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Chronic Migraine.

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I'm a 25 year old female. I've been getting treatment for 2 years for Chronic Migraine. My doctor recently ordered a brain MRI (w/o contrast) due to some symptoms I've been having, which include painful muscle spasms in my back, neck, arms, and hands, weakness in my arm/shoulder/hands, stabbing pains in my face, frequent twitching of my facial muscles (especially at night) - in my eye, upper lip, cheek, forehead, and even my ear, and fatigue.

I got my MRI report back & it showed some abnormalities (hyperintensities). My doctor says it's possible they are caused by migraine, but sent me to a neurologist to be sure. Unfortunately, my appointment isn't until June. The only other findings I've had are a borderline elevated ANA test(negative for lupus), and brisk reflexes noted on exam. Normal ESR and no bulging/herniated discs.

I'm wondering whether the locations of my brain lesions are common for migraine patients my age. I couldn't find much information on whether my lesion locations are in a typical pattern for someone my age with migraines or if they're more indicative of demyelinating disease like MS. I've heard that migraine lesions are often described as "punctate" on an MRI report. Is this always the case?

Would you be able to help me interpret my MRI results?
"Hyperintense long TR signal is seen within the bilateral periatrial white matter with the lesions having a perpendicular configuration relative to the lateral ventricles. Additional lesions are seen adjacent to the frontal horns as well as within the left frontal subcortical white matter and left centrum semiovale. These findings are nonspecific but greater than expected in a patient of this age and given the morphology and patient's age raise the possibility of demyelinating disease...Conclusion: Abnormal hyperintense signal predominantly within the periventricular white matter as well as within the left centrum semiovale. Some of lesions have a perpendicular configuration relative to the lateral ventricles. Findings may represent sequelae of demyelinating disease."

Thanks in advance for any help or guidance you can offer.

Category: Neurologist, Medical

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Dr. Sudhir Kumar
Category: Pediatric Neurologist
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Expert:  Dr. Sudhir Kumar
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Hi,

Thank you for posting your query at DoctorSpring.com.

I have noted your symptoms and also the MRI brain report. In addition, I also saw the images of MRI brain which you have attached.

First of all, I would like to reassure you that these abnormalities (lesions) on your MRI are typically seen in patients with chronic migraine. I am a busy neurologist and have been treating patients with migraine for more than 15 years. I see about 4-5 patients with migraine per day and most of them get at least one MRI brain done. I routinely see these lesions, which are hyperintense (bright) on T2W and FLAIR sequences. These are small (as in your case) and are mostly a little distance away from the ventricles (as in your case).

The reason for these lesions is believed to be mild ischemia (lack of blood flow to brain).

The very close differential diagnosis in your case would be multiple sclerosis (MS). In MS, the lesions are very close to ventricles, may enhance with contrast injection and lesions are of varying ages (some new and some old)- none of these are present in your case.

I agree that I have not published the data of thousands of MRIs that I have seen in patients with migraine, but based on my experience, your MRI findings fit in with a diagnosis of migraine.

I hope it helps. Please get back if you have any follow-up queries.

Best wishes,
Dr. Sudhir Kumar MD (Medicine), DM (Neurology)
Senior Consultant Neurologist


Patient replied :

Thanks very much for your quick reply and reassuring words. Could my muscle spasms also be coming from the Chronic Migraine? I have them all over my back (mostly upper and middle) and arms (they can actually be felt as tight knots on both sides but mostly the right).
My doctor had mentioned that they're a bit far from my head to all be caused by the migraine, but I'm at a bit of a lost as to what they can be from, as I've tried various lifestyle modifications and treatments and am still in a lot of pain much of the time.

My doctor suggested thoracic outlet syndrome as well. Do you think this is a worthwhile cause to look into in my case?


Expert:  Dr. Sudhir Kumar
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Hi,

Thank you for getting back.

Muscle spasms are most likely not related to migraine. So, we need to look for alternative causes.

They are most often due to posture, such as sitting at desk job/computer for long hour OR need to drive for long, etc.

In some cases, they could be due to pinched nerves in the neck/back region.

Mostly, muscle relaxants work. In addition, physiotherapy with IFT/ultrasound and neck/back extension exercises are also helpful.

Thoracic outlet syndrome is unlikely as a cause, and I do not think we should chase that.

I hope it helps.

Best wishes,

Dr. Sudhir Kumar MD (Medicine), DM (Neurology)
Senior Consultant Neurologist

Dr. Sudhir Kumar
Category: Pediatric Neurologist
Experience: 
Senior Residency, Fellowship: DM, Neurology, CMC, Vellore, 2001
Junior Residency: MD, Internal Medicine, CMC, Vellore, 1998
Medical School: MBBS, Christian Medical College, Vellore, 1995
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