairs: a population-based study. Cephalalgia 2000;20:821–5[Web of Science][Medline]
6. International Headache Society: The International Classification of Headache Disorders. 2nd ed. Oxford: Blackwell Publishing, 2003
7. Sjaastad O, Bakketeig LS, Petersen HC. Migraine with aura: visual disturbances and interrelationship with the pain phase. Vaga study of headache epidemiology. J Headache Pain 2006;7:127–35[Medline]
8. Solomon S. Migraine diagnosis and clinical symptomatology. Headache 1994;34:S8–S12[Web of Science][Medline]
9. Schoenen J, Sandor PS. Headache with focal neurological signs or symptoms: a complicated differential diagnosis. Lancet Neurol 2004;3:237–45[Web of Science][Medline]
10. Thurlow JA. Hemiplegia following general anaesthesia: an unusual presentation of migraine. Eur J Anaesthesiol 1998;15:610–2[Web of Science][Medline]
11. Gil-Gouveia R, Wilkinson PA, Kaube H. Severe hemiplegic migraine attack precipited by fentanyl sedation for oesophagogastroscopy. Neurology 2004;63:2446–7[Free Full Text]
12. Lin L, Adey C. Presentation of hemiplegic migraine–hemiplegia and hemi-sensory loss following general anaesthesia. Anaesth Intensive Care 2007;35:418–22[Web of Science][Medline]
13. Willson J, Kapur S. Apnoeic spells following general anaesthesia in a patient with familial hemiplegic migraine. Anaesthesia 2007;62:956–8[Web of Science][Medline]
14. Kurth T, Slomke MA, Kase CS, Cook NR, Lee IM, Gaziano JM, Diener HC, Buring JE. Migraine, headache, and the risk of stroke in women: a prospective study. Neurology 2005;64: 1020–6[Abstract/Free Full Text]
15. Agostini E, Aliprandi A. The complications of migraine with aura. Neurol Sci 2006;27(suppl 2):S91–S95[Web of Science][Medline]

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