In addition to acute and chronic forms of generalized post-traumatic headache, cranial trauma of almost any degree may precipitate a migraine in persons prone to the condition. A particularly troublesome variant occurs in a child or adolescent who, after a trivial or mild head injury, may lose vision, suffer severe headache or be plunged into a state of confusion, with belligerent and irrational behavior that lasts for hours or several days before clearing. The possible relationship to familial hemiplegic migraine and channelopathy has been mentioned earlier. In yet another variant, there is an abrupt onset of either one-sided paralysis or aphasia after virtually every minor head injury (we have seen this condition several times in college athletes) but without visual symptoms and little or no headache. Although a family history of migraine is frequent in such cases, there has been no history of hemiplegia in other family members. Of course, more treacherous conditions such as carotid artery dissection and subdural hematoma can simulate post-traumatic migraine.
This may present special difficulties in diagnosis, as a young child’s capacity for accurate description is limited. Instead of complaining of headache, the child appears limp and pale and complains of abdominal pain; vomiting is more frequent than in the adult, and there may be slight fever. Recurrent attacks were referred to in the past by pediatricians as the “periodic syndrome” as discussed in an earlier section. Another variant in the child is episodic vertigo and staggering (paroxysmal disequilibrium) followed by headache, probably a type of basilar migraine (see Watson and Steele). Also, there are puzzling patients with bouts of fever or transient disturbances in mood (“psychic equivalents”) and abdominal pain (abdominal migraine), that had been attributed to migraine.
Infants and young children may have attacks of hemiplegia (without headache), first on one side then the other, every few weeks. Recovery is usually complete, and arteriography in one child, after more than 70 attacks, was normal. Alternating hemiplegia of childhood may terminate in a dystonic state. There is probably a relationship of this condition to familial hemiplegic migraine (see earlier). One advantage of considering such attacks as migrainous is that it may protect some patients from repeated diagnostic procedures and surgical intervention; but, by the same token, it may delay appropriate investigation and treatment.
There are many causes of headache during pregnancy, as discussed further on, but among the most frequent and important is migraine. During pregnancy, migraines tend to abate, although there are notable exceptions, especially in the third trimester. It is not unusual to hear reports of auras dissociated from headache during pregnancy but, a marked change of headache pattern during pregnancy should lead to consideration of alternative diagnoses such as toxemia or cerebral venous sinus thrombosis. Nevertheless, migraine may make its first appearance during pregnancy, particularly in the first trimester. The causes of headache in a single-center study of pregnant women are given by Robbins and colleagues as detailed further on, who emphasize that migraine remains the most common, followed by a number of hypertensive disorders.
The treatment of migraine during pregnancy presents special issues that are discussed further on.
Transient Ischemic Attacks and Stroke With Migraine (See Also Chap. 33.)
Migraine complicated by stroke Rarely, migrainous neurologic symptoms, instead of being transitory, leave a prolonged or even permanent deficit (e.g., homonymous hemianopia), indicative of an ischemic stroke. A small number of these are attributed to migrainous infarction rather than being attributable to conventional mechanisms of stroke. Platelet aggregation, edema of the arterial wall, increased coagulability, dehydration from vomiting, and intense, prolonged spasms of vessels have all been implicated (on rather uncertain grounds) in the pathogenesis of arterial occlusion and strokes that complicate migraine (Rascol et al).