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Neurology (Expert Forum)
Complex migraines or early MS
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Complex migraines or early MS
by te6698, Feb 14, 2007 12:00AM
I'm a 29 year-old female who began having loss of peripheral vision back in July. I had 3-4 20 minute episodes of losing peripheral vision in one eye at a time (was like blackness came from the side of my vision) within a 2 week period.Symptoms then changed a bit to what neuro says are ocular migraines - reading about ocular migraines they do seem to fit except they can occur in both eyes at the same time, not just one which seems to be the typical symptom.Normal MRI of brain and C-spine and an MRA of head/neck which questioned stenosis in left internal and external carotid arteries.Follow up carotid ultrasound was negative.Bloodwork showed elevated CRP level, other blood tests neg for lyme,RA,lupus.Hx of early heart disease in family.Personal hx of high cholesterol, triglycerides and recently high BP.Neuro put me on Verapamil to see if it helped the ocular "episodes" as well as to see if it helps my regular migraine headaches.Episodes occurred again for roughly 4 weeks from August -September and other syptoms started occuring independent of the migraines or ocular migraines such as feeling of heaviness and/or weakness and tightness in arms.All symptoms resolved in late September until mid January. Now I am again having ocular disturbances nearly daily,arm aches/weakness and now occasional leg weakness for past 3 weeks - do these sound like MS symptoms?What about the normal MRI? Also worried about possible carotid issue given abnormal MRA, but normal ultrasound?
Doctor's Answer
by CCF-Neuro-M.D.-SH, Feb 26, 2007 12:00AM
First of all, keep in mind that I am unable to diagnose you because I am unable to examine you, this forum is for educational purposes.
The symptoms and story that you relate are not specific for any single disorder, but are most consistent with migraine headaches. Migraine headaches often have an 'Aura' which can preceed the headache, but can also occur during or even after the headache. The most common auras are visual, including sparkling lights, fortification spectra, a loss of peripheral vision and seeing halos around objects. Less common auras include numbness/tingling over part of the body, weakness on one side of the body (also called hemi-plegic migraine), confusion spells and problems speaking (also called aphasic migraines). The problem is that there is no test to confirm a spell is a migraine, except that it will get completely better with no residual problem in a few hours or so. Much of the testing in cases of suspected migraine related symptoms surrounds ruling out other diseases and trials of empiric medications. An MRI of the brain and cervical spine is a common first test to evaluate for things like Strokes, tumors and multiple sclerosis (all of which can cause similar symptoms). When the MRI is normal, this makes migraine much more likely (but does not prove it). A trial of a medication used to prevent migraines can provide more evidence for migraine if the spells improve/respond to the treatment (but again this is also indirect). Some medications work better for certain people. If verapamil, did not seem to work that well, you should try some other medications such as Nadolol, Topamax, Elavil, etc. until you find the best medication for you. I would also encourage you to have a repeat MRI whenever you have a change in your symptoms, such as when you developed the weakness, to evaluate for any other possible causes for the symptoms.
The MRA (magnetic resonance angiogram) is a calculated flow study (based on the time of flight +/- GAD contrast) that can often over estimated a possible vessel stenosis. Inaddition, many artifacts from metal/baces/etc in the mouth and interfere with the signal at the level of the carotids. Getting an ultra sound is a good first step to determine if real pathology is present. If doubt continues, a CT angiogram is a better study to determine a more accurate lumen of the carotid vessels.
I do not think your symptoms are consistent with multiple sclerosis(MS). MS usually presents with focal neurologic deficits that last for several weeks at time and then get mostly better, but the deficits build up over time. Common MS symptoms include pain in one eye with blurry vision (also called optic neuritis), double vision, numbness and tingling, and focal weakness. The MRI generally has more lesions that the patient remembers having symptoms for , since only lesions in select areas cause symptoms. If concerns about MS persist, then I would suggest a lumbar puncture (to look for inflammation, IgG index, oligoclonal bands) and visual evoked potentials (to look for evidence of past optic neuritis).
Finally, I am concerned about your history of high blood pressure, high cholesterol and elevated CRP (these all increase your stroke risk). I would suggest that you contact your primary care physician about anti-hypertensive medication and a possible statin (for cholesterol).
I hope this has been helpful.
The symptoms and story that you relate are not specific for any single disorder, but are most consistent with migraine headaches. Migraine headaches often have an 'Aura' which can preceed the headache, but can also occur during or even after the headache. The most common auras are visual, including sparkling lights, fortification spectra, a loss of peripheral vision and seeing halos around objects. Less common auras include numbness/tingling over part of the body, weakness on one side of the body (also called hemi-plegic migraine), confusion spells and problems speaking (also called aphasic migraines). The problem is that there is no test to confirm a spell is a migraine, except that it will get completely better with no residual problem in a few hours or so. Much of the testing in cases of suspected migraine related symptoms surrounds ruling out other diseases and trials of empiric medications. An MRI of the brain and cervical spine is a common first test to evaluate for things like Strokes, tumors and multiple sclerosis (all of which can cause similar symptoms). When the MRI is normal, this makes migraine much more likely (but does not prove it). A trial of a medication used to prevent migraines can provide more evidence for migraine if the spells improve/respond to the treatment (but again this is also indirect). Some medications work better for certain people. If verapamil, did not seem to work that well, you should try some other medications such as Nadolol, Topamax, Elavil, etc. until you find the best medication for you. I would also encourage you to have a repeat MRI whenever you have a change in your symptoms, such as when you developed the weakness, to evaluate for any other possible causes for the symptoms.
The MRA (magnetic resonance angiogram) is a calculated flow study (based on the time of flight +/- GAD contrast) that can often over estimated a possible vessel stenosis. Inaddition, many artifacts from metal/baces/etc in the mouth and interfere with the signal at the level of the carotids. Getting an ultra sound is a good first step to determine if real pathology is present. If doubt continues, a CT angiogram is a better study to determine a more accurate lumen of the carotid vessels.
I do not think your symptoms are consistent with multiple sclerosis(MS). MS usually presents with focal neurologic deficits that last for several weeks at time and then get mostly better, but the deficits build up over time. Common MS symptoms include pain in one eye with blurry vision (also called optic neuritis), double vision, numbness and tingling, and focal weakness. The MRI generally has more lesions that the patient remembers having symptoms for , since only lesions in select areas cause symptoms. If concerns about MS persist, then I would suggest a lumbar puncture (to look for inflammation, IgG index, oligoclonal bands) and visual evoked potentials (to look for evidence of past optic neuritis).
Finally, I am concerned about your history of high blood pressure, high cholesterol and elevated CRP (these all increase your stroke risk). I would suggest that you contact your primary care physician about anti-hypertensive medication and a possible statin (for cholesterol).
I hope this has been helpful.
Member Comments (6)
by robertmillerfoundation.org, Feb 16, 2007 12:00AM
Hi, I'm sorry to hear about your mystery symptoms. From my understanding this does not really sound like MS since visual symptoms with MS occur is only one eye most of the time (someone correct me if I'm wrong about that). With a normal Brain MRI, this makes MS even less likely. This is just an idea, but have you been evaluated for pseudotumor cerebri? Do you ever hear your heardbeat in your head/ears? It might not hurt to see an Neuro-opthamologist for an eye exam. I hope you feel better soon
by JCmcc, Feb 17, 2007 12:00AM
To: RE:
actually you are incorrect about that.
by te6698, Feb 17, 2007 12:00AM
To: robertmillerfoundation.org