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MRI in Migraineurs
Lawrence Robbins, MD and Harold Friedman, MD
November 1992, Posted June 1998
HEADACHE Volume 32, Number10, 507-508
Synopsis
Forty-six migraineurs and 69 age- and sex-matched controls referred for MRI scans of the brain were evaluated for the incidence of intracranial pathology.  Axial long TR/short TE and long TR/long TE and sagittal short TR/short TE scans were performed in all patients.  Enhancement with Gd-DTPA was performed in all controls and in nine migraineurs.  Six of 46 (13%) of the migraineurs had white matter lesions versus three of 69 (4.3%) of the controls.  The white matter lesions in migraineurs were seen in a younger age group than in the controls.  These findings agree with recent MRI studies.  Ischemia or an immune-based white matter demyelination are possible mechanisms for the white matter lesions.

Key words: migraine, MRI, white matter lesions

Introduction
Recent reports discussing the MRI evaluation of migraineurs have noted the high incidence of increased signal intensity in the white matter on T2 weighted scans.1-3  More recent studies have shown a lower frequency of high signal areas than earlier reports, especially in patients under 40. 4  The purpose of this study was to evaluate the percentage of migraineurs with white matter lesions versus a control group of age- and sex-matched controls.

Materials and Methods
The study group included 46 consecutive patients referred to the MRI center for migraine from the Robbins Headache Clinic.  The patients were between 17 and 55 years old, with a well-established history of migraine headache.  Sixty-nine age- and sex-matched patients referred to the MRI for possible 7th or 8th cranial nerve disease, scanned during the same time period, were utilized as controls.  No patients in the control group had a history of headache.

MRI examinations were performed on a 1.5 Tesla H.P.  gyroscan whole body imager (Phillips Medical Systems, Einthoven, Netherlands).  MRI exams were reviewed by a neuro-radiologist (Dr.  Harold Friedman).

All MRI studies included T2-weighted long TR/long TE and  proton density long TR/short TE 2100-2700/20-70 (TR/TE) axial scans and T1 weighted short TR/short TE 600/15 sagittal scans.  Axial T1-weighted scans were available in 14 migraineurs as  well as all controls.

All control patients received IV Gadopentate dimeglumine (Magnevist) as well as nine migraineurs.  The matrix was 204 x 256 or 256 x 256 and Field of View was 22-24 centimeters.  The slice thickness was 5 millimeters with a 40% gap.

Results
Six patients with migraines (13.6%) had white  matter lesions generally described as non-specific tiny lesions seen in the periventricular white matter or near the gray/white matter junction, predominantly in the parietal and posterior parietal regions.  Three of the 69 controls (4.3%) had bilateral white matter lesions.  Two migraineurs, 40 years of age or under, had white matter lesions, while none of  the controls in this age bracket had white matter lesions.
Two of the migraine patients had bilateral lesions primarily involving the trigone of the lateral ventricles.  One patient, with severe and frequent migraines and a chronically increased sedimentation rate, had multiple extensive areas of periventricular white matter high intensity lesions.  A second patient also had extensive bilateral white matter lesions.  One patient had bilateral lesions only in the centrum semiovale.  The final positive scan revealed unilateral frontal white matter lesions (Fig. 1,2).

Discussion
Similar white matter lesions, as seen on MRI, have been reported in previous studies.  The abnormalities have been most apparent in the T2  weighted images with white matter increased signal intensity, smaller and more non-specific than the typical multiple sclerosis demyelination.1,2,3,5  One previous study noted that 36 of 91 patients with migraine had small foci of sharply delineated lesions in the white matter.  Migraine with aura patients (43.4%) and complicated (40%) migraineurs had a higher percentage of white matter abnormalities than did migraine patients without aura (33.3%). The lesions were mostly in the centrum semiovale and the frontal white matter in younger patients, and they were found deeper in the white matter with increasing age.  MRI abnormalities did not correlate with duration, intensity, or frequency of headache.6

Increased white matter T2 signaI intensity on the MRI may be ischemic, it can represent demyelination, or an AVM may be present.  As previous studies have reported, a decrease in T8 suppressors in both migraine and multiple sclerosis, and other similarities, exist between the two illnesses.7,8  It may be that an immune-mediated demyelination is responsible for the white matter changes.  This explanation for these abnormalities would explain why we find this peculiar "white matter distribution" of the migraine lesions.



References
  1. Jacome DE, Leborgne J: MRI Studies in Basilar Artery Migraine.  Headache 1990; 30:88 - 89.
  2. Kaplan RD, Solomon GD, Diamond S, Freitag, FG: The Role of MRI in the Evaluation of a Migraine Population: Preliminary Data.  Headache 1987; 27:315 - 318.
  3. Soges LJ, Cacayorin ED, Petro GR, et al: Migraine: Evaluation by MR.  AJNR 1988; 9:425 - 429.
  4. Osborn RE, Alder DC, Mitchell CS: MR Imaging of the Brain in Patients with Migraine Headaches.  AJNR 1991; 12:521 - 524.
  5. Runge VN, Price AC, Kirshner HS, et al: The evaluation of multiple sclerosis by magnetic resonance imaging.  diographics 1986; 6:203 - 212.
  6. Igarashi H, Sakai F, Tazaki Y, Kan S, Saitoh Y: Magnetic Resonance Brain Imaging of Migraine.  Cephalaigia 1989; 9:189 190.
  7. Gilman-Sachs A, Robbins L, Baum L: Flow Cytometric Analysis of Lymphocyte Subsets in Peripheral Blood of Chronic Headache patients.  Headache 1989; 29:290-294.
  8. Robbins L: Migraine, Multiple Sclerosis, and Systemic Lupus Erythematosus.  Submitted for publication.