“Thoracic migraine” as a new manifestation of migraine: Case report

Abstract

Background and objectives

Abdominal pain is a well-known headache-associated symptom in migraine in children, but rarely in adults. We describe a case of a female patient with typical accompanying migraine symptoms without headache but with thoracic pain.

Case report

The present case of a 41 year-old-woman shows recurrent attacks with thoracic pain and typical accompanying migraine symptoms but without headache. Symptoms resolved upon treatment with triptans and beta blockers.

Discussion

This case might be interpreted as “thoracic migraine”, and extends the spectrum of migraine forms.

Conclusion

In patients with facial pain secondary to lung cancer, an anatomical connection between the vagal nerve, the nucleus tractus solitarii, the jugular ganglion and trigeminal system has been suggested. The present case might be an analogy to this explanation.

Introduction

Atypical manifestations of migraine such as abdominal migraine and cyclical-vomiting syndrome have been largely classified as childhood-specific syndromes for several decades. Several case reports have shown that abdominal migraine also occurs in adults, albeit rarely (1). The limitation to childhood has been abandoned in the current ICHD-III beta under 1.6, Episodic syndromes that may be associated with migraine (2). Here we present thoracic pain as a possible new episodic syndrome in association with migraine.

Case report

A 41-year-old woman was admitted for diagnosis and treatment of recurring thoracic pain attacks over four months. Attacks usually started with ravenous hunger approximately two hours before onset of thoracic pain. The pain initially started paravertebrally on both sides. It spread bilaterally ventrally over the course of the pain attack, approximating the T7 dermatomes (Figure 1). Pain intensity was described as 8 out of 10 on a numerical rating scale (NRS). Attacks were accompanied by nausea and vomiting. The patient described photo- and phonophobia during pain attacks not associated with headache. The symptoms led to withdrawal from social activities. Physical activity caused aggravation of the thoracic pain attacks and was therefore avoided. Frequency of pain attacks was one per week. Duration was usually six to eight hours, with resolution of the pain after sleeping for three hours. Attacks usually occurred during the weekend. There was no association to the menstrual cycle. There was an attack-free period during the patient’s summer vacation. Self-medication with ibuprofen 600 mg during the pain attacks was not effective. The patient described intense occupational and private stress over the last year. During the above-mentioned attacks, the patient did not describe any visual impairment. However, independently from these pain attacks, episodes of visual field defects that slowly developed over a time course of 30 minutes were described for several years. These were not followed by headache. These visual episodes had occurred four times over the last year. There were no migraine attacks without aura.

Figure 1.

Localisation of thoracic pain.

The patient did not suffer from any other diseases besides hypothyroidism, which was adequately replaced with L-Thyroxin 50 µg. There was no history of headache disorders. Family history concerning primary headache disorders was negative.

Neurological examination was normal. Gastroscopy, colonoscopy, blood tests as well as transthoracic echocardiography and electrocardiography were unremarkable. Cranial and spinal MRI were normal, besides a slight disc protrusion in between the fifth lumbar and first sacral bodies. Somatosensory evoked potentials of the median nerve showed normal latencies that were equal on both sides.

Suspecting an atypical presentation of migraine, acute therapy with zolmitriptan 5 mg nasal spray was prescribed. Prophylactic therapy was initially refused by the patient. Follow-up investigations two and four months later showed that the pain attacks responded well to triptan treatment, with complete resolution together with other symptoms (photo- and phonophobia, nausea and vomiting) two hours after medication. However, the patient still described attacks of thoracic pain approximately once a week. Furthermore, one attack presented itself with abdominal pain and no thoracic pain, while the accompanying symptoms were similar to the other episodes. After four months of acute therapy with triptans alone, the patient agreed to take metoprolol 50 mg as a prophylactic treatment. This led to a reduction of pain attacks to two attacks every month after two months of treatment. Follow-up period was one year.

Discussion

After the exclusion of other differential diagnoses, a diagnosis of probable “thoracic migraine” was reached because of the typical course of the attacks and the presence of typical migraine accompanying symptoms. Successful attack therapy with zolmitriptan and the reduction of pain attacks after intake of metoprolol support this diagnosis. In summary, all features met the criteria for abdominal migraine in ICHD 3 beta, with the exception that the pain was not abdominal but thoracic. So far, chest pain during migraine has been described as an accompanying symptom of the headache (3). In addition, two case reports about abdominal migraine described thoracic pain preceding the actual abdominal pain attack (4). The present case, as well as the above-mentioned case reports, show that thoracic pain as part of a migraine attack can occur as an aura symptom as well as a headache-associated symptom. However, in our case we reported chest pain as the only pain symptom of migraine, which has not been reported before.

The subsequent development of abdominal pain in the present case and the thoracic pain preceding the abdominal pain attack in two other patients (4) suggests a common pathway for both migraine-associated symptoms. This might be in analogy to facial pain secondary to lung cancer. In these cases, an anatomical connection between the vagal nerve, the nucleus tractus solitarii, the jugular ganglion and trigeminal system has previously been proposed (5). The pathophysiological causes of both associated symptoms are enigmatic (6). In conclusion, this case suggests that migraine should be considered in patients with the typical accompanying symptoms of migraine with pain other than headache.

Clinical implications

The first case report of migraine without headache but only with thoracic pain is presented.

Recurrent attacks of nausea, vomiting, phono- and photophobia and aggravation through physical activity without headache can be caused by atypical presentations of migraine (i.e. abdominal migraine and “thoracic migraine”).

Successful treatment with triptans and migraine prophylaxis (beta-blockers) can help to diagnose these cases.